Nycha Annual Recertification – Fill Out and Use This PDF

NEW YORK CITY HOUSING AUTHORITY

SECTION 8 HOUSING CHOICE VOUCHER PROGRAM

AFFIDAVIT OF INCOME – ANNUAL RECERTIFICATION PACKET

PLEASE READ THE ENTIRE ATTACHED INSTRUCTION BOOKLET BEFORE

COMPLETING THE ENCLOSED AFFIDAVIT OF INCOME

INSTRUCTIONS FOR COMPLETING AFFIDAVIT OF INCOME – SECTION 8 PROGRAM

DO NOT RETURN THESE INSTRUCTIONS WITH THE AFFIDAVIT OF INCOME DOCUMENTS.

Dear Tenant(s):

The Law requires you to verify your income and family composition each year to establish your eligibility to receive Section 8 rental assistance and to determine your share of the rent. You must answer all questions and complete all forms that apply to you and all

occupants of your apartment. If you FAIL to submit these forms the Housing Authority will start termination of subsidy action to suspend your Section 8 subsidy. Use the following guidelines when completing the Afidavit of Income. Please contact the Customer Contact Center at (718) 707-7771 if you have any questions.

LANGUAGE INFORMATION: Answer “Yes or No” and if no, check the appropriate box containing the language that applies. If no choice is appropriate, check “Other” and print the language that applies.

FAMILY COMPOSITION: List all persons in apartment, their relationship to the head of household (and co-head) using the relationship codes, Social Security Numbers, dates of birth. You must answer “Yes or No” for disabled and U.S. citizenship status.

EMPLOYMENT: You must answer “Yes or No”. List all household members who have a job. Include employment income for the last 12 months. Include income from wages, tips, commission and bonuses from all employers, not just the present one. Submit “Verification of Employment” form (enclosed) filled out by each employer and a copy of the previous year’s W-2 form for each household member who was employed. Include the full name, address and telephone number of employer(s).

SELF EMPLOYMENT: You must answer “Yes or No”. If you or any member of your household own a business, or have partial interest in

a business, you must include the ownership percentage (example: 100% ownership). Include name of business, gross receipts, net profit,

amount of personal drawings from the business, full address of business and telephone number. Unemployment Benefits: You must answer “Yes or No”. If yes, include name of recipient, last date of employment and the gross amount of unemployment benefits. Attach documentation to Affidavit showing proof of unemployment benefits.

SOCIAL SECURITY & SSI INCOME: You must answer “Yes or No”. If yes, list all household members, including minors, who receive this income. You must list the total monthly gross benefit amounts.

PUBLIC ASSISTANCE INCOME: You must answer “Yes or No” to both questions. If yes, list all household members who receive Public Assistance benefits. Include the case ID number and the total amount of benefits received each month.

CHILD SUPPORT/ALIMONY: You must answer “Yes or No”. If yes, list all household members who receive child support or alimony payments. Include total amounts received per week or per month. List the full name, address and telephone number of the income source provider. Submit copies of legal documents for anyone receiving child support or alimony.

CONTRIBUTIONS: You must answer “Yes or No”. If yes, list all household members who receive contributions from an outside source. List all contributions and non-cash items (such as groceries, clothing, etc). . List the full name, address and telephone number of the income source provider. Attach all documentation to the Affidavit.

PENSION/ANNUITY: You must answer “Yes or No”. If yes, list all household members who receive pension or annuity income. List full name and address of institution. Include total gross income amounts and attach a copy of the most recent statement.

NYCHA 059.612 (Rev. 7/10) & Reverse

MILITARY PAY / VETERAN’S ADMINISTRATION: You must answer “Yes or No”. If yes, list all household members who receive a Military Allotment or Veteran’s Administration income. List total gross amount and attach copy of documentation to Affidavit.

WORKER’S COMPENSATION: You must answer “Yes or No”. If yes, list all household members who receive Worker’s Compensation. Include the last day of employment and total gross benefit amount Attach copy of latest compensation statement.

STUDENT: You must answer “Yes or No”. If yes, list all household members who are students 18 years old or older. In addition, answer “Yes or No” if the student is a veteran, married, unmarried with dependent children. You must list the school’s name, address & telephone number. Attach proof of full-time or part-time status for each student 18 years old and older.

UTILITY: You must answer “Yes or No”. If yes, provide the name of the Utility Company, type(s) of service and account number

SEX OFFENDER REGISTRATION: You must answer “Yes or No”. If yes, provide name and State of sex offender.

EMERGENCY CONTACT: List the full name, address and telephone number of a relative or friend in case of an emergency.

TENANT SIGNATURE CERTIFICATION: You and your spouse / co-head must sign and date the Affidavit of Income. Failure to sign the Affidavit will delay or result in termination of your Section 8 subsidy.

CHILD CARE EXPENSES: You must answer “Yes or No” to all questions. If yes, you must list the names of all children currently living in your apartment that are 12 years old or younger for which child care expenses are unreimbursed to you. You must list the full name of each child care provider, if an individual or the name of the agency providing the child care service. Include the full address, contact person and telephone number for each child care provider listed. You must attach a notarized statement from the child care service provider listing the names of each child, total hours and the total amount child care expenses paid for services.

MEDICAL/DISABILITY ASSISTANCE EXPENSES: You must answer “Yes or No” to all questions. If yes, you must list all household members in your apartment who pay for Medicare, medical insurance. Include any anticipated medical expenses for the next 12 months and payments on past medical bills and disability assistance equipment. Include all disabled household members who have entered or re-entered the workforce after being unemployed for one or more years.

DECLARATION OF ASSETS: You must answer “Yes or No” to all questions. If yes, list all household members who have checking accounts, savings accounts, stocks, bonds, money market funds, certificate of deposits, trust funds, retirement accounts, life insurance policies, insurance settlements, inheritance, lottery winnings or any lump sum payments. List each individual type of account and include the account numbers for each. You must also list any type of ownership in real estate, house, cooperatives (co-op), or condominiums (condo). Print the full name of the financial institution for each account along with the address and telephone number. You must also attach a copy of the most recent financial statement for each account/assets listed on your Affidavit. If you have a passbook account, attach a copy of the current passbook page. You and your spouse/co-head must sign and date this form. Failure to sign this form will delay your recertification.

Also, if you answer yes to the question regarding the sale or disposal of assets in the past two years, list the name of each person who has sold or given away assets during the two year period, the type of asset, the date the asset was sold or given away, the total sale price, and the actual market value of the asset at the time of sale or disposal.

AFFIRMATION OF NON-EMPLOYMENT: All household members who are 18 years old or older, not working and not in school full time, must complete and sign this form.

DISABILITY STATUS AND NOTICE OF REASONABLE ACCOMMODATION: Check box 1 (Section A) and sign if no one in your household is disabled. Check box 1 (Section B) and sign if someone in your household is disabled and is not requesting the Housing Authority to provide a reasonable accommodation at this time, or, check box 2 (Section B) and sign if a household member(s) is disabled and is requesting the Housing Authority to provide a reasonable accommodation. If a reasonable accommodation is being requested, you must describe the specific type of accommodation in the space provided on the form.

THIRD PARTY VERIFICATION – CONSENT TO RELEASE INFORMATION: All household members 18 years old or older must complete and sign the Third Party Verification – Consent to Release of Information form enclosed. By signing this form you and members of your household are authorizing the New York City Housing Authority to obtain income information and the verification of expenses related to deductions directly from third party sources. Failure to provide the required signatures on this form shall result in termination of Section 8 subsidy.

ETHNICITY STATEMENT: The New York City Housing Authority is required by HUD to report the Race and Ethnicity of all Section 8 participants. You must indicate the Race and Ethnicity for your household on this form. Print your full name, address and social security number at the bottom of the Ethnicity Statement form.

VERIFICATION OF EMPLOYMENT: All household members 18 years old or older who are currently employed must have this form filled out and signed by their employer only. This form must be returned to the Housing Authority with the Affidavit.

NYCHA 059.612 (Rev. 7/10) – Reverse