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Letter 2019
Fort Smith Housing Authority
2100 North 31
st
Street
Fort Smith, Arkansas 72904
(479) 785-4881 FAX (479) 709-9381
HOUSING CHOICE VOUCHER/
SECTION 8 APPLICATION
Dear Applicant,
The Fort Smith Housing Authority has added two local preferences for which you
may qualify. The first is a working preference for families in which the head of
household or spouse works a minimum of thirty (30) hours per week at no less than
minimum wage, which is currently $7.50 per hour. You must have worked the last
six months and continue to work for twelve months after receiving the preference.
The second is for elderly, handicapped or disabled families. An elderly preference
is given to a family whose head of household or spouse is age 62 or older. A
disabled family is one in which the head of household or spouse is handicapped or
disabled. Enclosed is a copy of the two preferences we have added. If you believe
you qualify for either preference, please call to inquire at 479-782-4991 ext. 10.
Please note that these are local preferences only; they do not port out to other
agencies.
Sincerely,
Fort Smith Housing Authority
4-III.C.
SELECTION
METHOD
PHAs must describe the method for selecting applicant families from the waiting list, including
the system
of
admission preferences that the PHA will
use
[24
CFR 982.202(d)].
Local
Preferences [24
CFR
982.207;
HCV
p. 4-16)
PIMs
are pennitted
to
establish local preferences, and
to
give priority
to
serving families that
meet those criteria. HUD specifically authorizes and places restrictions on certain types
of
local
preferences. HUD also pennits the
PHA
to
establish other local preferences, at its discretion.
Any local preferences established must be consistent with the
PHA plan and the consolidated
plan, and must
be
based on local housing needs and priorities that can be documented by
generally accepted data sources.
PHAPolicy
All preferences are ranked and based
on
date
of
application
The
PHA will offer a preference
to
any family that
has
been terminated from its HCV
program due to insufficient program funding.
The Fort
Smith housing Authority has implemented five (5) local preferences:
(1) Abuse preference
(2) Natural disaster preference
(3) Elderly, handicapped or disabled preference
(4) Working
Preference
(5) One homeless family per month will be referred
by
local homeless services provider
agencies
A ViolencelDomestic
Abuse
preference
will apply when a victim is forced from
thek
residence by a
member
of
the
household acting in such
abusive
manner
that
it
is a
life
threatening
situation
.
Applicant
applying for
preference
shall
furnish
a
letter
from the Crisis
Intervention
Center
verifying the abuse.
An
applicant
granted
a
preference for abuse will be
required
to enroll into a
support
group
at
the Crisis
Intervention
Center
and
complete the course. Upon successful completion a
certificate will
be
given to
the
applicant.
If
an
applicant fails to complete the course
rental
assistance will
be
terminated
by
the
PHA
giving a
thirty
day
notice to
the
applicant
and
landlord.
The
applicant
shall also sign a certification
that
the formel'
abuser
will
not
under
:my circumstances reside with the
tenant
family unless the
PHA
has given
advance
written
approval. Applicant
must
apply
for
preference
within forty five (45)
days
of
being forced from their residence.
A
Natural
Disaster
pl'eference will apply when a victim
is
fOI'ced
to vacate
their
residence because
of
a
natural
disaster, in which the residence is
destroyed
or
left in
an
unlivable condition.
The
applicant
applying for the
preference
must
be the
person
named
on the lease
for
that
residence. Applicant
shall
furnish
proof
of
Ii:) Copyright 2005 Nan McKay & Associates, Inc.
Unlimited
copies
may
be
mad
e
for
in
ternal
use.
Page 4-11
Adminplan 9/1/05
residence
and
proof
of
action
that
caused it to become unlivable. Applicant
must
apply for preference
within
forty five (45) days
of
said disaster.
An elderly,
handicapped
or
disabled family
is
eligible
fOi'
a local preference if they
othenvise qualify for
the
rental
program
and
the head
of
household
or
spouse
is
62
years
of
age
or
older',
is
receiving SSI, Social Security,
or
another
type
of
payment
verifying disability.
A family will be eligible
for
the
working
preference
if
the
head
of
household
or
spouse has been employed full time for
at
least minimum wage
for
the last
consecutive
SLX
month
period
before application
is
made.
If
a family qualifies for
the preference the
working
member
must
maintain the full time status for
an
initial
consecutive twelve
month
period
after
they
are
accepted for the rental
program
and
rental assistance begins.
If
the working
member
loses tbei!' employment for any
reason
other
than
layoff
due
to lack
of
work
or
closure
of
tbe business
during
the
initial twelve month
period
tbe
Fort
Smith Housing
Authority
will terminate
rental
assistance
after
a
thirty
day
notice
of
termination in writing to tbe family
and
the
landlord.
For
purposes
of
tbis preference full time employment
is
a minimum
of
thirty hoUl's
per
week. ANY
NUMBER
OF
HOURS
LESS
THAN
THIRTY
IS
CONSIDERED
PART
TIME!
All adults in tbe household
must
sign an agreement
verifying tbey
understand
tbese conditions
and
agree to comply with them in
order
to
obtain the
Working
Preference.
A preference will be
provided
for one (1) homeless family
per
month.
In
order
to
receive the preference a family
must
be
referred
to
the
PHA
by a single collective
recommendation
from
local homeless services
provider
agencies.
©
Co
p
yr
ig
ht
20
05
Nan
McKay & Associat
cs.
Inc.
U
nlim
ited
co
pic
s
ma
y be
ma
de
for
internal use.
Page 4-12
Ad
minpI
an
9/
1
/0
5
[This page has been intentionally left blank]
Fort Smith Housing Authority
2100 North 31
st
Street
Fort Smith, Arkansas 72904
(479) 785-4881 FAX (479) 709-9381
FORM 1019
OFFICE HOURS: MONDAY THROUGH FRIDAY 8:00A.M. TO 4:30P.M.
NOTICE
The Fort Smith Housing Authority does not have funds available for immediate and/or
emergency rent assistance. Choosing of applicants is based on a first come, first serve
basis.
We are unable to give you an approximate date of how soon we will be able to help you.
Therefore, you will have to wait your turn on the waiting list.
We will need copies of birth certificates. If you do not have the birth certificates, then
you will have to send off for them.
If your income and money is derived from sources listed below, you are required to
provide our office with the following:
(a) Income earning statement;
(b) Statement from the Social Security Administration verifying social security
benefits received by you and members of your family;
(c) Statement from the Employment Security Division verifying unemployment
benefits received by you and members of your family;
(d) Recent statement from the Department of Health and Human Services
verifying the amount of your TEA & Food Stamps;
(e) Statement from Child Support Enforcement Unit, or a copy of a court ledger
verifying the amount of child support you receive in a 12 month period;
(f) Statement from all individuals providing you with financial assistance;
(g) Copy of your recent bank statement verifying your savings and checking
account, stocks, bonds, annuities, etc;
(h) Statement verifying VA benefits, workmen compensation, royalties,
retirement benefits, military pay, etc; and
(i) Copy of your divorce papers.
The Applicant/Tenant Certification form must be completed in its entirety and signed by
you and your spouse. Please answer each question. Do not put N/A or draw lines in
blanks. If you have a question about any particular question(s) on the form, do not
hesitate to ask questions. It is important that you be truthful and accurate when answering
the questions.
Thank you.
Fort Smith Housing Authority
2100 North 31
st
Street
Fort Smith, Arkansas 72904
(479) 785-4881 FAX (479) 709-9381
FORM 1019
ANNUALIZED INCOME FOR VERY LOW INCOME FAMILIES
NUMBER OF PERSONS IN HOUSEHOLD
1
2
3
4
5
6
7
8
VERY LOW INCOME
$16,500
$18,850
$21,200
$23,550
$25,450
$27,350
$29,250
$31,100
APPROXIMATE GROSS MONTHLY
$1,375
INCOME
$1,570
$1,766
$1,962
$2,120
$2,279
$2,437
$2,591
APPROXIMATE GROSS WEEKLY
$317
INCOME
$362
$407
$452
$489
$525
$562
$598
APPROXIMATE GROSS HOURLY INCOME
$7.93
$9.06
$10.19
$11.32
$12.23
$13.14
$14.06
$14.95
AMOUNTS ARE ON GROSS INCOME BEFORE
TAXES ARE TAKEN OUT
Please make a note of the amount of income
your household is allowed to
earn and still qualify for rental assistance. Be aware that the above chart
refers to your income at the time you are called in to be placed on the
program, not your income at the time of your application. If you are
presently over income, you may still make an application for the program.
If your income, when you are called in, is the same or higher than those
listed in the chart above, we will be unable to assist you.
Fort Smith Housing Authority
2100 North 31
st
Street
Fort Smith, AR 72904
(479) 785-4881 FAX (479) 709-9381
FORM 1013 c
WHAT CAN I DO IN THE MEANTIME?
HOMELESS INDIVIDUALS/FAMILIES LOCAL HOUSING AUTHORITIES:
& VETERANS: Alma Housing Authority
Next Step Day Room 9 West Main 632-2043
123 N 6
th
Street 782-5433
Monday-Friday 8:00 a.m. – 4:00 p.m. Crawford County Rental Assistance
Identification Assistance, Lunch Served Daily 11-A Pointer Trail West 474-0512
SERVICES ONLY: Greenwood Housing Authority
Area Agency on Aging 319 West Cedar Street 996-4661
524 Garrison 783-4500
Oklahoma Housing Finance Agency
Crawford-Sebastian Community Development HUD, P.O. Box 26720
4831 Armour 785-2303 Oklahoma City, OK 1-800-256-1489
Community Services Clearing House Van Buren Housing Authority
4420 Wheeler Ave. 782-5074 1701 Chestnut 474-6901
Department of Human Services (DHS) INCOME BASED HOUSING:
Fort Smith, 616 Garrison 782-4555 Allied Gardens
Van Buren, 704 Cloverleaf Cir. 474-7595 5221 Johnson 782-3611
Public Transit 783-6464 Briarwood Apartments
3400 Duke Ave. 646-2815
SERVICES AND HOUSING: North Pointe/Clayton Heights
Crisis Intervention Center 3408 N 6
th
St. 494-7729
5603 S 14
th
Street 782-1821
West Apartments
Gospel Rescue Mission/ Van Buren 4118 North 50
th
783-7663
201 Drennen 474-4163
ELDERLY/ DISABLED/HANDICAPPED:
Red Cross Gorman Towers
1709 S Greenwood 782-1056 5800 Grand 452-7670
Rescue Mission Mid-Town Apartments
310 N F Street 782-1443 1411 Rogers Ave. 783-1089
Salvation Army Nelson Hall Homes
401 North 6
th
783-6145 2100 N 31
st
Street 782-4991
[This page has been intentionally left blank]
1
Form 1108
NOTICE TO APPLICANTS APPLYING FOR
AND TENANTS CURRENTLY RECEIVING
HOUSING ASSISTANCE
The Law: Section 214 of the Housing and Community Development Act of 1980, as amended, prohibits
the Secretary of the Department of Housing and Urban Development (HUD) from making financial
assistance available to persons who are other than United States citizens, nationals, or certain
categories of eligible noncitizens either applying to or residing in specified Section 214 covered
programs. Section 214 was implemented by a final “Noncitizens Rule” entitled Restrictions on Assistance
to Noncitizens, which was published in the Federal Register on Monday, March 20, 1995 (60 FR 14846-
4861).
When the Law Became Effective: The Noncitizens Rule became effective on June 19, 1995. Until the
final rule took effect, the Housing Agency was prohibited from taking any action based on the citizenship
or eligible immigration status of applicants and tenants.
What the Law Means to You: The receipt of financial housing assistance is contingent upon you and
your family submitting evidence either of 1) citizenship, or 2) eligible immigration status.
Type of Programs this Law Applies to: The noncitizens Rules applies to the following HUD assisted
housing programs:
1) Section 8 Rental Voucher Program
2) Section 8 Moderate Rehabilitation Program
3) Public and Indian Housing Programs
What Persons Are Covered By This Law: Section 214 applies to all applicants who apply for housing
assistance, applicants who are already on a waiting list for housing assistance, and tenants who are
already receiving housing assistance under a covered program. Section 214 covers: 1) Citizens and 2)
Noncitizens who have eligible immigration status.
What Evidence Will Be Required: Each family member, regardless of age, is required to submit the
following evidence:
For citizens or nationals: A signed declaration of U.S. citizenship (whether by birth or
naturalization).
For Noncitizens who are 62 years of age or older and receiving housing assistance on June 19,
1995: A signed declaration of eligible immigration status and
proof of age.
For All Other Noncitizens, the Evidence Consists of: 1) a signed declaration of eligible
immigration status; 2) the immigration and Naturalization Service (INS) documents listed below
on this page; and 3) A signed verification consent form.
2
Form 1108
For All Other Noncitizens, What Immigration Status is Eligible? Under the Noncitizens Rule, a
noncitizen would have eligible immigration status under any one of the following six categories which
are determined by the INS pursuant to the Immigration and Nationality Act (INA):
1) Immigrant Status Under s101 (a)(15) or 101 (a)(20) of INA: A noncitizen lawfully
admitted for permanent residence, as defined by §101 (a)(20) of the INA, as an
immigrant, as defined by §101 (a)(15) of the INA (8 U.S.C. 1101 (a)(20) and 1101 (a)(15)),
respectively [immigrant status]. This category includes a noncitizen admitted under
§§210 or 210A of the INA (8 U.S.C. 1160 or 1161) [special agricultural worker status]
who has been granted lawful temporary resident status.
2) Permanent Residence Under §249 of INA: A Noncitizen who entered the U.S. before
January 1, 1972, or such later date as enacted by law, and has continuously maintained
residence in the U.S. since then, and who is not ineligible for citizenship, but now is
deemed to be lawfully admitted for permanent residence as a result of an exercise of
discretion by the Attorney General under §249 of the INA (8 U.S.C. 1259) [amnesty
granted under INA 249].
3) Refugee, Asylum, or conditional Entry Status Under §§207, 208 or 203 of INA: A
noncitizen who is lawfully present in the U.S. pursuant to an admission under §207 of
the INA (8U.S.c. 1157) [refugee status]; pursuant to the granting of asylum (which has
not been terminated) under §208 of the INA (8 U.S.C. 1158)[asylum status]; or as a
result of being granted conditional entry under §203 (a)(7) of the INA (U.S.C. 1153
(a)(7)) before April 1, 1980, because of persecution or fear of persecution on account of
race, religion, or political opinion or because of being uprooted by catastrophic national
calamity [conditional entry status].
4) Parole Status Under §212 (d)(5) of INA: A noncitizen who is lawfully present in the U.S.
as a result of an exercise of discretion by the Attorney General for emergent reasons or
reasons deemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. 1182
(d)(5)) [parole status].
5) Threat to Life or Freedom Under §243(h) of INA: A noncitizen who is lawfully present in
the U.S. as a result of the Attorney General’s withholding deportation under §243(h) of
the INA (8 U.S. C. 1253(h)) [threat to life or freedom].
6) Amnesty Under §245A of INA: A noncitizen lawfully admitted for temporary or
permanent residence under §245A of the INA (8 U.S.C. 1255(a)) [amnesty granted under
INA 245A].
What INS Documents Are Acceptable? The original of one of the following documents is acceptable
evidence of eligible immigration status, subject to verification with INS:
1) Form I-151, Alien Registration Receipt Card (issued to lawful permanent residents prior
to 1979). Form I-151 will no longer be valid after March 20, 1996. Detailed information
on how and where to apply for a new green card may be obtained by telephoning the
INS toll-free number 1-800-755-0777.
3
Form 1108
2) Form I-151, Alien Registration Receipt Card (for permanent resident aliens).
3) Form I-94, Arrival-Departure Record, with one of the following annotations:
a. “Admitted as Refugee Pursuant to Section 207”;
b. “Section 208” or “Asylum”
c. “Section 243(h)” or “Deportation stayed by Attorney General”;
d. “Paroled Pursuant to Section 212 (d) (5) of the INA”
4) If Form I-94, Arrival-Departure Record, is not annotated, then accompanied by one of
the following documents:
a. A final court decision granting asylum (but only if no appeal is taken);
b. A letter from an INS asylum officer granting asylum (if application sis filed on or
after October 1, 1990) or from an INS district director granting asylum (if
application filed before October 1, 1990);
c. A court decision granting withholding of deportation; or
d. A letter from an asylum officer granting withholding of deportation (if
application filed on or after October 1, 1990).
5) Form I-688, Temporary Resident Card, which must be annotated “Section 245A” or
“Section 210”;
6) Form I-688b, Employment Authorization Card, which must be annotated “Provision
of Law 274a.12 (11)” or “Provision of Law 274a.12”;
7) A receipt issued by the INS indicating that an application for issuance of a
replacement document in one of the above-listed categories has been made and
the applicant’s entitlement to the document has been verified; or
8) If other documents are determined by the INS to constitute acceptable evidence of
eligible immigration status, they will be announced by notice published in the
Federal Register.
Note: Family members are required to submit the original document(s) providing acceptable
evidence of eligible immigration status. The Housing Agency may not retain the original
document(s). The Housing Agency must immediately make copies from the original
document(s) and return the original document(s) to the family member.
When Must Evidence of Eligible Immigration Status Be Submitted? Evidence of eligible immigration
status must be submitted at the times specified below, subject to any extension granted in accordance
with the paragraph below which discusses extensions of time to submit evidence of eligible immigration
status.
4
Form 1108
Applicants: The Housing Agency must ensure that evidence of eligible immigration status is
submitted not later than the date the Housing Agency anticipates or has knowledge that
verification of other aspects of eligibility for assistance will occur.
Families already receiving assistance on June 19, 1995: For a family already receiving the
benefit of assistance in a covered program on June 19, 1995, the required evidence shall be
submitted at the first regular reexamination after June 19, 1995, in accordance with program
requirements.
New occupants of assisted units: For any new family member(s), the required evidence shall be
submitted at the first interim or regular reexamination following the person’s occupancy.
Changing participation in a HUD program: Whenever a family applies for admission to a Section
214 covered program, evidence of eligible immigration status is required to be submitted in
accordance with the requirements of the Noncitizens Rule unless the family already has
submitted the evidence to the Housing Agency for a covered program.
One-time evidence requirement for continuous occupancy: For each family member, the family
is required to submit evidence of eligible immigration status only one time during continuously-
assisted occupancy under any covered program.
What Happens if One or More Family Members Does Not Qualify? Assistance to a family may not be
delayed, denied, or terminated because of the immigration status of a family member except as
provided below. “Family” as used herein refers to both applicants and tenants.
Assistance to an applicant shall not be delayed or denied, and assistance to a tenant shall not be
delayed, denied, or terminated, on the basis of eligible immigration status of a family member if:
1) The primary and secondary verification of any immigration documents that were timely
submitted has not been completed;
2) The family member for whom required evidence has not been submitted has moved from
the tenant’s dwelling unit;
3) The family member who is determined not to be in an eligible immigration status following
INS verification has moved from the tenant’s dwelling unit;
4) The INS appeals process has not been concluded;
5) For a tenant, the Housing Agency informal hearing process has not been concluded;
6) Assistance is prorated;
7) Assistance for a mixed family is continued; or
8) Deferral of termination of assistance is granted.
5
Form 1108
9) Assistance to an applicant may be delayed after the conclusion of the INS appeal process,
but not denied until the conclusion of the Housing Agency informal hearing process, if an
informal hearing is requested by the family.
Assistance to an applicant shall be denied, and a tenant’s assistance shall be terminated, in accordance
with the procedures for any of the following events:
1) Evidence of citizenship (i.e., the Declaration) and eligible immigration status is not
submitted by the date specified or by the expiration of any extension granted ; or
2) Evidence of citizenship and eligible immigration status is submitted timely, but INS primary
and secondary verification does not verify eligible immigration status of a family member;
and
a. The family does not pursue INS appeal or Housing Agency informal hearing rights; or
b. INS appeal and Housing Agency informal hearing rights are pursued, but the final
appeal or hearing decisions are decided against the family member.
What Rights of Appeal are Available? Three distinct forms of appeal process are available to both
applicants and tenants:
1) Appeal to INS: The following instructions apply to the right of appeal to the INS:
a. Submission of request for appeal: When the Housing Authority receives notification
that INS secondary verification failed to confirm eligible immigration status, the
Housing Agency shall notify the family of the results of the INS verification. The
family shall have 30 days from the date of the Housing Agency’s notification to
request an appeal of the INS results. The request for appeal shall be made by the
family communicating that request in writing directly to the INS. The family must
provide the Housing Agency with a copy of the written request for appeal and proof
of the mailing. For good cause shown, the Housing Agency shall grant the family an
extension of the time within which to request an appeal.
b. Documentation to be submitted as part of the appeal to INS: The family shall
forward to the designated INS office any additional documentation or written
explanation in support of the appeal. The appeal must include a copy of the original
Form G-845S received from the INS annotated at the top center in bold print: HUD
APPEAL. The appeal must also include two stamped envelopes, one addressed to
the applicant or tenant family, and one addressed to the Housing Agency.
c. Results of INS Appeal:
(i) The INS will issue the results of the appeal to the family, with a copy to
the Housing Agency, within 30 days of its receipt. If, for any reason, the
INS is unable to issue a response within the 30-day time period, the INS
will inform the family and the Housing Agency of the reasons for the
delay.
6
Form 1108
Note: The INS response will be indicated in section B of form G-845S,
Document Verification Request, which is returned to family and the Housing
Agency. The INS response will be indicated in Section B by a mark in one of the
following boxes: 1, 2, 5, 6, 8, 11, 12, 15 or 18.
(ii) When the Housing Agency receives a copy of the INS response, the
Housing Agency shall notify the family of its right to request an informal
hearing on the Housing Agency’s ineligibility determination.
d. No delay, denial or termination of assistance until completion of INS appeal
process; direct appeal to INS: Pending the completion of the INS appeal, assistance
may not be delayed, denied or terminated on the basis of immigration status.
2) Informal Hearing with the Housing Agency
a) When request for hearing is to be made: After receiving notification of the INS
decision on appeal, or in lieu of requesting an appeal to the INS, the family may
request that the Housing Agency provide an informal hearing. This request must be
made either within 14 days of the date the Housing Agency mails or delivers the
notice of denial or termination of assistance, or within 14 days of the mailing of the
INS appeal decision (established by the date of the postmark).
b) Extension of time to request hearing: The Housing Agency will extend the period of
time for requesting a hearing (for a specific period) upon good cause shown.
c) Informal hearing procedures:
(i) For tenants: the procedures for the hearing before the Housing Agency
as set forth in 24 CFR Part 966.
(ii) For applicants: the procedures for the informal hearing before the
Housing Agency are as follows:
(A) Hearing before an impartial individual: The applicant shall be
provided a hearing before any persons(s) designated by the
Housing Agency (including an officer or employee of the
Housing Agency), other than a person who made or approved
the decision under review, and other than a person who is a
subordinate of the person who made or approved the decision;
(B) Examination of evidence: The applicant shall be provided the
opportunity to examine and copy, at the applicants expense and
at a reasonable time in advance of the hearing, any documents
in the possession of the Housing Agency pertaining to the
applicant’s eligibility status, or in the possession of the INS (as
permitted by INS requirements), including any records and
regulations that may be relevant to the hearing;
7
Form 1108
(C) Presentation of evidence and arguments is support of eligible
immigration status: The applicant shall be provided the
opportunity to present evidence and arguments in support of
eligible immigration status. Evidence may be considered
without regard to admissibility under the rules of evidence
applicable to judicial proceedings;
(D) Controverting evidence of the project owner: The applicant
shall be provided the opportunity to controvert evidence relied
upon by the Housing Agency and to confront and cross-examine
all witnesses on whose testimony or information the Housing
Agency relies.
(E) Representation: The applicant shall be entitled to be
represented by an attorney, or other designee, at the
applicant’s expense, and to have such person make statements
on the applicant’s behalf;
(F) Interpretive services: The applicant shall be entitled to arrange
for an interpreter to attend the hearing, at the expense of the
applicant or Housing Agency, as may be agreed upon by both
parties;
(G) Hearing to be recorded: The applicant shall be entitled to have
the hearing recorded by audiotape (a transcript of the hearing
may, but is not required to, be provided by the Housing
Agency); and
(H) Hearing decision: The Housing Agency shall provide the family
with a written final decision, based solely on the facts presented
at the hearing, within 14 days of the date of the Housing Agency
informal hearing. The decision shall state the basis for the
decision.
3) Judicial relief: A decision against a family member under the INS appeal process or the
Housing Agency’s informal hearing does not preclude the family from exercising the right,
that may otherwise be available, to seek redress directly through judicial procedures.
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I
V
V
A Guide for Applicants & Tenants of
Public Housing & Section 8 Programs
What is EIV?
The Enterprise Income Verification (EIV) system is a
web-based computer system that contains
employment and income information of individuals
who participate in HUD rental assistance programs.
All Public Housing Agencies (PHAs) are required to
use HUD’s EIV system.
What information is in EIV and where does it
come from?
HUD obtains information about you from your local
PHA, the Social Security Administration (SSA), and
U.S. Department of Health and Human Services
(HHS).
HHS provides HUD with wage and employment
information as reported by employers; and
unemployment compensation information as reported
by the State Workforce Agency (SWA).
SSA provides HUD with death, Social Security (SS)
and Supplemental Security Income (SSI) information.
What is the EIV information used for?
Primarily, the information is used by PHAs (and
management agents hired by PHAs) for the following
purposes to:
1. Confirm your name, date of birth (DOB), and
Social Security Number (SSN) with SSA.
2. Verify your reported income sources and
amounts.
3. Confirm your participation in only one HUD
rental assistance program.
4. Confirm if you owe an outstanding debt to any
PHA.
5. Confirm any negative status if you moved out
of a subsidized unit (in the past) under the
Public Housing or Section 8 program.
6. Follow up with you, other adult household
members, or your listed emergency contact
regarding deceased household members.
EIV will alert your PHA if you or anyone in your
household has used a false SSN, failed to report
complete and accurate income information, or
is receiving rental assistance at another address.
Remember, you may receive rental assistance at
only one home!
EIV will also alert PHAs if you owe an outstanding debt
to any PHA (in any state or U.S. territory) and any
negative status when you voluntarily or involuntarily
moved out of a subsidized unit under the Public
Housing or Section 8 program. This information is used
to determine your eligibility for rental assistance at the
time of application.
The information in EIV is also used by HUD, HUD’s
Office of Inspector General (OIG), and auditors to
ensure that your family and PHAs comply with HUD
rules.
Overall, the purpose of EIV is to identify and prevent
fraud within HUD rental assistance programs, so that
limited taxpayer’s dollars can assist as many eligible
families as possible. EIV will help to improve the
integrity of HUD rental assistance programs.
Is my consent required in order for information
to be obtained about me?
Yes, your consent is required in order for HUD or the
PHA to obtain information about you. By law, you are
required to sign one or more consent forms. When
you sign a form HUD-9886 (Federal Privacy Act
Notice and Authorization for Release of Information) or
a PHA consent form (which meets HUD standards),
you are giving HUD and the PHA your consent for
them to obtain information about you for the purpose
of determining your eligibility and amount of rental
assistance. The information collected about you will be
used only to determine your eligibility for the program,
unless you consent in writing to authorize additional
uses of the information by the PHA.
Note: If you or any of your adult household
members refuse to sign a consent form, your
request for initial or continued rental assistance
may be denied. You may also be terminated from
the HUD rental assistance program.
What are my responsibilities?
As a tenant (participant) of a HUD rental assistance
program, you and each adult household member must
disclose complete and accurate information to the
PHA, including full name, SSN, and DOB; income
information; and certify that your reported household
composition (household members), income, and
expense information is true to the best of your
knowledge.
Remember, you must notify your PHA if a household
member dies or moves out. You must also obtain the
PHA’s approval to allow additional family members or
friends to move in your home prior to them moving in.
What are the penalties for providing false
information?
Knowingly providing false, inaccurate, or incomplete
information is FRAUD and a CRIME.
If you commit fraud, you and your family may be
subject to any of the following penalties:
1. Eviction
2. Termination of assistance
3. Repayment of rent that you should have paid
had you reported your income correctly
4. Prohibited from receiving future rental
assistance for a period of up to 10 years
5. Prosecution by the local, state, or Federal
prosecutor, which may result in you being
fined up to $10,000 and/or serving time in jail.
Protect yourself by following HUD reporting
requirements. When completing applications and
reexaminations, you must include all sources of
income you or any member of your household
receives.
If you have any questions on whether money received
should be counted as income or how your rent is
determined, ask your PHA. When changes occur in
your household income, contact your PHA
immediately to determine if this will affect your rental
assistance.
What do I do if the EIV information is
incorrect?
Sometimes the source of EIV information may make
an error when submitting or reporting information about
you. If you do not agree with the EIV information, let
your PHA know.
If necessary, your PHA will contact the source of the
information directly to verify disputed income
information. Below are the procedures you and the
PHA should follow regarding incorrect EIV information.
Debts owed to PHAs and termination information
reported in EIV originates from the PHA who provided
you assistance in the past. If you dispute this
information, contact your former PHA directly in writing
to dispute this information and provide any
documentation that supports your dispute. If the PHA
determines that the disputed information is incorrect,
the PHA will update or delete the record from EIV.
Employment and wage information reported in EIV
originates from the employer. If you dispute this
information, contact the employer in writing to dispute
and request correction of the disputed employment
and/or wage information. Provide your PHA with a
copy of the letter that you sent to the employer. If you
are unable to get the employer to correct the
information, you should contact the SWA for
assistance.
Unemployment benefit information reported in EIV
originates from the SWA. If you dispute this
information, contact the SWA in writing to dispute and
request correction of the disputed unemployment
benefit information. Provide your PHA with a copy of
the letter that you sent to the SWA.
Death, SS and SSI benefit information reported in
EIV originates from the SSA. If you dispute this
information, contact the SSA at (800) 772–1213, or
visit their website at: www.socialsecurity.gov. You
may need to visit your local SSA office to have
disputed death information corrected.
Additional Verification. The PHA, with your consent,
may submit a third party verification form to the
provider (or reporter) of your income for completion
and submission to the PHA.
You may also provide the PHA with third party
documents (i.e. pay stubs, benefit award letters, bank
statements, etc.) which you may have in your
possession.
Identity Theft. Unknown EIV information to you can
be a sign of identity theft. Sometimes someone else
may use your SSN, either on purpose or by accident.
So, if you suspect someone is using your SSN, you
should check your Social Security records to ensure
your income is calculated correctly (call SSA at (800)
772-1213); file an identity theft complaint with your
local police department or the Federal Trade
Commission (call FTC at (877) 438-4338, or you may
visit their website at: http://www.ftc.gov). Provide your
PHA with a copy of your identity theft complaint.
Where can I obtain more information on EIV
and the income verification process?
Your PHA can provide you with additional information
on EIV and the income verification process. You may
also read more about EIV and the income verification
process on HUD’s Public and Indian Housing EIV web
pages at: http://www.hud.gov/offices/pih/programs/ph/rhiip/uiv.cfm.
The information in this Guide pertains to
applicants and participants (tenants) of the
following HUD-PIH rental assistance programs:
1. Public Housing (24 CFR 960); and
2. Section 8 Housing Choice Voucher (HCV),
(24 CFR 982); and
3. Section 8 Moderate Rehabilitation (24 CFR
882); and
4. Project-Based Voucher (24 CFR 983)
January 2010
February 2010
THIS SECTION FOR OFFICE USE ONLY
APP #: __________ DATE: __________________ TENANT #: __________
CERT #:_________ REVIEWED BY: ___________
HAP #: __________ TIME: __________
APPLICANT/TENANT CERTIFICATION
When completing this form, you MUST use the correct legal name for each member of your household as it appears on the
social security card. ALL adult members of the household must sign below certifying the information pertaining to them. If
completing by hand, PLEASE PRINT.
I. Household Composition: List all adults who will be living in your home, listing head of household first
Adults
18 and Older (Legal Name)
Date of
Birth
Relationship to
Head of
Household
Social Security
Number
Race
Hispanic
(Y or N)
Place of
Birth
(City/State)
List all children under 18 years of age who will be living in your home:
List names of children as they
appear on social security card
Date of
Birth
Relationship to
Head of
Household
Social Security
Number
Race
Hispanic
(Y or N)
Place of
Birth
(City/State)
Primary Contact Number: (_____) _____—__________ Secondary Contact Number: (_____) _____—__________
Current Address: ________________________________________________________________________________________
(Street Address) (City, State & Zip Code)
Mailing Address: ________________________________________________________________________________________
(Street Address) (City, State & Zip Code)
Please check box if you are homeless.
Are you, or any member of your household, subject to a lifetime sex offender registration requirement in any state?
Yes_____ No______
II. Assets: Please answer the following with either YES or NO:
(1) Do you or any member in your household own or have an interest in any real estate, boat, mobile home,
property, and/or commodity? ______ (2) Do you own any stocks or bonds? ______ (3) Do you have a savings
and/or checking account? ______ (4) Do you own a car? ______ (5) Do you own or have an interest in any income-
producing assets not listed above? ______
If the answer to any of the above is YES, please explain below:
_
_
_
_
_
III. Household Income: List all money earned or received by everyone living in your household; including: money from
wages, self-employment, child support, alimony, AFDC, social security, SSI, worker’s compensation, veterans benefits,
retirement benefits, pensions, unemployment benefits, baby-sitting, caring for others, stock dividends, income from
bank accounts, rental property income, music entertainment business, and all other sources of compensation.
Household Member
Amount Received
Weekly/Bi-weekly
Monthly
Type of Income
Please list employer, hourly rate, and whether you are a full or part-time employee:
Does anyone outside the household pay for any of your bills or give you money? _____
If yes, please provide the name and address of the person assisting you and what assistance you are receiving:
If you are receiving food stamps, please list the monthly dollar amount: $_________________
If you are getting TEA, please list your caseworker’s name: ________________________________________________
List your landlord’s name and telephone number: ________________________________________________________
If your children are attending school, list the school name and address:
Child’s Name School Name Address
Are you renting, renting to own, or do you own your home? ________________________________________________
Have you ever applied for or participated in a rental assistance program? _____________________________________
I, do hereby swear and attest, that all of the information above about me is true and correct. I understand that willful false
statements, misrepresentation of the facts, and failing to make a full disclosure of the information above are grounds for
termination.
Signature of Head of Household Date Signature of Spouse Date
Signature of other adult Date Signature of other adult Date
WARNING!! Title 18, Section 1001 of The United States Code, States that a person is guilty of a felony for knowingly and
willingly making false or fraudulent statements to any department or agency of the Unites States.
READ AND INITIAL THAT YOU UNDERSTAND
If you change your address after submitting an application, you MUST notify us in writing at: Fort Smith Housing Authority,
2100 N. 31
st
Street, Fort Smith, AR 72904. Returned mail due to an incorrect address will IMMEDIATELY terminate this
application!
INITIAL __________________ DATE _______________
Fort Smith Housing Authority
2100 North 31
st
Street
Fort Smith, Arkansas 72904
(479) 785-4881 FAX (479) 709-9381
1033b
SECTION 8 MODERATE REHAB PROGRAM
RENTAL ASSISTANCE
The Boardwalk apartment complex located at 4201 Kinkead is privately owned and has made
available its one, two and three bedroom apartments to families determined eligible for
participation in the rental assistance program by the Fort Smith Housing Authority.
The apartments rent unfurnished and they come equipped with air-conditioners, smoke alarms,
range, refrigerator, and dressing room. The apartments are gas heated, having wall furnaces or gas
central heating units, and the owner pays the gas and water expenses.
Boardwalk Apartments has a laundry room, security guard, parking facilities for tenants and
visitors, and a play area for small children.
If you are interested in leasing an apartment at Boardwalk, you must furnish the following
documentation which enables us to determine your eligibility.
1. PROOF OF ALL HOUSEHOLD INCOME (WAGES, LAST THREE (3) CONSECUTIVE
CHECK STUBS OR STATEMENT FROM THE EMPLOYER, SS, SSI, DONATIONS,
CONTRIBUTIONS, CHILD SUPPORT, FOOD STAMPS, ETC.). ALL INCOME
VERIFICATION MUST BE NO OLDER THAN SIXTY (60) DAYS
2. SOCIAL SECURITY CARDS & BIRTH CERTIFICATES FOR ALL HOUSEHOLD
MEMBERS
3. PICTURE ID FOR ALL ADULTS
4. MARRIAGE LICENSE IF MARRIED
5. MOST RECENT BANK STATEMENTS
You must apply for Boardwalk Apartments in person from 8:30am – 11:00am
or 1:00pm – 3:15pm, every weekday except Tuesday.
When eligibility is determined, you will be required to complete an application at the Boardwalk
apartment manager’s office located at 4301 Kinkead Apt. #8. The manager must approve your
application to lease an apartment at Boardwalk.
When a vacant apartment (of your particular bedroom size) becomes available, you will be
notified by Boardwalk to come in for an interim update and briefing session. You will then be
sent to the apartment manager to make the necessary arrangements to move into your apartment.
I HAVE READ THE ABOVE INFORMATION. I DO________ DO NOT_________ WISH
TO APPLY AT BOARDWALK APARTMENTS.
NAME: ____________________________________________________
DATE: _________________________
[This page has been intentionally left blank]
Fort Smith Housing Authority
2100 North 31
st
Street
Fort Smith, Arkansas 72904
(479) 782-4991 FAX (479) 782-0120
FORM 1103
AUTHORIZATION TO RELEASE INFORMATION
I authorize the Fort Smith Housing Authority to obtain information about me or my family that is
pertinent to eligibility for or participation in rental assistance programs.
Information covered: Inquiries may be made about:
Child Care Expenses Credit History
Criminal Activity Family Composition
Employment, Income, Pensions, & Assets Federal, State, Tribal, or Local Benefits
Handicapped Assistance Expenses Identity & Marital Status
Medical Expenses Social Security Numbers
Residences & Rental History Unemployment Compensation
Any individual or organizations that may release information
Any individual or organization including any Governmental organization may be asked to release
information. For example, information may be requested from:
Banks & other financial institutions
Courts, Law Enforcement Agencies
Credit Bureaus, Employers (past & present), Landlords
Providers of: alimony, child care, child support, credit, handicapped assistance, medical care,
pensions/ annuities, schools & colleges, utility companies, and welfare agencies.
The U.S. Social Security Administration and U.S. Department of Veterans Affairs
CONDITIONS
I agree that photo copies of this Authorization may be used for the purpose stated above. If
I do not sign this Authorization, I also understand that my housing assistance may be
denied or terminated.
_________________________________ ______________________________
Printed name of Head of Household Printed name of Spouse
____________________________________________ ________________________________________
Signature of Head of Household Date Signature of Spouse Date
____________________________________________ ________________________________________
Printed name of other adult Printed Name of other adult
____________________________________________ ________________________________________
Signature of other adult Date Signature of other adult Date
[This page has been intentionally left blank]
FORM 1086
IF THIS FORM IS NOT COMPLETED BY YOUR CURRENT LANDLORD AND RETURNED WITH YOUR
APPLICATION YOU WILL NOT BE ELIGIBLE TO GO PORTABLE DURING THE FIRST YEAR YOU ARE ON
HOUSING ASSISTANCE.
CERTIFICATION OF RENT
We are required by Federal regulations to verify the amount of rent charged and what utilities are paid
for directly by the applicant. Therefore, we would appreciate your completing the certification below on
behalf of the applicant. If you are renting, please have the Landlord complete the statement below.
I, ________________________________, hereby certify that __________________________________
applicant (s)
lives at _________________________________________, and is obligated to pay rent in the amount of
$___________ per ________ plus the following utilities: ______________________________________.
The housing was leased to: ______________________and _____________________ on ____________.
(head of household) (spouse) (month/day/year)
I certify the above to be a true and accurate statement.
Owner Telephone Number
Agent Date
CERTIFICATION OF RESIDENCE
We are required by Federal regulation to verify the place of residence on all applicants applying for
participation in the Section 8 Existing Housing Program. Therefore, we would appreciate your
completing the Certification below on behalf of the applicant. If you are living with parents, other
family members or friends, have them complete the statement below.
I, _________________________________, hereby certify that __________________________________
applicant (s)
lives at ____________________________________________. This has been his/her place of residence
since _____________.
(month/day/year)
I certify the above to be a true and accurate statement.
Signature of person certifying residency Date
Home Address
Telephone Number
WARNING!! Title 18, Section 1001 of The United States Code, States that a person is guilty of a felony
for knowingly and willingly making false or fraudulent statements to any department or agency of the
Unites States.
[This page has been intentionally left blank]
OMB Control # 2502-0581
Exp. (07/31/2012)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
Unable to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
Signature of Applicant
Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520).
The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing
providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for
occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of
providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the
tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as
confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management
controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection
of information, unless the collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will
be used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
[This page has been intentionally left blank]
Paperwork Reduction Notice: The information collection requirements contained in this notice have been approved by the
Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3520) and assigned OMB
control number 2577-0266. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and a
person is not required to respond to a collection of information unless the collection displays a current valid OMB control
number.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
Public Housing (24 CFR 960)
Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
Section 8 Moderate Rehabilitation (24 CFR 882)
Project-Based Voucher (24 CFR 983)
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is
maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights. PHAs are required to provide this notice to all applicants and program participants and you are
required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e. abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date.
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
OMB No. 2577-0266 Expires 04/30/2013
April 26, 2010
Form HUD-52675
2
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants. PHAs will be able to access this information to determine a
family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, your current rental assistance may be terminated and your future request for HUD rental assistance may be
denied for a period of up to ten years from the date you moved out of an assisted unit or were terminated from a HUD
rental assistance program.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD.
2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request.
What do I do if I dispute the debt or termination information reported about me?
You should contact the PHA, who has reported this information about you, in writing, if you disagree with the reported
information. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. Disputes must be made within three years
from the end of participation date. Otherwise the debt and termination information is presumed correct. Only the
PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status.
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature Date
Printed Name
OMB No. 2577-0266 Expires 04/30/2013
April 26, 2010
Form HUD-52675
Fort Smith / Sebastian County
Housing Authority
2100 North 31st Street
Fort Smith, AR 72904
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Fort Smith Housing Authority

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Completed 12 February 2022

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