Quincy Housing Authority Form – Fill Out and Use This PDF

OFFICE USE ONLY		Quincy Housing Authority	Date
Control #____________		80 Clay Street	and
L NL	Min ______	Quincy, Mass. 02170	Time Stamp
BR _____	Priority____	617-847-4350
______________________
		Application for Housing

Incomplete applications will not be processed. Please complete all information requested on the application. If a question is not applicable, please write N/A. Make sure you sign the last page.

1.Applicant Name: _______________________________________________________________

2.Current Address: _______________________________________________________________

City: _________________________________________State:________ Zip Code: __________

3.Current Mailing Address: _________________________________________________________

4.	Home Phone: ( ) ____________________ Work Phone: ( ) _________________________
5.	Please provide the full name, including Maiden Names, and Middle Initial of all Household Members who

will be living in the unit.______________________________________________________________________

First	.Middle.	Last	.	Maiden	.Date of .	Place	.Sex. Relation to .	Social*
Name	Initial	Name		Name	Birth	of Birth	Head	Security

_________________________________________________________________________________Number__

You____________________________________________________________________Head______________

__________________________________________________________________________________________

_____________.____________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

*The Social Security Number will be used to verify income, assets, and criminal record information..

6.Racial Designation: Responding to this question is optional. Your status with respect to tenant selection procedures may be affected by this information. If anyone in your household is a Minority, you may classify your

household in that Minority category.			Circle One:	American Indian	Asian	Black White Hispanic
7.	Veteran’s Preference:
	Veteran Status: Circle One		Veteran	Non-Veteran
	Dates of Military Service:	From: _______________ To: _________________
8.	Do any of the Situations listed below apply to you? (Circle one)				YES	NO
If Yes, Please indicate which one:

-Homeless due to Displacement by Natural Forces.(Fire, Flood or Earthquake)

-Homeless due to Displacement by Public Action (Urban Renewal).

-Homeless due to Displacement by Public Action (Sanitary Code Violations).

-Emergency Case – Acute Medical Emergencies or Abusive Situations in accordance with the Emergency Case

Plan

8.a. What community were you displaced from: ______________________________.

8.b. Are you seeking local preference in Quincy. (Circle One) YES NO

9. Is there a member of your household who requires a wheelchair accessible unit?

Circle One

Yes

No

10. Income Data:

Employment: Household Member who is working: (Name) ______________________________________

Place of Employment: ___________________________________________________________

Salary: $_____________ circle one weekly, bi-weekly, monthly

Employment: If there is a 2nd Household member working, please complete:

Name of Worker: _______________________________________________________________

Place of Employment: ___________________________________________________________

Salary: $_____________ circle one weekly, bi-weekly monthly

Other Sources of Income: Please show monthly income from all sources, If zero, indicate -0-.

TAFDC	$_____________	V.A. Pension	$___________
Social Security	$_____________	Pension	$____________
Soc. Sec. Disability	$_____________	Child Support	$____________
Alimony	$_____________	Any Other Income $___________

11.List below all assets of all household members:

____________________________________________________________________________

Household	Type of	Bank	Value
Member	Asset
-____________________________________________________________________________
-____________________________________________________________________________
-____________________________________________________________________________

-____________________________________________________________________________

Have you or any household member sold or transferred any property in the last four years: Circle One: Yes No If yes, date of sale: _____________________________

Amount of Sale: $___________________ Mortgage Owed at the time of the sale: $_______________

Do you own a home or other real estate property now: (Circle one) YES NO

If YES, please describe, including location: _______________________________________________

12. Have you or any household member ever received housing assistance from this or any other housing agency or

group, including Public Housing, MRVP, DHP AHVP, 707 or Section 8. (Circle one) Yes	No
If yes: Name of household head at that time: ________________________________________
Address: _______________________________________________________________
Landlord Name: _______________________Phone number: _____________________
Landlord Address: _______________________________________________________
Agency Subsidy was through: _______________________________________________
Dates you received subsidy: FROM: _______________ TO: _____________________
Reason you moved out: ___________________________________________________

13.Are you a board member, employee, or a member of the immediate family of any employee or board member of this housing Authority

Yes

No

If yes, please explain: _________________________________

14.Please list the addresses of all residential settings (Apartments, houses, shelters, group homes, etc) in which you lived during the last five years. You should either list the landlord (owner) or Program Director. Please be sure you list dates of occupancy.

Current Address: __________________________________________________________________________

Landlord Name: ________________________________________ Phone Number _____________________

Landlord Address: _________________________________________________________________________

Dates of Occupancy: Moved in ________________ to Present

Please state why you wish to moved from this address: _____________________________________________

Previous Address: _________________________________________________________________________

Landlord Name: _______________________________________ Phone Number: _____________________

Landlord Address: _________________________________________________________________________

Dates of Occupancy: Moved in: _____________ to Moved Out ___________

Please state why you moved from this address: ___________________________________________________

Previous Address: _________________________________________________________________________

Landlord Name: ______________________________________ Phone Number: ______________________

Landlord Address: _________________________________________________________________________

Dates of Occupancy: _________Moved in: ____________to Moved-out : ____________

Please state why you moved from this address: ___________________________________________________

Previous Address: _________________________________________________________________________

Landlord Name:_______________________________________Phone Number: _______________________

Landlord Address: _________________________________________________________________________

Dates of Occupancy: __________ Moved in: __________ to Moved out: ____________

Please state why you moved from this address: ___________________________________________________

15. Have you or any household member ever lived outside Massachusetts.

Circle One

Yes

No

If yes, please list the member's name and the states resided.

Name: _____________________________

State(s) ________________________________________

IMPORTANT NOTICE: Please read carefully

The Quincy Housing Authority has been granted CORI access. All household members are therefore advised that a copy of their criminal history will be obtained from the Criminal History Systems Board before they are offered housing through the Quincy Housing Authority.

__________________________________________________________________________________________

16.The following question is for applicants who are applying for elderly/disabled housing where eligibility is based upon a household member having a disability.

Do you or a household member have an impairment that is expected to be of long- continued and indefinite duration which substantially impedes the ability to live independently and is of such a nature that the ability to live independently could be

improved by more suitable housing conditions? Circle One: Yes No

Note: Disability will be verified by the QHA in accordance with applicable regulations

__________________________________________________________________________________________

APPLICANT CERTIFICATION:

I understand this application is not a unit offer, until such time as the Authority informs me that I have been offered a unit pursuant to my application. Based on this application, I understand that I should not make any plans to move or terminate my present tenancy until I have received an offer from the Authority. I certify that the information I have given in the application is true and correct and that any false statements or misrepresentation may result in the denial of my application. I understand that it is my responsibility to inform the Quincy Housing Authority, in writing, of any change in address, income or household composition.

I hereby grant permission to the Quincy Housing Authority to inquire and obtain information about me and my family that is pertinent to eligibility for or participation in assisted housing programs, including credit investigation reports and criminal record information.

_____________________________________	________________________
Applicant Signature	Date

EQUAL HOUSING OPPORTUNITY

NOTICE OF RIGHT TO REASONABLE ACCOMMODATION

QUINCY HOUSING AUTHORITY

80 Clay Street, Quincy, Massachusetts 02170

(617) 847-4350

TDD NO. (800) 545-1833, EXT.115

If you have a disability and as a result of your disability you need . . .

a change in the rules or policies or how we do things that would give you an equal chance to live here and use the facilities or take part in programs on site,

a change or repair in your apartment or a special type of apartment that would give you an equal chance to live here and use the facilities or take part in programs on site,

a change or repair to some other part of the housing site that would give you an equal chance to live here and use the facilities or take part in programs on site,

A change in the way we communicate with you or give you information,

you may ask for this kind of change, which is called a REASONABLE ACCOMMODATION.

If you can show that have a disability and if your request for accommodation is reasonable (*does not pose “an undue financial or administrative burden”), we will try to make the changes you request.

We will give you an answer in thirty (30) days unless there is a problem getting the information we need or unless you agree to a longer time. We will let you know if we need more information or verification from you or if we would like to talk to you about other ways to meet your needs.

If we turn down your request, we will explain the reasons and you can give us more information if you think that will help.

If you need help filling out a REASONABLE ACCOMMODATION REQUEST FORM or if you want to give us your request in some other way, we will help you.

You can get a REASONABLE ACCOMMODATION REQUEST FORM from Kathleen Healy, Administrative Assistant, Quincy Housing Authority.

*In simple language this legal phrase means if it is not too expensive or too difficult to arrange.

Have you been a victim of domestic violence, dating violence or stalking? If so, you should know your rights as a public housing tenant.

The Housing Authority may not deny you admission to public housing solely because you or a household member are or have been a victim of domestic violence, dating violence or stalking.

The abuser's acts or threats of domestic violence, dating violence or stalking against you or a household member are not good cause for evicting you from public housing. You do not violate your lease if you or a household member has been the victim of acts of domestic violence, dating violence or stalking.

The Housing Authority cannot evict you from public housing on t he basis of criminal activity directly relating to domestic violence, dating violence or stalking against you or a household member, unless the Housing Authority can show there is an actual and immediate threat to the safety of other tenants or Housing Authority staff if you are not evicted.

If the abuser is a household member, the Housing Authority can evict your abuser for his or her acts of domestic violence, but (assuming you continue to qualify for public housing) it may not evict you or otherwise penalize you, unless (as described above) it can show there is an actual and imminent threat to the safety of other tenants or Housing Authority staff if you are not evicted.

The Housing Authority may evict you for serious or repeated lease violations that are unrelated to the domestic violence, dating violence or stalking against you, as long as it does not hold you to a more demanding set of rules than it applies to tenants who are no victims of domestic violence, dating violence or stalking.

The Housing Authority can ask you to prove, or "certify" that you or a household member is a victim of domestic violence, dating violence or stalking and thus entitled to the above rights.

If the Housing Authority asks you to certify that you or a household member are a victim of domestic violence, dating violence or stalking you must provide that certification within 14 business days of the request.

There are certain documents that the Housing Authority must accept as proof that you or a household member are a victim of domestic violence, dating, violence or stalking, including police or court records and certain statements from attorneys, medical professionals and domestic violence advocates. The Housing Authority also has discretion to accept any other kind of evidence that shows you or a household member are a victim of domestic violence, dating violence or stalking.

Specifically, any one of the following is sufficient proof that you or a household member are a victim of domestic violence, dating violence or stalking and entitled to the above rights:

A written, signed statement from a victim services provider that states under penalty of perjury that the provider believes the incidents in question were acts of domestic violence, dating violence or stalking against you or a household member and includes the name of the abuser. You or the household member must also sign the document.

A written, signed statement from a medical professional that states under penalty of perjury that the medical professional believes the incidents in question were acts of domestic violence, dating violence or stalking against you or a household member and includes the name of the abuser. You or the household must also sign the document.

A written, signed statement from an attorney that states under penalty of perjury that the attorney believes the incidents in question were acts of domestic violence, dating violence or stalking against you or a household member and includes the name of the abuser. You or the household member must also sign the document.

A police record that indicates that you or a household member was a victim of domestic violence, dating violence or stalking that names the abuser.

A court record (for example, a protective order) that indicates you or a household member was a victim of domestic violence, dating violence or stalking that names the abuser.

In general, the Housing Authority must keep confidential any information you or the household member provide about the violence against you or the household member unless you or the household member give permission for us to share the information with someone else. The Housing Authority may use this information, however, if it needs the information in a eviction proceeding (for example, in order to evict an abuser). A Housing Authority can also disclose this information if required to do so by law.