Fillable Iowa Finance Authority (IFA) APPLICATION FOR HCBS RENT

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Iowa Finance Authority (IFA) APPLICATION FOR HCBS RENT

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The Iowa Finance Authority (IFA) APPLICATION FOR HCBS RENT form is 5 pages long and contains:

  • 3 signatures
  • 31 check-boxes
  • 77 other fields

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File type: PDF

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Page 1
Application for HCBS Rent Subsidy (Effective 1/1/2021)
Iowa Finance Authority
Iowa Finance Authority (IFA)
APPLICATION FOR HCBS RENT
SUBSIDY
Date received by IFA:
1. Please type or print the following information and mark the correct boxes.
This application is: New Application Annual Renewal Change of Information
2. Applicant Information
First Name Last Name
Social Security # Date of birth
Address Line 1
Address Line 2
City Zip
County Phone #
Email
3. Income Information
Amount of income anticipated each
month during the next 12 months
4. Rental Unit Information
Date moved in
Total monthly rent
for entire unit
Number of bedrooms
in unit
Number of additional
qualified dependents (as
claimed by the applicant
for federal tax purposes)
Additional Household Member Date of Birth Relationship
5. HCBS Waiver Information
Does the applicant participate in Money Follows the Person (MFP)? Yes No
Does the applicant participate in one of the HCBS Waiver programs? Yes No
Does the applicant participate in the Habilitation Waiver program? Yes No
If MFP or Habilitation waiver, documentation verifying participation
must be attached
(If the answer to all three questions is “No”, STOP now and do not submit this application).
Page 2
Application for HCBS Rent Subsidy (Effective 1/1/2021)
Iowa Finance Authority
6. Case Manager Contact Information
First Name Last Name
Email Organization
Phone # Fax #
Address Line 1
Address Line 2
City State
Zip
7. Legal Guardian Information (if applicable) - Proof of Guardianship or POA may be
requested
First Name Last Name
Relationship to
Applicant
Phone #
Address Line 1 Address Line 2
City State
Zip Email
8. Correspondence Directed To: At least one email address other than the applicant
MUST be provided!
All correspondence relating to initial
approval or denial, renewal notices,
policy changes, etc. will be sent to the
applicant. In addition, the applicant
elects that correspondence also be
directed to one or more of the following
individuals:
Applicant Legal Guardian
Case Manager Payee
If the recipient will receive payments
by direct deposit, check to indicate one
or two individuals who should receive a
monthly email telling when payments
have been released from Iowa Finance
Authority.
Check ONE or TWO
Applicant Legal Guardian
Case Manager Payee
Email if not already on application:
Phone if not already on application:
9. Payee Information – complete if different from applicant
Organization
Name,
if applicable
Phone #
Contact Name Address
City State
Zip Email
10. Rent Subsidy Information
Has applicant received any other rent subsidy in the
past six months?
Yes No
If yes, please explain who provided that subsidy and
why it was cancelled
Is applicant currently on wait list for HCV/Section 8
program?
Yes No
If yes, please provide which housing authority can
verify wait list status or submit documentation
showing active status.
I understand that in order to remain eligible for the HCBS rent subsidy program it is
a requirement to sign up for section 8/HCV wait list and follow through with all
appointments/letters when offered. I will communicate with IFA regarding any changes
regarding section 8, including proof of application and/or determination of (in)eligibility for
section 8/HCV as provided by the housing authority.
Signature
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of
the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use
of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any
person who knowingly or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a
misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek
other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions
for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42
U.S.C. 408 (a) (6), (7) and (8)
Page 3
Application for HCBS Rent Subsidy (Effective 1/1/2021)
Iowa Finance Authority
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Page 4
Application for HCBS Rent Subsidy (Effective 1/1/2021)
Iowa Finance Authority
11. Declaration
I, the undersigned, declare the following:
1) The information in this application is true to the best of my knowledge;
2) I believe the applicant meets the requirements of the program;
3) The application is not submitted with the intent to gain financial assistance to
which the applicant is not eligible;
4) I understand the requirement to notify IFA within ten (10) working days if
income changes by more than $100/month or if any other information from the
application form changes.
5) Failure to notify IFA of changes or the making of false statements may result in
repayment of the amount that was received while ineligible, and/or termination
of rental assistance;
6) I understand that abusive or threatening language or behavior toward IFA staff
may result in termination of subsidy; and
7) Iowa Finance Authority quality assurance measures for this program will include
audits of the information provided.
Printed Name Signature
Date
Relationship to
Applicant
Self Case Manager Legal Guardian Other, specify
Please provide phone number and/or email if not already provided in application:
I will be responsible for repaying any overpayment that may occur as a result of not
reporting such changes within ten (10) working days, or before the next payment is
sent:
Printed Name Signature
Date Email
Relationship
to Applicant
Self Case Manager Legal Guardian Other, specify
Please provide phone number if not already provided in application:
12. Electronic Funds Transfer Information
Routing
Number
Your account
number
Account type Checking Savings
Bank Name
Send completed application and attachments to: HCBSIFA@IowaFinance.com OR
Iowa Finance Authority
HCBS Rent Subsidy Program
1963 Bell Ave, Ste. 200
Des Moines, IA 50315
Because applicants are added to the waiting list based on when a completed application with
all required attachments is received by our office, it is to your benefit to submit the
application and documentation by email.
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Page 5
Application for HCBS Rent Subsidy (Effective 1/1/2021)
Iowa Finance Authority
SELF CHECKLIST
I have included the following documents in this order:
Application form, marked correctly at top of page 1 – MUST include an email address
for at least one person other than the applicant to ensure that important email
notices are received.
Income Verification to include entire SS/SSI award letter or bank statement showing
direct deposits of SS/SSI funds, pension statements, wage reports from most recent
three months if applicable, as well as verification of any other income
Copy of lease showing applicant as tenant, number of bedrooms in unit, rent amount
for the entire unit, and signed by the landlord as well as the applicant or the
applicant’s legal guardian
Documentation dated within the last 12 months verifying that applicant has applied
for Section 8 Rental Assistance administered by the local public housing authority.
Acceptable documentation would include one or more of the following:
1. Copies of ongoing correspondence with the Public Housing Authority (PHA) (dated
within the last 12 months)
2. Notice from PHA that you have been placed on a waiting list showing your number
on the wait list or the approximate wait time
a. Call during annual renewal to determine if you (your family) remains on the
waiting list
b. Note the answer, the name of the person to whom you spoke, date and time of
call, and attach to copy of wait list letter
c. If you find you have been dropped from wait list, provide an explanation of
why, and reapply for that rent assistance as soon as possible.
3. Notice from PHA that waiting list is closed and written statement of intent to apply
when re-opens.
It is the responsibility of the applicant and all representatives to monitor the local
public housing authority for times when Section 8 applications will be accepted. If
the waiting list opens, the applicant, or their representative, is expected to submit an
application during the time period when the PHA accepts applications.
Documentation verifying participation in Money Follows the Person or Habilitation
waiver if applicable - IFA can verify participation in the other waiver programs.
PLEASE NOTE: If the applicant obtains eligibility
for any other local, state or federal rent subsidy,
IFA must be notified within 10 working days. The
HCBS rent subsidy is a temporary subsidy and is
only available to the applicant until such time that
the applicant becomes eligible for any other local,
state or federal rent subsidy.
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Iowa Finance Authority (IFA) APPLICATION FOR HCBS RENT

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Completed 27 January 2021

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