Mbq Voucher Program Form – Fill Out and Use This PDF

Baltimore Housing Mobility Program

20 South Charles Street, Suite 801

Baltimore, Maryland 21201

410-223-2222

www.brhp.org

Preliminary Application Packet Instructions

Checklist

Use this checklist to keep track of each item you need to do. This will help you avoid having your application returned or delayed for not being complete.

☐The Head of Household (HOH) must fill in and sign the PRELIMINARY APPLICATION, pages 1-3.

☐Read and sign the SUPPLEMENTAL AUTHORIZATION FOR THE RELEASE OF INFORMATION, page 5.

☐Read and sign the AUTHORIZATION FOR THE RELEASE OF INFORMATION/ PRIVACY ACT NOTICE,

pages 7-8.

☐Fill in the optional SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING form if the

HOH would like the Program to have another contact person on file, or check the box on the form to choose not to provide the contact information. See page 9.

☐Mail or bring the completed forms to the Baltimore Regional Housing Partnership,

20 S. Charles Street, Suite 801, Baltimore, MD, 21201. Office hours are Monday through Friday 8:30 am to 5:00 pm.

General Information

•The Program will not process an incomplete application. Check that you have answered all the questions.

•You will receive a letter after the Program processes your application to notify you if you are eligible or not for placement on the wait list. Due to the Wait List closing on March 31, 2017, it may take 120 to 180 days to get your letter.

•If your contact information changes, you must fill out a CHANGE OF ADDRESS FORM. You can find the form at www.brhp.org. You can also get the form at our front desk.

•After two tries to reach an applicant at the last known address, the Program will withdraw your application. You will not be able to reapply unless the wait list reopens.

•For more information, or if you are disabled and need assistance, call 410-223-2222.

REV010617

The Baltimore Regional Housing Partnership is an equal housing opportunity provider.

PRELIMINARY APPLICATION

Baltimore Housing Mobility Program

The Baltimore Housing Mobility Program places all qualified applicants on the wait list in the order received. The Program selects applicants from the wait list based on the Thompson v. HUD Settlement Agreement. Applicants chosen from the wait list complete counseling workshops and need to meet all Program requirements before getting a Housing Choice Voucher.

	1	Head of Household Information
		Fill in or check the required information for the Head of Household.
	Name
	Home Address
	City		State	Zip Code
	Mailing Address
	City		State	Zip Code
	Phone		Cell Phone
	Email

Race:	□ American Indian/Alaska Native	Ethnicity:	□ Hispanic or Latino
	□ Asian		□ Not Hispanic or Latino

□Black/African American

□Native Hawaiian/Pacific Islander

□White

Do you have a disability?	□ Yes	□ No
Do you require a special accommodation or service to communicate with	□ Yes	□ No
the Program?

2	Wait List Eligibility
	Check an answer for each.
I live in Housing Authority of Baltimore City (HABC) family public housing.		□ Yes	□ No
I lived in HABC family public housing between January 31, 1995, and present.		□ Yes	□ No
I was displaced from closed or torn down HABC family public housing.		□ Yes	□ No
I am on the HABC family public housing or Housing Choice Voucher wait list.		□ Yes	□ No
I live in Baltimore City. BRHP will check if you live in an eligible area.		□ Yes	□ No

Baltimore Housing Mobility Program | 20 South Charles Street, Suite 801 | Baltimore, Maryland | 21201

Page 1 of 9

PRELIMINARY APPLICATION

3Other Information

Check an answer for each.

Are you a current public housing resident with a prior application for a	□ Yes	□ No
Housing Choice Voucher or a pending transfer request?
Do you have an urgent need to relocate? If yes, check all that apply:	□ Yes	□ No

☐Documented health condition of a family member

☐Need for housing closer to place of employment, education or training

☐Other:

Do you have children under the age of 18 living in your household? If yes,	□ Yes □ No
check all that apply:
☐ Head of Household is employed
☐ Head of Household is willing to participate in a job-training program
☐ Head of Household is age 62 or older, or is a person with disabilities

	4	Household Composition
		Fill in or check the required information for each household member.

Last Name
First Name
Social Security #		_ _ _ - _ _ - _ _ _ _		_ _ _ - _ _ - _ _ _ _		_ _ _ - _ _ - _ _ _ _
Date of Birth		_ _ / _ _ / _ _ _ _		_ _ / _ _ / _ _ _ _		_ _ / _ _ / _ _ _ _
Sex		□ M	□ F	□ M	□ F	□ M	□ F
Relationship to
Head of		Self
Household
		Other Member 3		Other Member 4		Other Member 5
Last Name
First Name
Social Security #		_ _ _ - _ _ - _ _ _ _		_ _ _ - _ _ - _ _ _ _		_ _ _ - _ _ - _ _ _ _
Date of Birth		_ _ / _ _ / _ _ _ _		_ _ / _ _ / _ _ _ _		_ _ / _ _ / _ _ _ _
Sex		□ M	□ F	□ M	□ F	□ M	□ F
Relationship to
Head of
Household
Page 2 of 9	The Baltimore Regional Housing Partnership is an equal housing opportunity provider.

SUPPLEMENTAL AUTHORIZATION FOR RELEASE OF INFORMATION

Baltimore Housing Mobility Program

The purpose of this form and your signature(s) is to obtain information about you and your family that is pertinent to the administration of the Baltimore Housing Mobility Program and to determine initial eligibility or continued eligibility for participation in the Program.

The Program may request information from any listed entity or provider of:

ACADEMIC INSTITUTION	FEDERAL GOVERNMENT AGENCY	RETIREMENT BENEFITS
CHILD SUPPORT AGENCY	FINANCIAL INSTITUTION	STATE GOVERNMENT AGENCY
COURT AWARD	LANDLORD	STUDENT FINANCIAL AID
CREDIT REPORTING AGENCY	LAW ENFORCEMENT AGENCY	TRIBAL BENEFITS
CRIMINAL BACKGROUND CHECK	LOCAL GOVERNMENT AGENCY	UTILITY COMPANY
EMPLOYMENT	PENSION

Required Signatures

Your signature below authorizes the Baltimore Regional Housing Partnership to obtain your credit report. Under the Fair Credit Reporting Act, you must be told if information in your credit report has been used against you. If that happens, the Baltimore Regional Housing Partnership will provide you with the name, address, and phone number of the agency that provided the credit information.

I agree that photocopies of this authorization may be used for the purposes stated above.

If I, or any adult member of my family, fail to sign this form, I understand that this action may constitute grounds for denial of eligibility or termination of assistance of tenancy, or both.

______________________________________________________________________________

Signature of Head of HouseholdDate

______________________________________________________________________________

Signature of Adult Household MemberDate

______________________________________________________________________________

Signature of Adult Household MemberDate

______________________________________________________________________________

Signature of Adult Household Member	Date
	REV052616

Baltimore Housing Mobility Program | 20 South Charles Street, Suite 801 | Baltimore, Maryland | 21201

Page 5 of 9

	Authorization for the Release of Information/	U.S. Department of Housing
		and Urban Development
	Privacy Act Notice
		Office of Public and Indian Housing
	to the U.S. Department of Housing and Urban Development (HUD)	OMB CONTROL NUMBER: 2501-0014
	and the Housing Agency/Authority (HA)	exp. 07/31/2017

Original is retained by the requesting organization.	ref. Handbooks 7420.7, 7420.8, & 7465.1	form HUD-9886 (07/14)

Preliminary Application Packet

Page 7 of 9

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

Signatures:
_____________________________________________	______________
Head of Household	Date
___________________________________________		__________________________________________________	________________
Social Security Number (if any) of Head of Household		Other Family Member over age 18	Date
__________________________________________________	_______________	__________________________________________________	________________
Spouse	Date	Other Family Member over age 18	Date
__________________________________________________	_______________	__________________________________________________	________________
Other Family Member over age 18	Date	Other Family Member over age 18	Date
__________________________________________________	_______________	__________________________________________________	________________
Other Family Member over age 18	Date	Other Family Member over age 18	Date

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully 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, the HA or the owner responsible for the unauthorized disclosure or improper use.

Original is retained by the requesting organization.	ref. Handbooks 7420.7, 7420.8, & 7465.1	form HUD-9886 (07/14)

Page 8 of 9