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WACO HOUSING AUTHORITY & AFFILIATES

Housing Assistance Application

Do Not Write In This Area - WHA USE ONLY







	Bedroom Size	Application No.

This form must be completed in your own handwriting.

PLEASE PRINT AND USE BLUE OR BLACK INK.

NAME

(HEAD OF HOUSEHOLD)

MAILING ADDRESS

CITY, STATE, ZIP

HOME PHONE NUMBER

WORK or OTHER PHONE NUMBER

APPLYING FOR:

( X ) Public Housing (Kate Ross, South Terrace, Estella Maxey)

RACE: (check all that apply to you)
( ) White ( ) Black/African	(	)	Hispanic	( ) American Indian or	( ) Hawaiian or ( ) Asian ( ) Other
				Alaskan	Other Pacific

PRINCIPAL LANGUAGE:	(	)	English	( ) Spanish	( ) Other

HOUSEHOLD MEMBERS

List all persons who will be living in your household, beginning with head of household at #1.

	LEGAL NAME	Relationship	Social Security	Occupation or		City & State of
No	LEGAL NAME	to Head of	Social Security	Occupation or	Date of Birth	City & State of	Age	Sex
No	(Must use correct legal name)	to Head of	Number	School Name	Date of Birth	Birth	Age	Sex
	(Must use correct legal name)	Household	Number	School Name		Birth
		Household
1		HOH

2

3

4

5

6

7

8

INCOME

List all income of household members listed ABOVE (including benefits for children) (Salary, Tips, Social Security, SSI, TANF, Food Stamps, Pensions, Child Support, etc.)

ONE SOURCE OF INCOME PER LINE

FAMILY MEMBER

SOURCE OF INCOME

(Job, SS, SSI, TANF, Individual, child

support)

AMOUNT

HOW OFTEN

(weekly, monthly, bi-monthly, etc.)

INCOME INFORMATION

				(These questions apply to all household members)	YES	NO
Has anyone in your household applied for any benefits or money which is in the process of being approved?

Does anyone outside of your household pay for any of your bills or expenses?

Are you entitled to	(	) Child Support	(	) Alimony ( ) Maintenance?

Do you receive	(	) Child Support	(	) Alimony ( ) Maintenance?

Does anyone in your household receive an educational scholarship or grant?

MONTHLY EXPENSES

(From preceding month)

Rent	Telephone	Medical	Credit Card

Electric	Auto Payment	Cable	Credit Card

Gas	Auto Insurance	Insurance	Loan

Water	Child Care	Rentals	Other

CHILDCARE EXPENSES

Do you pay childcare expenses?	( ) Yes	( ) No

If yes, list each child’s name below			Amount	Per (Month, Weekly, etc.)

HANDICAPPED ASSISTANCE EXPENSES

FAMILY MEMBER(S)

Amount

Per

(Month, Weekly, etc.)

Reason

MEDICAL AND UNUSUAL EXPENSES

ELDERLY FAMILIES ONLY

	Amount	Per (Month, Weekly, etc.)
Medicare

Other health insurance

Regular payments on medical bills

Regular payments for medicine

Anticipated healthcare related expenses in the next 12 months

Have you or anyone in your household ever owned a home or property?

( ) Yes

( ) No

ASSETS

List all assets of all “Household Members listed on page 1. (real estate, boats, mobile homes, etc.)

ASSETS	CASH VALUE

VEHICLES

How many vehicles does the family own?_________

Owner	Make	Model	Year	Color	License #	State

HOUSING AUTHORITY OF THE CITY OF WACO, TEXAS

LOCAL PREFERENCE CLAIM FORM

For Public Housing and Section 8 Applicants

READ CAREFULLY AND CHECK ONLY THE PREFERENCES THAT APPLY TO YOU.

∙VETERAN’S PREFERENCE:

The head of household and/or spouse is currently a member of the Armed Forces, or the head of the household and/or spouse has an honorable discharge from the Armed Forces.

In the case of a divorce or legal separation, the head of the household or former spouse must provide the Waco Housing

Authority with documentation that the head or spouse has rights to benefits; there is no right to the veteran’s preference.

∙EMPLOYMENT PREFERENCE:

Families whose head of household or spouse is employed.

Families whose head of household or spouse has been given a bona fide offer of employment.

This preference does not require a minimum of income, but the family’s annual income cannot exceed current very low income guidelines by HUD. Must have a minimum of 20 working hours a week for Section 8 and 24 hours a week for Public Housing

No minimum length of time is required for the head or spouse to be employed. After move-in the employment must continue for twelve (12) months or longer.

∙ELDERLY:

Head of Household or Spouse is 62 years of age or older.

∙DISABLED AND HANDICAPPED HEAD OF HOUSEHOLD:

This preference only applies to the Head of Household.

∙JOB TRAINING / SCHOOL PREFERENCE:

The head of household or spouse is currently enrolled and participating in a job-training program that prepares them for entering or re-entering the job market.

Families where the head of household or spouse is a graduate of a job-training program that prepared them for entering or re-entering the job market.

Head of Household is currently enrolled in educational programs working toward a degree. Must be a full-time student (twelve hours or more) or give verifiable justification for carrying a lesser number of hours.

∙DOMESTIC VIOLENCE PREFERENCE:

Household annual income cannot exceed current income guidelines by HUD

Must be certified by the Family Abuse Center that provides shelter or counseling to victims of domestic violence.

The Housing Authority shall determine that the domestic violence occurred recently (within 1 year) or is of a continuing nature.

The applicant shall certify that the person who engaged in such violence will not reside with the family unless Housing Authority has advance written approval.

The Housing Authority may deny or terminate assistance to the family for breach of certification.

FOR PUBLIC HOUSING RESIDENTS ONLY

TARGET UP AND OUT:

For families living in Public Housing who wish to move into the private sector and receive rental assistance through the

Section-8 Program, and participate in the home ownership program. Families must meet the following guidelines:

1.Families must have resided in public housing a minimum of one year, and participate in the Family Self-Sufficiency Program.

2.The family must participate in a job training program or attend an institution of higher learning or must maintain an earned income for a minimum of one year.

3.Families must be crime and drug free. This includes all persons on the lease.

4.Families must have a record of timely rent payments, for a twelve (12) month period. No balances left from month to month. Rent must be paid on or before the 5th of each month.

5.All school-age children must be attending school regularly. School verification with authorized signature.

6.Families must have established a pattern of keeping their apartment and premises clean both inside and outside with no graffiti. This includes roof, yard, stairways and porches.

7.Must be in good standing with Public Housing at time of transfer.

8.Development managers must certify that the families have met the requirements.

I understand that my application is not a determination of eligibility for assisted housing / public housing. I will not immediately be offered housing, but will be placed on a Waiting List with other applicants, who may claim and/or are entitled to LOCAL PREFERENCE. The eventual extension of housing benefits will be based upon my place on the waiting list.

/	/
Social Security Number			Applicant Signature		Date

EMERGENCY CONTACT

NAME

ADDRESS

PHONE NUMBER(S)

RELATIONSHIP

	PERSONAL REFERENCES
	(relatives, close friends, employers, Pastor, neighbors, etc.)
NAME		PHONE NUMBER

ADDRESS		RELATIONSHIP


NAME		PHONE NUMBER

ADDRESS		RELATIONSHIP


NAME		PHONE NUMBER

ADDRESS		RELATIONSHIP

RESIDENCE HISTORY

(List where you have lived for at least the last three years beginning with where you live now)

(If you live with someone else that pays the rent or owns the property, list that person as your landlord)

CURRENT STREET ADDRESS	MOVE-IN DATE		CURRENT RENT

CURRENT LANDLORD NAME	CURRENT LANDLORD’S PHONE NUMBER


PREVIOUS ADDRESS	MOVE-IN DATE	MOVE-OUT DATE	RENT

LANDLORD NAME	LANDLORD’S PHONE	NUMBER


PREVIOUS ADDRESS	MOVE-IN DATE	MOVE-OUT DATE	RENT

LANDLORD NAME	LANDLORD’S PHONE	NUMBER

BANKING INFORMATION

List banking information for all “Household Members” listed on page 1. (checking, savings, credit union shares, annuities, stocks, bonds, CD’s, etc.)

Name of Financial Institution	Type of Account	Current Balance

	CREDIT HISTORY

CREDITOR		PHONE NUMBER

ADDRESS		CREDIT TYPE (loan, credit card, car payment, etc.)


CREDITOR		PHONE NUMBER

ADDRESS		CREDIT TYPE (loan, credit card, car payment, etc.)

INPUT CLERK:

DATE:

PROGRAM INTEGRITY INFORMATION

(These questions apply to all household members) (All questions must be answered)

HAVE YOU, YOUR SPOUSE, OR ANY HOUSEHOLD MEMBER LISTED ON YOUR APPLICATION:

YES

Been evicted or asked to move out of any rental property?
If yes, Who?	Where?	When?

Broken a rental agreement or lease contract?
If yes, Who?	Where?	When?

Been sued for nonpayment of rent?
If yes, Who?	Where?	When?

Been sued for damage to rental property?
If yes, Who?	Where?	When?

Been arrested for criminal activity?
If yes, Who?	Where?	When?

Been convicted of a crime?
If yes, Who?	Where?	When?

Been arrested and/or convicted for the use, sale, manufacture, or distribution of any controlled substance?
If yes, Who?	Where?	When?

Lived in Subsidized Housing (Public Housing, Section 8, etc.)?
If yes, Who?	Where?	When?

Been evicted from Public or Assisted housing for violent criminal or drug related activity?
If yes, Who?	Where?	When?

Used a name other than the one you are using now?
If yes, what name?

Used a social security number other than the one listed above?
If yes, what is it?


DO YOU, YOUR SPOUSE, OR ANY HOUSEHOLD MEMBERS LISTED ON YOUR APPLICATION:			YES	NO


Currently use a controlled substance or illegal drug?
If yes, explain

Owe money to a Public or Assisted Housing Agency?
If yes, Who?	What Agency?

Have any relatives (by blood or marriage) who are now an employee of Waco Housing Authority?

If yes, Who?

Are you or anyone listed on your application a registered sex offender?

Does anyone listed on page 1 as a “Household Member” claim mobility, visual or hearing impairment, or other special need which would require a special type of unit or other accommodation?

If yes, please describe:

Do you expect anyone to move in or out of your household within the next 12 months?

If yes, explain:

Does anyone live with you now that is not listed on page 1?

If yes, who?

Do you have any pets?

If yes, what kind?

AUTHORIZATIONS, REPRESENTATIONS AND CERTIFICATIONS

I/We do hereby authorize the Waco Housing Authority to release information regarding any of the following information for purposes of verifying information on my/our apartment rental application. I understand that previous or current information regarding me/us may be needed. Verifications made may include any of the groups or individuals as defined below. I/We understand that this authorization cannot be used to obtain information about me/us that is not pertinent to my eligibility for and continued participations as a qualified tenant.

	Groups or Individuals that may be asked:
Past and present employers	Welfare Agencies	Veterans Administration
Support & Alimony Providers	State Unemployment	Retirement Systems
Educational Institutions	Social Security Administration	Medical & Child Care Providers
Banks & other financial Institutions	Previous Landlords (including	Criminal History
Tenant Tracker	Public Housing Agencies)	Texas Dept. of Transportation

I understand that any misrepresentation of information or failure to disclose information requested on this application may disqualify me from consideration for admission or participation, and may be grounds for eviction or termination of assistance.

WARNING: Title 18, Section 1001 of the U.S. 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 or the Department of Housing and Urban Development.

NOTICE: Any attempt to obtain Public Housing, any rent subsidy or rent reduction by false information, impersonation, failure to disclose or other fraud, and any act of assistance to such attempt is a crime under Federal Law.

SIGNATURE

Head of Household, as listed on page 1 of this application, must sign below certifying that the information on this application is

true and correct.

Signature of Head of Household						Date
Drivers License #:			State:

The back page of this application will be given to you after your application is checked over. There is important information on both sides of this page. Please initial below to show receipt of this information.

I acknowledge receipt of the notice, “Reasonable

Accommodations for Applicants with Disabilities.”

(Please initial, this is for page 7 of this application)

Initials _____________ Date ____________

I acknowledge receipt of the HUD notice,

“Things You Should Know” about fraud.

(Please initial, this is for page 8 of this application)

Initials _____________ Date ____________

Notice to all Applicants:

Reasonable Accommodations for Applicants with Disabilities

The Housing Authority is a public agency that provides low rent housing to eligible families including Families with children, elderly families, disabled families, and single people. PHA is not permitted to

discriminate against applicants on the basis of their race, religion, sex, color, national origin, age, disability, or familial status. In addition, PHA has a legal obligation to provide “reasonable accommodations” to

applicants if they or any family members have a disability. A reasonable accommodation is a structural change a PHA can make to its units or common areas, or a modification of a rule, policy, procedure, or

service, that will assist an otherwise eligible applicant or resident with a disability to make effective use of a PHA’s programs. Examples of reasonable accommodations would include:

Making alterations to a PHA unit so it could be used by a family member with a wheelchair;

Adding or altering unit features so they may be used by a family member with a disability;

Installing strobe type flashing light smoke detectors in an apartment for a family with a hearing impaired member;

Permitting a family to have a large dog to assist a family member with a disability in a PHA Family development where the size of dogs is usually limited;

Making a large type of documents, Braille documents, cassettes or reader available to an applicant with vision impairment during the application process;

Making a sign language interpreter available to an applicant with a hearing impairment during the interview or meetings with PHA staff;

Permitting an outside agency or individual to assist an applicant with a disability to meet the PHA’s applicant screening criteria.

An applicant family that has a member with a disability must still be able to meet essential obligations of tenancy. They must be able to pay rent, to care for their apartment, to report required information to the Housing Authority, to avoid disturbing their neighbors, etc., but there is no requirement that they be able to do these things without assistance.

If you or a member of your family have a disability and think you might need or want a reasonable accommodation, you may request it at any time in the application process or at any time you need an accommodation. This is up to you. If you would prefer not to discuss your situation with the housing authority, that is your right.

Things You

Should Know

Don't risk your chances for Federally assisted housing by providing false, incomplete, or inaccurate information on your application forms.

	This is to inform you that there is certain information you must provide when applying for assisted housing. There are
Purpose	penalties that apply if you knowingly omit information or give false information.
Purpose

Penalties	The United States Department of Housing and Urban Development (HUD) places a high priority on preventing fraud. If your
for	application or recertification forms contain false or incomplete information, you may be:
Committing	O	Evicted from your apartment or house
Fraud	O	Evicted from your apartment or house
Fraud	O	Required to repay all overpaid rental assistance you received
	O
	O	Fined up to $10,000
	O	Imprisoned for up to 5 years
	O	Prohibited from receiving future assistance
	Your State and local governments may have other laws and penalties as well.
Asking	When you fill out your application, you should know what is expected of you. If you do not understand something, say so.
Questions	Ask questions.
Completing	When you give your answers to application questions, you must include the following information:
The
Application

OAll sources of money you or any member of your household receive (wages, welfare payments, alimony, social

Income	security, pension, etc.)

OAny money you receive on behalf of your children (child support, social security for children, etc.)

OIncome from assets (interest from a savings account, credit union, or certificate of deposit - dividends from stock, etc.)

OEarnings from second job or part time job

OAny anticipated income (such as a bonus or pay raise you expect to receive)

Assets

Family/household Members

Signing the

Application

OAll bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that are owned by you and any adult member of your family’s household who will be living with you

OAny business or asset you sold in the last 2 years for less than its full value, such as your home to your children

OThe names of all of the people (adults and children) who will actually be living with you, whether or not they are related to you

ODo not sign any form unless you have read it, understand it, and are sure everything is complete and accurate.

OWhen you sign the application and certification forms, you are claiming that they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information.

OInformation you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State or private agencies to verify that it is correct.

You must provide updated information at least once a year. Some programs require that you report any changes in income or

Recertifications family/household composition immediately. Be sure to ask when you must recertify. You must report on recertification forms:

OAll income changes, such as pay increases and/or benefits, change or loss of job and/or benefits, etc., for all household members

OAny move in or out of a household member

OAll assets that you or your family/household members own and any assets that were sold in the last 2 years for less than their full value

Beware of	You should be aware of the following fraud schemes:
Fraud	O Do not pay any money to file an application
	O Do not pay any money to file an application
	O Do not pay any money to move up on the waiting list
	O Do not pay for anything not covered by your lease
	O Get a receipt for any money you pay
	O Get a written explanation if you are required to pay any money other than rent (such as maintenance charges)

Reporting Abuse

If you are aware of anyone who has falsified an application, or if anyone tries to persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible, then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline (800) 347- 3735. You can also write to: HUD-OIG HOTLINE, (GFI), 451 Seventh Street, S.W., Washington, DC. 20410.

Question	Answer
Form Name	WACO Housing Authority Application Form
Form Length	3 pages
Fillable?	Yes
Fillable fields	108
Avg. time to fill out	22 min 25 sec
Other names	wacopha, housing authority waco texas, housing waco tx, waco housing

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