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 |
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______________________ |
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Application for Housing |
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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 |
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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: |
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Veteran Status: Circle One |
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Veteran |
Non-Veteran |
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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: |
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-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?
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 |
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-____________________________________________________________________________ |
-____________________________________________________________________________ |
-____________________________________________________________________________ |
-____________________________________________________________________________
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: ________________________________________ |
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Address: _______________________________________________________________ |
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Landlord Name: _______________________Phone number: _____________________ |
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Landlord Address: _______________________________________________________ |
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Agency Subsidy was through: _______________________________________________ |
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Dates you received subsidy: FROM: _______________ TO: _____________________ |
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Reason you moved out: ___________________________________________________ |
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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.
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
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 here 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)
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.
