Fillable Housing Assistance Fund Use of Funds Form Please (ACT)

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Housing Assistance Fund Use of Funds Form Please (ACT)

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The Housing Assistance Fund Use of Funds Form Please (ACT) form is 2 pages long and contains:

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  • 50 other fields

Country of origin: US
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Housing Assistance Fund
Use of Funds Form
Please fill out the following two pages along with standard Ryan White Client Intake Form and attach all necessary
supporting documentation. Failure to submit a complete application and required documentation may result in request
being denied and returned to applying case manager.
I. Personal Household Information
# of Adults in Household: ______________ Age(s) and race(s) of adults: ___________________________________
# of Adults identifying as Hispanic: _____________________________
# of Children in Household: ____________ Age(s) and race(s) of children: _________________________________
# of children identifying as Hispanic: ____________________________
Monthly rent payment: ________________ Net monthly Income: ________________ x 100 = ________________%
*Client must be within 40-80% of net to income ration in order to qualify for housing services
For example, $800 per month for rent, divided by $1,600 net monthly income x 100= 50%
II. Is the applicant currently receiving, on a waiting list or been denied for other forms of housing assistance
(indicate date or N/A)? Case managers must access all other available programs before applying to the HAF. Please
indicate the programs that have been applied to
Receiving (Date) Waiting List (Date) Ineligible (Date)
Section 8 _________________ _________________ _________________
RAP _________________ _________________ _________________
Shelter + Care _________________ _________________ _________________
211/CAN _________________ _________________ _________________
Other _________________ _________________ _________________
If the person is not currently receiving a subsidy or on a waiting list for other housing assistance, explain why:
Describe the steps to be taken by applicant to keep current housing affordable in the event that this assistance is
terminated:
Clearly describe the reason for arrearage (documentation should back up reason):
III. Please specify the use of funds requested.
A. First month’s rent Date (m/y): ____________________ Amount: ________________________
B. Ongoing rental assistance of $150 Date (m/y): ____________________ to Date (m/y): ____________________
C. Arrearage Date (m/y): ____________________ Amount: ________________________
Date (m/y): ____________________ Amount: ________________________
Total: ___________________________
D. One-Time Payment Reason: __________________________________________________________
Attach all of the following information. Applications without complete documentation will be denied.
Verification of income for all members of household.
Rental Verification Form signed by landlord/property manager which verifies tenancy.
For Arrearage: Statement from property owner/bank not to evict if payments are brought up to date.
Documentation to support request (if applicable).
Signatures: client signatures on release form, application form (below); case manager and supervisor signatures on
application form (below).
IV. Rental Unit/Landlord/ Manager Information (Person or agency to whom check will be made out)
Rental Unit Address: ________________________________________________________________________________
Name of Landlord/Manager: ________________________________________ Phone/Fax: ______________________
Mailing Address: ___________________________________________________________________________________
I acknowledge that all information contained in this application is true and correct to the best of my knowledge. I
authorize my case manager to discuss the information contained in this application with representatives of the Housing
Assistance Fund. I also promise to immediately inform my case manager of any and all changes to my income or housing
status.
Client Name (please print): ___________________________________________________________________________
Client Signature : _______________________________________________________ Date: _____________________
Case Manager Name (please print): _____________________________________________________________________
Case Manager Signature: _________________________________________________ Date: _____________________
Agency: ____________________________________ Phone: __________________ Fax: ______________________
Address: __________________________________________________________________________________________
Supervisor's Signature: __________________________________________________ Date: _____________________
Last Updated March 2019
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Housing Assistance Fund Use of Funds Form Please (ACT)

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Completed 8 February 2021

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