Fillable RECERTIFICATION CHECKLIST YOU MUST PROVIDE COPIES OF EACH (City of Garland)

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RECERTIFICATION CHECKLIST YOU MUST PROVIDE COPIES OF EACH (City of Garland)

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RECERTIFICATION CHECKLIST
YOU MUST PROVIDE COPIES OF EACH ITEM ON THE CHECKLIST BELOW & BRING TO YOUR APPOINTMENT.
BIRTH CERTIFICATES AND SOCIAL SECURITY CARDS for all new members of the household (related or
not). If the birth certificates are not in English, please have them translated and notarized. All adults must provide
current photo identification. If any member’s name has changed, provide documentation.
FOODSTAMPS & TANF. Bring letter, no older than 30 days, from the Department of Human Services showing the
amount of benefits you receive.
BENEFITS. Bring current verification if any household member receives any benefits from Social security, Veterans,
retirement, unemployment, workman’s comp, etc. Any benefit received must be verified. Call 1-800-772-1213 to request
a printout of your monthly SS and SSI benefits.
EMPLOYMENT. Provide your last 4 paycheck stubs and your employer’s name address, and phone number.
ASSETS. If any member of the household has a checking or savings account, please bring a current statement with you.
Or if you own stocks, CD’s, or bonds, bring current statements showing the balances of the assets.
CHILD SUPPORT. Provide your CIN number or a current verification from the Attorney General’s office showing the
amount of support received monthly if any.
CHILD CARE EXPENSES. Provide last 4 receipts of payment, and your childcare providers name, address, and
LEASE. Provide a copy of your current or renewed lease.
UTILITY BILLS. Provide a copy of your recent electric, gas, and water bills.
PROVIDE A COPY OF YOUR FILED TAX RETURN FOR CURRENT TAX YEAR. This includes your W2’s,
1040, EIC, Schedule A and any other forms for deduction claimed.
MEDICAL EXPENSES. (FOR ELDERLY AND DISABLED FAMILIES ONLY)
Provide receipts for the medical/dental expenses that you have already paid for the past 12 months.
EACH MEMBER OF THE HOUSEHOLD AGE 18 AND OLDER THAT IS NOT IN SCHOOL OR WORKING, MUST
ATTEND THIS APPOINTMENT. YOU MUST PROVIDE PROOF OF STUDENT STATUS; THAT INCLUDES SCHOOL
NAME AND ADDRESS. (Report card or college transcript)
IF YOU NEED SPECIAL ACCOMODATIONS DUE TO YOUR/FAMILY MEMBER’S DISABILITY SUCH AS A HOME
VISIT, LIVE IN AIDE, ADDITIONAL/SEPARATE BEDROOM YOU MUST COMPLETE A REQUEST FOR SPECIAL
ACCOMMODATION FORM & PROVIDE A DOCTOR’S STATEMENT
RELOCATION PROCESS
GHA PARTICIPANTS ARE ONLY ALLOWED TO MOVE AT ANNUAL RECERTIFICATION
1. Provide the case manager with a copy of your move out notice at your appointment. Your notice must have your
landlord’s signature or proof that it was sent certified mail. Please check your lease expiration date to ensure that you are
not breaking the lease. Make sure the notice states the specific date you will vacate the unit, date of notice, unit address,
and your signature.
2. Inform the inspector that you will be moving, so he can check for damages. If it has already passed inspection and you’ve
completed step 1, you will receive your voucher estimates and voucher at your appointment. Otherwise your will need to
call the case manager to schedule another appointment, to get your relocation paperwork.
3. DO NOT SIGN ANY NEW LEASES, MAKE DEPOSITS, OR PICK UP ANY KEYS TO FOR A NEW UNIT, UNTIL
YOU HAVE DISCUSSED THIS MATTER WITH YOUR CASE MANAGER
You cannot be given voucher estimates over the phone. The estimates must be calculated; an appointment is necessary.
COMPLETE THE ENCLOSED APPLICATION AND BRING WITH YOU TO YOUR APPOINTMENT
(SOILED/STAINED DOCUMENTS WILL NOT BE ACCEPTED)
APPLICATION FOR RE-CERTIFICATION
Section 8 Housing Choice Voucher Program
Limited English Proficiency:
Do you require oral and/or written information in any language other than English? Yes No
If yes, which language: ____________________________. Contact your housing representative.
If no, continue.
Use the correct legal name for each person who will reside in the same unit exactly as it appears on his/her
Social Security card. All persons age 18 and over must sign this application certifying the information
pertaining to them is correct. Do not leave any section of the application blank. If a section does not apply to
you, write N/A in it.
Applicant Name: _____________________________________________________________________
Current Address: __________________________________________________Apt. No. ____________
City ____ _______ State: ___ Zip: _______________
Home Phone #: _ Work Phone #_______________ Cell Phone #: ___________________
Email address: ___________________________________________________________________________
Emergency Contact Information Name: _____________________________________________________
Address: ____________________________________________________________________________
City ____ ______ State: ___ Zip: ________
Home Phone #: _ Work Phone #_______________ Cell Phone #: ___________________
Email address: ___________________________________________________________________________
Social Security Number: Is any household member’s current legal name different than the name on his/her
Social Security card?
Yes No
If yes, contact the Social Security office immediately to obtain a corrected card with your current legal name.
Has any adult member ever used any name(s) or Social Security number(s) other than the one you are
currently using?
Yes No
If yes explain ___________________________________________________
PAGE 1 OF 8
RE-CERTIFICATION APPLICATION – Section 8 Housing Choice Voucher Program
I. HOUSEHOLD COMPOSITION (list all persons who will stay in the apartment)
*Participants are not required to disclose being disabled. However, benefits for which persons with disabilities are entitled
cannot be provided unless the participant discloses being disabled.
Adults (age 18 and older)
Last
Social Security #
Relation
to Head
S
e
x
Race
and
Ethnicity
Birth Date Age
Disabled*
Yes/No
Student
Yes/No
List most recent date
Employed
Received
TANF
HEAD
First MI
Last
First MI
Last
First MI
Minors (Under Age 18)
Last
Social Security
#
Relation
to
Head
S
e
x
Race/
Ethnicity Birth Date Age
Disabled*
Y/N
Name/Address of Absent Parent
(if applicable)
First MI
Last
First MI
Last
First MI
Last
First MI
PAGE 2 OF 8
Additional Family Members:
Adults (age 18 and older)
Last
Social Security #
Relation
to Head
S
e
x
Race
and
Ethnicity
Birth
Date
Age
Disabled*
Yes/No
Student
Yes/No
If Under 18:
Name/Address of Absent Parent
(if applicable)
List most recent date
Employed
Received
TANF
First MI
Last
First MI
Last
First MI
Last
First MI
Last
First MI
Last
First MI
Last
First MI
Last
First MI
Last
First MI
PAGE 3 OF 8
I. Household Composition continued
1. Is any household member over age 18 a full time student (other than head of household or spouse of
head of household or co-head)?
Yes No
If yes, list name and the school they attend.
Full-Time Students: List the family member name and school name, address and phone number of all
family Members who are attending school full time:
a. Name of Family Member
School Name:
School Address:
School Telephone Number:
School FAX Number:
a. Name of Family Member
School Name:
School Address:
School Telephone Number:
School FAX Number:
a. Name of Family Member
School Name:
School Address:
School Telephone Number:
School FAX Number:
2. Does anyone in your household require special accommodations due to a handicap or disability?
Yes No
If yes, specify requirements: ______________________________________
4. Does any elderly or disabled household member require a Live-in Aid? Yes No
PAGE 4 OF 8
II. INCOME AVAILABLE TO HOUSEHOLD
List all income earned or received by everyone living in the household regardless of age.
List gross amounts of income (before deductions).
Income Source
Yes
No
Family Member
Source
Amount
Wages or Earnings
$
$
TANF
$
Pension or Retirement
$
$
SSI
$
$
Social Security
$
$
Child Support
$
$
Unemployment Benefits
$
$
Worker’s Compensation
$
$
Alimony
$
Military Income
$
Regular Contributions or
Gifts
$
$
Self Employed (lawn care,
hair stylist, baby sitting,
adult care, etc.)
$
Temp. / Sporadic Income $
Cyclical or Seasonal Work
$
Student Financial Assistance
(such as)
Scholarships
Grants
Work study
$
$
$
Lump Sum Payments $
Food Stamps $
Veterans Administration $
PAGE 5 OF 8
Previous Year’s Tax Return. Indicate the amount of the gross income shown by each family member
(other than minors) residing in your household who submitted an individual or joint Federal Income Tax Return.
Taxpayer Date of Return Gross Income
Taxpayer Date of Return Gross Income
Taxpayer Date of Return Gross Income
1. Does anyone outside the household help with bills on a regular basis? Yes No
2. If yes, list name of each person or agency that assists with bills:
a. ________________________________________________________
b. ________________________________________________________
c. ________________________________________________________
3. If reporting zero income, how much is your rent and utilities? $_________
4. Do you have a car? Yes No. If Yes, how do you make the payments? ____________________
Does someone make the car payments for you? Yes No. If Yes, who? ____________________
III. QUALIFYING FOR THE EARNED INCOME EXCLUSION (If there is not a disabled adult in the
household, Skip to section IV ASSETS)
1. Has any disabled adult household member started a new job or had an increase in earnings since the
last certification?
Yes No. If Yes, who? __________________ If No, skip to Section IV Assets.
2. How much did the person listed above earn in the 12 months immediately before their increased
earnings or new employment? $_______. Where was the previous employment? _________________
3. Did the person listed above receive TANF Benefits at any time in the six (6) months before this
employment or increase earnings began?
Yes No. When? _____________________________
4. Was the employed person participating in a self-sufficiency or job training program at the time they
started this job or received an increase in earnings?
Yes No. If Yes, list the training program
and dates of enrollment: ______________________________________________________________
IV. ASSETS
1. Does any household member listed have assets or receive income from assets? Check all that apply to
household.
Type Asset
Type Asset
Real Estate Yes No Checking Account Yes No
Stocks
Yes No
Savings Account
Yes No
Bonds
Yes No
Certificate(s) of Deposit
Yes No
Company Retirement or Pension Fund
Yes No
Trusts
Yes No
Insurance Settlements
Yes No
Other
Yes No
PAGE 6 OF 8
■
2. Has any asset been given away or sold for less than its fair market value in the past 2 years? Yes No
If yes, what? _________________________________________________________________________
What was its market value? $ __________. How much did you receive? $ __________
3. How much interest or other income have you received from assets? $____________
V. MEDICAL AND DISABILITY ASSISTANCE
1. List all medical expenses the family anticipates paying during the next 12 months that will NOT be
reimbursed by insurance or other outside source. Do NOT include life or burial insurance premiums.
(Complete only if the Head of household or Spouse is disabled or is 62 years of age or older.)
TYPE OF EXPENSE AMOUNT TYPE OF EXPENSE AMOUNT
Medical insurance(s) $ Doctor's Visits $_______________
Prescription medicine(s) $ $_______________
__________________________ $ ___________ $_______________
__________________________ $ ___________ $_______________
2. Do you pay for attendant care or auxiliary apparatus for a disabled household member in order for them or
any other family member to work?
Yes No
If yes, Itemize:
a. ________________________________________________________
b. ________________________________________________________
c. ________________________________________________________
VI. CHILD CARE
1. Do you pay for Child Care for children age 12 or younger while you work, attend school, or seek
employment? __ If yes, to whom are expenses paid? _________________________ ___
How much per month? ________
2. Address of Child Care provider: _________________________________________________________
Phone number of Child Care Provider _______________
3. What amount is reimbursed? ___________________________ Source: ________________________
VII. ADDITIONAL INFORMATION
1. Did you fail to report any income received by any members of your household during the past twelve (12)
months to this Housing Agency?
Yes No. If yes, list below the amounts of unreported income.
$________________ Source: Name_____________________ Address ___________________________
2. Answer the following questions only if you are requesting a transfer or remaining in place.
A. Are you current with your share of the rent to the landlord? Yes No
If not, explain _______________________________________________________________________
B. Are all utilities (gas, electricity, water) on in your unit today? Yes No
C. Who is your utility company and the account number? _____________________________________
PAGE 7 OF 8
All information provided on this application and at the interview is subject to verification. All family
members age 18 or over should review the information on this form, the Federal Privacy Act, and all
required releases which MUST be signed in order to be considered for housing.
By my signature below, I do hereby swear and attest that all information on this application is true and correct.
I understand that I must report any changes in income, assets, family composition, address, or phone number
to the Housing Authority within 14 days of such change for my application to remain valid. By my signature, I
grant permission for the Housing Authority to verify information necessary to determine my eligibility and
suitability for housing. I further understand that false statements or information are grounds for denial of this
application.
__________________________
Signature of Head of Household Date
___________________________
Signature of Spouse of Head of Household or 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 UNITED STATES.
If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll-free hot line at 1-800-669-9777.
I certify that the Housing Representative has explained every section of this application to the family and
that Garland Housing Agency will verify all information provided by the family.
_____________________________________ _____________________________
Housing Representative Date
PAGE 8 OF 8
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RECERTIFICATION CHECKLIST YOU MUST PROVIDE COPIES OF EACH (City of Garland)

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Completed 3 August 2020

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