Fillable Penn Terrace Pre Application Packet (CITY OF INDEPENDENCE, KANSAS)

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Penn Terrace Pre Application Packet (CITY OF INDEPENDENCE, KANSAS)

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Administrative Offices | 811 W. Laurel | Independence, KS 67301 Penn Terrace Apartments | 401 South Penn | Independence, KS 67301
PHONE | 620-332-2536 * FAX | 620-331-5701 PHONE | 620-331-1678 * FAX | 620-331-4998
www.independenceks.gov
We wish to thank you for your interest in Penn Terrace Apartments, located in Independence, Kansas.
We are a 99-unit, HUD Section 8 Subsidy Apartment Complex for Seniors 62 and older or disabled
persons aged 18-49 or disabled persons aged 50-61, in that order.
Our apartments are conveniently located just 3 blocks from the downtown area with a private parking
lot for residents.
Penn Terrace Apartments is owned by the City of Independence and is managed by the Independence
Housing Authority.
Enclosed you will find information about our apartments with floor plans and a brief description of
inclusions. Also included is a preliminary application for occupancy and a HUD-92006 Contact form,
both of which you will need to fill out and return to Penn Terrace Apartments. After receiving the
application your name will be placed on a waiting list for occupancy.
If we may be of further assistance, please contact us at the address and/or telephone number below.
Again, thank you for inquiring about Penn Terrace Apartments and we look forward to serving you.
Kim Stevenson
Penn Terrace Apartments
Things You Should Know
Don't risk your chances for federally assisted housing by providing false, incomplete, or inaccurate information on your application forms.
Purpose
This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if
you knowingly omit information or give false information.
Penalties for Committing Fraud
The United States Department of Housing and Urban Development (HUD) places a high priority on preventing fraud. If your application or
recertification forms contain false or incomplete information, you may be:
Evicted from your apartment or house:
Required to repay all overpaid rental assistance you received:
Fined:
Imprisoned; and/or
Prohibited from receiving future assistance.
Your State and local governments may have other laws and penalties as well.
Asking Questions
When you meet with the person who is to fill out your application, you should know what is expected of you. If you do not under stand
something, ask for clarification. That person can answer your question or find out what the answer is.
Completing The Application
When you answer application question s, you must include the following information:
Income
All sources of money you or any member of your household receives (wages. welfare payments, alimony, social security, pension, etc.):
Any money you receive on behalf of your children (child support, social security for children, etc.);
Income from assets (interest from a savings account, credit union, or certificate of deposit: dividends from stock, annuity, etc.);
Earnings from second job or par t time job;
Any anticipated in come (such as a bon us or pay raise you expect to receive)
Assets
All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that are owned by you and any adult member of your
family's household who will be living with you.
Any business or asset you sold in the last 2 year s for less than its full value, such as your home to your children.
The names of all of the people (adults and children) who will actually be living with you, whether or not they are r elated to you.
Signing the Application
Do not sign any form unless you have read it, understand it, and are sure everything is complete and accurate.
When you sign the application and certification for ms, you are claiming that they are complete to the best of your knowledge and belief.
You are committing fraud if you sign a form knowing that it contains false or misleading information.
Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the
income you report with various Federal, State, or private agencies to verify that it is correct.
Recertifications
You must provide updated in formation at least once a year. Some programs require that you report any changes in income or
family/household composition immediately. Be sure to ask when you must recertify. You must report on recertification forms:
All in come changes, such as increases of pay and/or benefits, change or loss of job and/or benefits, etc., for all household members.
Any move in or out of a household member; and,
All assets that you or your household member s own and any assets that was sold in the last 2 years for less than its full value.
1 of 2
Beware of Fraud
You should be aware of the following fraud schemes:
Do not pay any money to file an application;
Do not pay any money to move up on the waiting list;
Do not pay for anything not covered by your lease;
Get a receipt for any money you pa y; and,
Get a written explanation if you are required to pay for anything other than r en t (such as maintenance charges).
Items Needed During Application Process:
Current Driver License or Identification Card
We will need to see your current Driver License or Identification Card, Prior to moving into Penn Terrace if you
lived in another state you will need to get a license or identification card that is issued by the State of Kansas.
Birth Certificates
You must bring a Certified Birth Certificate, of each person who will be residing in the household. If there is not a
Birth Certificate available, you must apply for a Certified Copy of Birth Certificate from the state in which you were
born. If your Birth Certificate could not be obtain for various reasons you will need to ask for further instructions.
Social Security Cards
A Social Security card is REQUIRED FOR EVERY MEMBER of the household. We cannot accept a copy of any
social security card; we must see the original card. If you have lost your card call Social Security Administration and
request an application form to replace the lost card(s). Also we must receive a copy of the application for
replacement.
Full Time Students
If any members of the household are 18 years of age or older and still attend school full-time, bring information about
where they go to school.
Handicap or Disability
If any member of the household is handicapped or disabled, bring documentation stating handicap or Disability and
what accommodation is needed. Also any information about any income the member receives because of his/her
handicap.
Income/Assets
Bring information about any of the following Income/Assets:
1. 3-6 Statements, 3-6 Pay Check Stubs
2. Addresses and Phone Number of all contacts
Expenses
Bring information about any of the following expenses:
1. Medical expenses not covered by insurance (age 62 & over families only)
2. Medical insurance premiums or amounts deducted from your pay for medical insurance.
(Age 62 & over families only)
3. Child care expenses to care for your child (ren) while you work.
4. Expenses to care for a handicapped or disabled family member while you work.
5. Addresses and Phone Number of all contacts 2 of 2
PRE-APPLICATION/WAITING LIST OFFICE USE ONLY
Please complete & return to: Date:_________Time:_________
Penn Terrace Apartments Rec’d by:___________________
401 S Penn Ave Independence, KS 67301
P: 620-331-1678 | E: pennterrace@independenceks.gov
This pre-application is used to request placement on the waiting list for Penn Terrace Apartments: high-rise
apartments, subsidized with Section 8, for person(s) 62 years and older OR non-elderly disabled persons who
are 18-49 years of age OR near-elderly disabled persons who are 50-61 years of age, in that order. Income
requirements apply. To apply, completely fill out each section of this application. Do not leave any question
blank.
1. Household Composition. List the Head of Household and all other members living in the unit. If your mailing
address or phone number changes, please notify the Penn Terrace office immediately.
Full Name (First, Middle, Last)
Relation
to H.O.H.
SSN
Age
Sex
Marital Status
Self
____________________________________________________________________________________________
Mailing Address City State Zip
____________________________________________________________________________________________
Address where you are currently living City State Zip
(if different from mailing address from above)
____________________________________________________________________________________________
Home phone Cell Phone Email
1b. Pets. Do you have a pet? ⬜ No OR ⬜ Cat ⬜ Dog Breed:__________________ Weight: ___________
2. Current Living Situation & Accessibility. Answer the following in regards to your current living & housing
situation.
2b. Which of the following best describes your current
living situation:
⬜ I own my place of residence. ⬜ I rent my place of residence.
⬜ I am living with friends or family. ⬜ Other: __________________________________________
2c. Do you need a handicap-accessible unit: ⬜Yes ⬜ No
3. Income.
3a. What is the household’s total
monthly income? Include gross
income from all household members
before any deductions (such as
Medicare).
$__________________________
3b.Household income source(s). Check all that apply.
⬜ Wages ⬜ Social Security/SSI ⬜ Child Support ⬜ Alimony
⬜ Disability ⬜ Public Assistance ⬜ Unemployment ⬜ Pension
⬜ Annuity Income ⬜ Someone pays my bills/gives me money
⬜Self Employment ⬜ Other: ______________________________
3c. If employed, name of employer: _____________________________________________________________
4. Assets.
4a. What is the household’s total
value of all allowable assets? Include
cash value of all household member’s
assets.
$___________________________
4b. Household assets. Check all that apply.
⬜ Checking ⬜ Savings ⬜ CDs ⬜ Money Market Funds
⬜ IRA, 401(k) or retirement accounts ⬜ Annuities
⬜ Stocks, Savings Bonds or Treasury Bills ⬜Trust Funds
⬜ Whole of Universal Life Insurance ⬜ Real Estate
⬜ Cash on hand or in safety deposit box ⬜ Prepaid debit card
⬜ Assets held in another state or foreign country
⬜Other: ___________________________________________________
5. Medical Expenses- for Seniors 62 and older ONLY.
Only medical expenses that have recurring monthly payments
are allowable.
5b. What is the household’s TOTAL
monthly medical expenses?
$___________________________
5c. Household Medical expenses. Check all that apply.
⬜ Medicare ⬜ Medicare supplement (Medigap)
⬜ Medicare Part D (Prescription drug coverage)
⬜ Prescription drug copays ⬜ Public Assistance (HCBS, etc.)
⬜ Long-term care insurance ⬜ Medical bills on a payment plan
⬜Other:_____________________ ⬜ Other: ____________________
6. Background Information. Please check yes or not to all questions. You may provide an explanation for any or
all of your answers by attaching it to this application.
Have you or any household members been convicted of a felony in the last 10 years? ⬜Yes ⬜No
Do you or any household members currently have an outstanding felony charge that has not been settled in a court
of law? ⬜Yes ⬜No
Are you or any members of your household currently subject to a state sex-offender registration law? ⬜Yes ⬜No
Have you or any household members ever filed bankruptcy? ⬜Yes ⬜No
Have you or any household members ever been evicted from another rental unit? ⬜Yes ⬜No
Have you or any household members ever left a rental unit still owing rent or money for damages? ⬜Yes ⬜No
CERTIFICATION OF APPLICANT: I hereby certify that the information provided in this application is true
& accurate. I understand that providing false information may result in my application being cancelled or
denied. I understand that at the time I rise to the top of the waiting list, I will be required to verify the
information I have provided here. I accept the responsibility for keeping Penn Terrace Apartments informed of
my current address and I understand that my application may be cancelled if I fail to do so.
__________________________________________________________________________________________
Signature of Head of Household Date Signature of Spouse or Co-H.O.H. Date
OMB Control # 2502-0581
Exp. (
02/28/2019)
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)
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Penn Terrace Pre Application Packet (CITY OF INDEPENDENCE, KANSAS)

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