1. No category

FOR OFFICE USE ONLY 11/ 16
Date :
Application Number:
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ORLANDO HOUSING AUTHORITY
PUBLIC HOUSING/ ADMISSIONS APPLICATION
Name (First)_ _ _ _ _Middle_ _ _ _ _ _ _ _ _ Last Name._ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _Apt. #_ _ _ _ _ _ _ _ _ __
City _ _ _ _ _ _ _ _ _ _ _ _ _ _ State._ _ _ _ _ _ _ __
Phone# (
Zip Code._ _ _ _ _ _ _ __
---------Work/Message Phone#_ (
Email Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I
NAME OF PERSON WE MAY CONTACT IF WE CANNOT REACH YOU:
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NAME
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RELATIONSHW
0 Yes 0
•
Do you Speak English?
•
Name of English Speaking Contact person (IF AVAILABLE):
I
NAME
ADDRESS
TELEPHONE NUMBER
No If not what language do you speak?_ _ _ _ _ _ _ _ _ __
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RELATIONSHIP
ADDRESS
TELEPHONE NUMBER
HOUSEHOLD COMPOSITION· (LIST ALL PERSON INCLUDING YOURSELF WHO WILL BE PART OF THE HOUSEHOLD)
'
Member No.
Last
'
Name of Family Member (List Head First
First
Middle
Social
Security#
123-45-6789
Relation
to Head
Date of
Birth
0110112016
Age
Sex
DISABLED
YIN
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Do you expect changes in the number of person in your household o Yes o No If yes e x p l a i n , - - - - - - - - - Is any member of the household a full time student over 18 years of age? o Yes o No If yes, list n a m e s : - - - - - - - *Race
(May use more than one)
*RACE CODE
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax: (407) 894·7172 • TDD#: 407/894-9891 • Relay#: 711
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•This information is required, for statistical purposes only, so the Department of Housing and Urban Development (HUD) may determine the degree to which minority families utilize
its programs. The General Counsel of HUD has ruled that the regulation issued on behalf of the Secretary requiring collection of racial and ethnic data has the force and effect of law
and takes precedence over any conflicting State or Local requirements.
EARNED INCOME FOR ALL HOUSEHOLD MEMBERS: (LIST BOTH FULL AND/OR PART TIME EMPLOYMENT AND/OR INCOME FROM SELF-EMPLOYMENT)
HOUSEHOLD MEMBER NAME
NAME AND ADDRESS OF EMPLOYER
GROSS EARNINGS
Per year:$
Per year:$
Per year:$
OTHER SOURCES OF INCOME FOR ALL HOUSEHOLD MEMMBERS: (EXAMPLE: MFTP, GA, SOCIAL SECURITY, SSI DISABILITY COMPENSATION,
ALIMONY CHILD SUPPORT DIVIDENDS PENSIONS TRUST FUNDS ANNUITIES INCOME FROM RENTAL PROPERTY AND ARMED FORCES RESERVES)
'
'
'
'
'
'
'
SOURCE
HOUSEHOLD MEMBER
GROSS EARNINGS
$
Per Year
$
Per Year
$
Per Year
ASSETS OF ALL HOUSEHOLD MEMBERS: (EXAMPLE, SAVINGS AND CHECKING ACCOUNTS, SAVINGS CERTIFICATES, CREDIT UNION SHARES, MONEY
MARKET FUNDS STOCKS BONDS IRA ACCOUNT)
'
'
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NAME AND ADDRESS OF BANK/FINANCIAL INSTITUTION
HOUSEHOLD MEMBER
ACCOUNT NO.
AMOUNT
•
•
Do you currently own real estate DYes DNO If yes, please state location and value of property------Have you sold or transferred real estate within the last 12 months? DYes DNo If yes, w h e n ? - - - - - - - - -
•
Do you have life insurance? DYes
COMPANY NAME
DNo If yes, list company name, address policy# and loan value : _ _ _ _ __
ADDRESS
POLICY NO.
LOAN VALUE
DEDUCTIONS:
1.
Do you pay for childcare while a family member is employed or attending school? DYes ONo
Name offamily member(s) employed or attending school _ _ _ _ _ __
List child care provider's name: __________________
Address and Zip Code: _ _ _ _ _ _ _ _ _ __
Telephone number:
Cost$
per ___(week, month, or year etc)
Are you receiving any assistance with childcare costs? DYes DNo If yes, list the source and amount of assistance:
2.
Does your household incur expenses related to a handicap or disability that allow a family member to work?
DYes DNo If yes, e x p l a i n : - - - - - - - - - - - - - - - - - - - - - - - - - - -
IF THE HEAD OF HOUSEHOLD OR SPOUSE ARE AGE 62 OR OLDER AND/OR DISABLED, PLEASE ANSWER QUESTIONS 3
THROUGH 8 BELOW:
3. Are you or a household member receiving Medicare Benefits? Yes D NoD
4.
Are you or a household member receiving Medical Assistance through the Welfare Department? Yes D
NoD
5.
Do you or a household member pay for any medical insurance/hospitalization (such as Blue Cross, etc) Yes D NoD
If yes, indicate amount of premium and how often paid:$ ___ per
(week, month, year etc.)
6.
Are you or a household member making payments on outstanding medical bills? Yes D
NoD
If yes, to whom?
Amount per month$_______
7.
Do you or a household member incur expenses for prescription drugs or medical supplies on a regular basis that are not
covered by Medical Assistance or health insurance? Yes o No o If yes, list name and address of pharmacy or medical
provider: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax: (407) 894-7172 • TDD#: 407/894-9891 • Relay#: 711
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8.
Do you or a household member anticipate any health care related expenses for the next 12 months which are not
covered by Medical Assistance or Health insurance? Yes o Noo
NON-ECONOMIC INFORMATION:
1.
Have you or any household member EVER served or are you or any household member currently serving in
the United States military service? DYes DNo If yes, list name of household member and relationship to
head of household: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
2.
Have you or any household member EVER served under the direction of the Armed Forces and clandestine
forces of the United States? DYes DNo If yes, list name and location of s e r v i c e - - - - - - - - - -
3.
Have you or any household member EVER been charged with or arrested for a criminal offense or other unlawful act?
DYes DNo. Was this cha rge or arrest related to an act of physical violence including domestic violence or the
possession, use, sale or manufacture of a controlled substance (illegal drugs)? DYes DNo. If yes, explain and list
ALL arrest dates :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - Where did the charge(s) or arrest(s) occur?
City
4.
County _ _ _ _ _ _ _ _ _ _S t a t e - - - - - - - - - -
Have you or any household member EVER been convicted of a criminal offense or other unlawful act (include
all levels of conviction)? DYes DNo. Was the conviction related to an act of physical violence including
domestic violence or the possession, use sale or manufacture of a controlled substance (illegal drugs)? DYes
DNo. If yes, explain and list ALL conviction d a t e s : - - - - - - - - - - - - - - - - - - Where did the conviction(s) occur? City _ _ _ _ _ _ _ C o u n t y - - - - - - - - - - State
5.
Have you or any household member EVER been convicted from a federally subsidized housing program or
found ineligible for rent assistance by another housing authority due to violence or drug-related criminal
activity? Yes D NoD If yes, e x p l a i n : - - - - - - - - - - - - - - - - - - - - - - - - -
6.
Are you or is any member of your household required to register under any state's Sex Offender registration program?
DYes DNo. If yes, is this a lifetime registration requirement? DYes DNo.
7.
Are you currently on probation/parole due to a conviction for a criminal offense or other unlawful act?
DvesDNo.lfyes, state name and address of probation/parole o f f i c e r : - - - - - - - - - - - - Dates of probation/parole: from _ _ _ _ _ _ _ _ _ _ _ _ _ _ t o - - - - - - - - - - - -
8.
Have any of the children listed as household members or any child(ren) expected to become a household
member EVER been diagnosed as having an elevated level of lead in their blood? DYes DNo. If yes, list the
names of the child(ren) diagnosed with the c o n d i t i o n : - - - - - - - - - - - - - - - -
9.
If you are age 62 or older, would you prefer to live in housing designated specifically for seniors? Yes o
Noo
10. Do you or any household member(s) require any modification in PHA procedures or special adaptations to a
housing unit in order to accommodate a handicap or disability? Yes D NoD If yes, describe the reasonable
accommodation required :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
11. Have you or any member of your household EVER lived in Public Housing or participated in the Section 8
Program in Orlando? Yes D NoD If yes, when and where :_ _ _ _ _ _ _ _ _ _ _ _ _ _ __
12. Have you or any member of your household EVER received housing assistance through a Federally Subsidized
housing program anywhere? Yes D NoD If yes, where and w h e n - - - - - - - - - - - 390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fa x; (407) 894-7172 • TDD#: 407/894-989 1 • Relay#: 711
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Did anyone help you fill out this application? Yes 0 NoD
If yes, please provide the following:
Full Name: _ __ _ _ _ _ _ _ _ __
Signature: _ _ _ _ _ _ _ _ _ _ __
Title/Relationship _ _ _ _ _ _ _ __
Date: _ _ _ _ _ _ _ _ _ _ _ _ __
1/WE UNDERSTAND THAT TillS IS NOT A CONTRACT AND DOES NOT BIND EITHER PARTY. 1/WE CERTIFY
THAT THE INFORMATION GIVEN TO THE PUBLIC HOUSING AGENCY OF THE CITY OF ORLANDO ON
HOUSEHOLD COMPOSITION, INCOME, NET FAMILY ASSETS AND ALLOWANCES AND DEDUCTIONS IS
ACCURATE AND COMPLETE TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF. 1/WE UNDERSTAND
THAT FALSE STATEMENTS OR INFORMATION ARE PUNISHABLE UNDER FEDERAL LAW. 1/WE ALSO
UNDERSTAND THAT FALSE STATEMENTS OR INFORMATION ARE GROUNDS FOR TERMINATION OF
HOUSING ASSISTANCE AND TERMINATION OF TENANCY.
WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE
WILLFUL FALSE STATEMENTS OR MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S.
AS TO ANY MATTER WITHIN ITS JURISDICTION.
SIGNATURE OF APPLICANT: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
DATE: - - - - -I - - -
SIGNATURE OF SPOUSE/ PARTNER: _ _ _ _ _ _ _ _ _ _ _ _ __
DATE: - -I- - -I - - -
SIGNATURE OF
ADULT HOUSEHOLD MEMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ __
DATE: - -I- - -I - - -
SIGNATURE OF
ADULT HOUSEHOLD MEMBER: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE: _ _ _ _/ _ _
HOUSL""G AUTHORITY STAFF - - - - - - - - - - - - - DATE: _ _ _ _ __
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax: (407) 894-7172 • TDD#: 407/894-9891 • Relay#: 711
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ORLANDO HOUSING A.UTHORITV
Landlord Reference Form
Client Name: _ _ __ _ _ _ _ _ Client Number:------- Date:----I authorize the Orlando Housini Authority. its subsidiaries, or its management to investigate my
rental history. The Investigation may include, but is not limited to, the questions listed below:
Date
Applicant Signature
·····························································································································································································
o e com Jeted b Landlor
Your tenant has applied for rental from the Orlando Housing Authority. As part of the qualification
process, we require a reference from the applicant's current landlord and basic information
requested below.
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Date of Residency: Move-In Date: ____ Move-Out Date: _ _ _.Number of Occupants: _ __
1. Did the resident pay their rent on time? DYes
DNo Monthly rent amount: _ _ _ __
2. Rent is generally paid: DOn Time DOccasionally Late DOften Late
3. Did resident, their guest, or family damage the apartment or the property? DYes DNa
Comments:_____________________________________________
4. Does the resident have pets? DYes
ON o
5. Have there been any noise complaints, disturbances, or other concerns in reference to this
resident and/or household? DYes DNo Comments:----------------6. Have any legal notice been served to this resident? DYes DNo Comments:-----7. Did the resident give you proper notice to vacate? DYes DNo
8. Will you rent to this person again? DYes DNo Comments:---------------9. Is this a Public Housing Community? DYes DNa lfyes, name ofPHA: - - - - - - - 10. Any additional comments/information:------------------
Person Completing Form:
Name/Title
Signature
Date
Phone
Return completed .form to:
Admissions and Occupancy Department
Orlando Housing Authority
Phone: (407) 894-1500 ext.5301 or 5302
If by mall: 390 N. Bumby Ave., Orlando, FL 32803
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895·3300 • Fax; (40D 894-7172 • TDD: (407) 894·9891 Relay#: 711
www.orl-oha or~
U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing
Authorization for the Release of Information/
Privacy Act Notice
to the U.S. Department of Housing and Urban Development (HUD)
and the Housing Agency/Authority (HA)
CUB CONTROL NUMBER 1501.0014
llql.1/3112014
IHA requesting release of infolmation: (Cross out space if none)
(Full address, name of contact person, and date)
PHA requesting release a( infonnation; (Croa out space If none)
(Fun address, name of contact person. and date)
THE ORLANDO HOUSING AUTHORITY OF
THE CITY OF ORLANDO, FLORIDA
390 NORTH BUMBY AVENUE
ORLANDO, FLORIDA 32803
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988. as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (I)
HUD and the Housing Agency/Authority (HA) to request verification ofsalary arid wages from current or previous employers; (2)
HU D and the HA to request wage and unemployment compensation claim information from the state agency responsible for
keeping that information; (3.) HUD to request certain tax return
i'nforrnation from the U.S , Social Security Administration and the
U.S. Internal Revenue Service. The Jaw also requires independent
verification of income information. Therefore, HUD or the HA
may request information from financial institutions to verifY your
eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HUD and the HA need this information
to verify your household's income, in order to ensure that you are
eligible for assisted housing benefits and that these benefits are set
at the correct level. HUD and the HA may participate in computer
matching programs with these sources in order to verify your
eligibility and level of benefits.
Uses of In formation to be 0 btained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of I 974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as
to other government agencies for law enforcement purposes, to
Federal agencies for employment suitability purposes and to HAs
for the purpose ofdetermining housing assistance. The HA is also
required to protect the income information it obtains in accordance
with any applicable State privacy law. HUD and HA employees
may be subject to penalties for unauthorized disclosures or improper uses ofthe income information that is obtained based on the
consent form. Private ownen may not request or receive
Information authorized by this form.
Who Mu.d Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household become 18 years of age.
Original is retained by the requesting organization.
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PH A-owned rental public housing
Turnkey Ill Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or termination ofbenefits is subject to the HA 's grievance procedures and
Section 8 informal hearing procedures.
Sources
or Information To Be Obtained
State Wage Information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited to the wage and self employment information and payments ofretirementincorneasreferenced at Section 6103(1)(7){A)
of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is
limited to unearned income [i.e., interest and/dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and dividends). 1understand that income information obtained from these
sources will be used to verify information that I provide in
detennining eligibility for assisted housing programs and the level
of benefits. Therefore, this consent form only authorizes release
directly from employers and financial institutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.
ref. Handbooks 7420.7, 7420.6, & 7465.1
form HUD-9886 (7/94)
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 BUD'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 coruent form expir~s 36 month.:! after signc:d.
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)
Autorizaci6n para divulgar informacion/
Aviso sobre Ia Ley de Confidencialidad
envlado al Departamento de Vivienda y Desarrollo Urbano (HUD) de los EE.UU.
a Ia Oficina/Autorldad de Vivlenda (HA)
Departamento de Vlvfenda
y Desarrollo Urbano de los EE.UU.
Ofldna de Vlvlenda PUbRca y para
Comunidades lndigenas
y
Oflcina de VIVienda PUblica (PHA) que solicita Ia divulgad6n de informaci6n.
(Tache Ia casJIIa sl no correspond•.)
(Escrfba Ia direcd6n completa, el nombre del representante y Ia fecha.)
Oflcina de VIVienda para Comunidades lndigenas (IHA) que
sonata Ia divulgac:l6n de lnformac:l6n. (Tache Ia casllla sl no
corresponde.) (Esalba Ia dlreccl6n completa, el nombre
del representante y Ia fecha.)
Orlando Housing Authority
390 N. Bumby Ave.
Orlando, Fl32803
Autorldad: La Secci6n 904 de Ia ley Stewart B. McKinney de Enmiendas 1 Ia
Asistencia pan las Personas sin Hopr de 1988, en su forma Cl1lllmdada por Ia
Secci6n 903 de Ia ley de Vivienda y Desarrollo Comunitario de 1992 y Ia
Secci6n 3003 de Ia ley General de Conciliaci6n del Presupuesto de 1993. Esta
ley se encuen!I3 en Ia Secci6n 3544 del Trtulo 42 del C6diao de los EE.UU.
Se exige que los solicilantes o Reeptores de llistencia con arreglo 1 los
siguientes programas firmen este fonnulario de consentimiento:
Vivicnda pUblica de alquiler de propiedad de una PHA.
Opor:tunidades de adquisici6n de vivienda propia para entrega Dave en
mano de tipo III (alquilcr con opci6n de compn).
Oportunidad de adquisici6n de vivienda propia con un sistema de ayuda
mutua.
Dicba ley exi&e que usted tirme un tbrmulario de coo.scntimiento en virtud del
cua1 autoriza (I) 11 Departamento de Vivienda y Desarrollo Urbano (Department
of Housing and Urban Devel~mcnt, en 1delante HUD) y 1 Ja Oticina/Autoridad
de Vivicnda (Housing Ageocy/Authority, en 1delante HA) pall solicitar
verificaciones de los sueldos y salarios devengados de empleadores actuates o
anteriores; (2) 11 HUD y 1 Ia HA pall solicitar informaci6n sobre reclamaciones
de pago de salaries o indettm.izaci6n por desempleo 1 Ia entidad estatal
encargada de mantcner dicba informaci6n; y (3) al HUD para solicitar cierta
informaci6n sobre Ia declaraci6n de renta 1 Ja Administnci6n de Seguridad
Social (Social Security) y at Servicio de Rentas 1ntemas de los EE.UU. (IRS). La
ley exige ademas una verificaci6n independicnte de Ja infonnaci6n sobre
ingruos. Por lo tanto, el HUD o Ia HA puede solidtar informaci6n 1
instituciones tinanderu para verificar su idoneidad y el monto de loa beneficios.
FhuUdad: AI firmar este formulario de conscntimiento, usted 1utnriza al HUD y
- 1 ia HA mencionada para solicitar informaci6n sobre sus ingresos 1 las fuentes
citadas en el formulario. Ambos organismos necesitan esa informaci6n para
. veriticar · ingreso fiuDiliar con el tin de ccrciorarse de que ustcd rcUne las
condiciones para recibir bcneticios de asistcncia para consc&Uir vivicnda y que
~~ bcnetkios se tijen en el monte corm:to. Tanto el HUD como Ia HA pueden
~atticipar en proif111W electr6nicos de concordancia con estas fuentes para
verificar su idoneidad y el monto de los beneficios.
Vivicnda alquilada segW1 las disposiciones de las Secciones 23 y t9(c).
Pagos de asistcncia pan vivicnda seg(m las disposiciones de Ia Secci6n
23.
Vivienda de propiedad de una HA pall alquilcr a comunidades indicenas.
Certiticado de alquiler seglln las disposiciones de Ia Secci6n 8 de 1a ley
de Vivicnda de los EE.UU. de 1937.
Cup6n de alquilcr seglln las disposiciones de Ia Secci6n 8.
Rehabilitaci6n modcrada se&Un las disposiciones de Ia Secci6n 8.
Omlsl6n de Ia firma del formularlo de consentlmiento: Si usted no firma el
formulario de c~ento se lc puedc revocar su idoneidad o se le pueden
s~ los. bcneticios de vivienda, o ambas cosas. La revocaci6n de Ja idoneidad
o Ia suspensi6n de los beneticios esti sujett al procedimiento di: presentaci6n de
quejas de Ia HAy de audiencia informal indicados en Ia Secci6n 8.
. ~~at~ deacopio d~ iJlfor~cl6n:
su
Formas de empleo de Ia lnformacl6n obtenlda: Se exige que el HUD proteja
ta informaci6n obtenida sobre ingresos, de conronnidad con Ia ley de
Confidencialidad de 1974, Secci6n SS2a del Titulo S del C6digo de los EE.UU.
El HUD puede divulgar informaci6n (distinta de Ia corrcspondiente a
declaraciones de renta) para ciertas cbses de uso ordinario, por ejemplo, 1 otros
organismos gubemamentales con ftneS de aplicaci6n de Ia ley, a organismos del
gobiemo federal con tines de detenninaci6n de Ia idoneidad para el empleo, y 1
las J{A con el objeto de determinar el monto de Ia asistencia para conscguir
vivienda. Tambic!n se exige que Ia HA proteja Ia informaci6n sobre inzresos que
obtenp, de conformidad con cualquier ley estatal de confid.:ncialidad aplicable
al caso. Los empleados del HUD y de Ia HA pueden estar sujetos 1 sanciones por
divulpci6n no autorizada o por uso impropio de Ia inronnaci6n sabre ingresos
obtenida con el fonnulario de consentimiento. Los propletarios partlculares no
pueden solicitar nl reciblr informaci6n autorizad:a por este formuJ:ario.
Qulin debe flrmar el rormulario de consentlmiento: Cada familiar residente
en Ia propic:dad mayor de 18 aiios debe tirmar el fonnulario de·conscntimiento.
E.s precise obtener Ia fmna de nuevos adultos que ingresen a Ia residencia o de
quio:nes cumplan 18 alios.
La organizaclon solidtante guarda el original.
•
.
_ .. _
Eodda~S
Cs_ta~es- de ~O,lliO
de ~Ol1Jil!':iQ~-sob~
s$rios.
<Este
-·· I
.
.
·-. - .
, CQ~~ntimicntp se IU!Uta 1 ~ ~i6n po~ concepto de _salario y desempleo
QUe !Je m,e ha l'IP.io IICCi6dicamente en lOS ultiJDos $. anOS Cuamfo he recibido
benetlcios-de _asistcncia pall conseguir vivienda.) Administra~i6n ci~ Se~~d
Social de los EE.UU. (solamente el HUD). (Este consentimiento se limita 1 1a
infonnaci6n sobre Salario y empleo independiente Y sobre el pa1o de ingreso de
i jubilaci6ri,-citados eti Ia Seccion 6t03(1)(7)(A) del C6dijo del servu;io de Rentu
< lnternaS de los EE.UU.)
' Scrvicio de Rentu.lntemas de los EE.UU. (IRS) (solamente el HUD). (Este
conscntimiento se limita at ingreso no !aboral [por ejemplo, intereses y
dividcndos].)
Tambi= se puede obtener infonnaci6n directamente de: (a) los empleadores
actuates y anteriores, sobre sueldos y salaries Y (b) las instituciones rllllllcieras,
sobre ingresos no laborales (por ejemplo, intereses y dividendos). Tenco
ent.:ndido que Ia inronnaci6n sobre injp'e!OS obtenida de estas fuentes se
empleari para verificnr Ia informaci6n proporcionada por mi, con el tin de
determinar mi idoneidad para participar en los prognmas de asistencia para
conseguir vivienda y el monto de los beneficios. Por to tanto, este formulario d~
conscntimiento solamente autoriza Ia divulgaci6n de infonnaci6n directamente
de los emplendores y las instituciones financieru por cualquier periodo de los
ultimos S niios cuando he recibido beneficios de asistencia para conseguir
vivienda.
Pagina I de 2
Formulario HUD-9886-Spanlsh (7/94)
Ref lAanuales 7420.7, 7"20.8 y 7455.1
Consentimlemto: Doy mi consemtimlentD para permldr que el HUD • Ia HA soUdtem y obteacaa lnformacloa sobre mls lnzresos de las fueates
citadas ea este formul a rio con el fiJI de verlficar mlldoneldad y el monto de los beneficlos de co11formldad con los procramu de aslstenc:ia
para vlvienda del HUD. Teneo entendido que lu HAque redbu lnformaci6n sobre mls lncresos por medio del presente formulario de
consentlmlento no pueden emplearla para denegsr, reduclr o suspender Ia aslstencla sla efectuar prlmerD una verlficad6a lndependiente del
moato c:orrespondiente, sl realmente tuve acceso a los rondos y cuiado se reclbleron. Ademas. se me debe dar Ia eportllnidad de refutar esas
determlnaclones.
Este fonnulario de conscntimicnto se vcnce 36 mcses dcspu~ de finnarlo.
Firmas:
Jefe de &milia
Fecba
No. del seguro social (si existe) deljefe de familia
Otro familiar mayor de 18 aoos
Fccba
C6nyuge
Fecba
Otro familiar mayor de 18 1iios
Fecha
Otro familiar mayor de 18 anos
Fccha
Otro familiar mayor de 18 anos
Fccba
Otro familiar mayor de 18 1nos
Fccha
Otro familiar mayor de u
Fecha
anos
Aviso sobre Ia Ley de Confidenclalldad. Autoridad: El Departamento de Vivicnda y Desarrollo Ur:bano (HUD) est! 1utorizado para acopiar esta
informacion en virtud de Ia Ley de Vivienda de los EE.UU. de 1937 (Secci6n 1437 et seq. del Titulo 42 del C6digo de los EE.UU.), el Titulo VI de Ia
Ley de Derccbos Civiles de 1964 (Scccion 2000d del Titulo 42 del C6digo de los EE.UU.) y Ia Ley de Vivicnda Justa (Sccci6n 3601-19 del Titulo 42
del C6digo de los EE.UU.). La Ley de Vivicnda y Desarrollo Comunitario de 1987 (Sccc;i911..3543 4el Ti(ulo ~2 del C6digo de los EE.UU.) exige que
los solicitantcs y participantes prescnten el nlimero de seguro social de cada familiar mayor de scis aiios de cdad. Fmalidad: El HUDusa Ia
infunnacion sabre sus ingresos y otra informacion acopiada para detcrminar su idoneida(,t. el: tamano apropiado-dc las babitacioncs y el monto que.
pagari su familia por alquilcr y scrvicios pUblicos. Otros usos: el HUD usa Ia infonpaci6n sobrc su ingrcso familiar y otra infurmaci6n acopiada para
ayudar a- administrar-y supcrvisar los pro&J'llDliS de -vivienda rcalizados con asistcncia.de esc.orpms~. _pr;ctt~cr el ~ fi:nanci_c:rQ d~l G:obicrno 0
vcrificar Ia exactitud de Ia informacion proporcioaada. Esta infonnacion pucde divulga~ ~ entidadcs f~~~. estatalcs y l~cs id6~, cuaildo
proceda, y 1 investigadores y fiscales cncargados de tramitar casos civiles y penal~. :r;aslll_l\O"s 110r.matiyos, De lo contmio, Ja infurmaci6n nose
~elari ni divulgari fuera del HUD, excepto en los casos pcrmitidos o cxigidos por. la-ley;- ~lll)!:i6n: !}stcd debe proporcionat toda-la informaciOn .
solicitada porIa HA, incluso el numero de scguro social que tengan o uscn ustcd y todos lo~ denu\s familiares mayores de seis alios de edad Es
obligatorio dar el numcro de scguro social dc todos los familiares mayores de seis aiios.de edad; su omisi6n afectari su idoneidad. La omisi6n de
cuafquicr parte de Ia infonru~ci6n solicitada pucde haccr que se demorc o dcniegue ,Ia aprobaci6n de su solicitud por 1'1Z9n!=5 de idoneidad
Sanclones por el uso lndebldo del presente formula rio de consentlmiento:
El HUD, Ia HAy cualquier propietario (o empleado del HUD, Ia HA o el propictario) pucden cstar sujetos a sanciones por divulgaci6n no autorizada
0
por uso indebido de Ia infonnaci6n acopiada con el presente fonnulario de consentimicnto.
El uso de Ia infonnaci6n acopiada con el fonnulario HUD-9886 se limita a los fines citados en el mismo. Cualquier persona que, a sabiendas
0
intencionalmente, solicite, obtenga o rcvele infonnaci6n de manera fraudulenta sobn: un solicitante o participante pucde cstar sujeta a acusacion por
dclito mcnor y 1 imposici6n de una multa mAxima de SS.OOO.
Cualquicr solicitante o participante afectado porIa divulgaci6n ncgligente de informaci6n puede iniciar una ace ion civil por daD.os y peljuicios contra
el oficial o funcionario del HUD, Ia HA o el propietario responsable de Ia divulgaci6n no autorizada o del uso indebido, o buscar otra indemnizaci6n
por parte de CIIOS, SegUR proccda.
Est• documento es traduce/on de un documento jurfdlco expedldo por el Departamento · de Vlvlenda y Desa"ollo Urbano
(HUD), el cual proporclona esta traduce/on so/amente • modo de convenlencla para que /e ayude a usted a comprender sus
derechos y obllgaclones. La version en Ingles es e/ documento oflclal, legal y que rfge. Esta traduce/on no constltuye un
documento oflclal.
La organizaclon sollcitante conserva el original.
Piglna 2 de 2
Formularlo HUD-9888-Spanfsh (7194)
R..f. M<II1Uctf"~~o 74:20.7, 7420.8 y 1465.1
STUDENT ENROLLMENT VERIFICATION
Parent Name
Client#
-----
----------------------------
Student Name:
----------------------------------------------------------
Student SS#:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Student Address: __________________________________________________
The above names student's family is applying /re-certifying eligibility for housing assistance under a program
of the Department of Housing and Urban Development (HUD). HUD requires us to verify all information that
is used in determining the eligibility or level of benefits. In order to ensure timely processing of the assistance
application/ re-certification, promptly return this form to:
Orlando Housing Authority
390 North Bumby Avenue
Orlando, Florida 32803
If you have any question please feel to contract our office at (407) 894-1500 ext 5301.
Thank you for your cooperation
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
INFORMATION REQUESTED
Must be completed by school offlclal
School Name: ________________________________
School Address:. ________________________________________________
Cl1il i's
Par~nt
and'or Guardian: _________________________________________________
Please Affix Stamp or Seal Here
The individual above is enrolled at this institution
- - - Full-Time
---- Part- Time
_ _ Not Enrolled
Signature Authorized Representative
Title/ Position
Date:------------------------
Telephone
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300
• Fax#: 407/894-7172
• TDD#: 407/894-9891 • Relay#: 711
~11)
STUDENT ENROLLMENT VERIFICATION
Parent Name
Client#-------
----------------------------
Student Name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
StudemSS#:______________________________________________________
Student Address:._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
The above names student's family is applying /re-certifying eligibility for housing assistance under a program
of the Department of Housing and Urban Development (HUD). HUD requires us to verify all information that
is used in determining the eligibility or level ofbenefits. In order to ensure timely processing of the assistance
application/ re-certification, promptly return this form to:
Orlando Housing Authority
390 North Bumby Avenue
Orlando, Florida 32803
If you have any question please feel to contract our office at (407) 894-1500 ext 5301.
Thank you for your cooperation
••••• •• ••• ••••••••••• •••••• • •• ••• •••••• •••• ••••• •• •••• ••• •••••• •••••• ••••••• •••••••••••••••
INFORMATION REQUESTED
Must be completed by school official
School Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
School Address: _________________________________
Child 's Parent and/or Guardian: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Please Affix Stamp or Seal Here
The individual above is enrolled at this institution
- - - Full-Time
- - - - Part- Time
---- Not Enrolled
Signature Authorized Representative
Title/ Position
Date: ----------------------------
Telephone
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300
•
Fax#: 407/894-7172
Yo 1.1. Yo .Ll ri -O h.l . Of O
•
TDD#: 407/894-9891
• Relay#: 711
~til
ORLANDO HOUSING AUTHORITY
Verification of Employment
Date: _______
Client Number: _ _ _ _ _ __
Address of E m p l o y e e : - - - - - - - - - - - - - - - - - - - - - - - Social Security Number:---------
Please Complete The Followin~: Information
(This Portion is to be completed by the Employer)
Job T i t l e : - - - - - - - - - - -
Hire D a t e : - - - - - - - - - - -
Gross Earnings
Average number of hours worked per week:
Hourly pay rate: $_ _ _ _ __
Pay period (Weekly), (Bi-weekly), (Monthly), (Semi-Monthly):--------Average Overtime Hours Per Week:
Rate: $__________
Average Weekly Tips:
Average weekly commission: _ _ __
Anticipated Pay Increase: Proposed new pay rate$
Effective Date: _ _ _ __
Earnings record: Past year's actual gross earnings: $_______________
This amount earned from:
to
---------
**If this employee is a seasonal employee, please provide an annual gross salary**
(An example would be a school system employee)
Annual Gross Earnings$ _ _ _ _ _ __
This amount earned f r o m - - - - - - - - - - t o - - - - - - - - Name of Employe~-------------------------Address of E m p l o y e r : - - - - - - - - - - - - - - - - - - - - - - - City _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ _ _ _ _ _ Zip Code _ _ _ __
Phone __________________ Fax: _______________________________
Completed B y : - - - - - - - - - Title: _ _ _ _ _ _ _ _ _ Date: ______
Important Note: The United States Code, Title 18 (Criminal Procedure), Section 1001, makes it a criminal offense to willfully make
a false statement or representation concerning any matter within the jurisdiction or agency of the United States.
**PLEASE PROVIDE PAYROLL HISTORY IF HOURS VARY**
6.\IJ
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax; (407) 894-7172 • TDD: (407) 894·9891 Relay#:X,
Revised 07/15
www. orl-oha.or~
ORLANDO HOUSING AUTHORITY
Social Security No.: - - - - - - - - - -
Employee Name: - - - - - - - - - - - - -
Address=------------------------------------V8llflCATIONOF~ATIONOFEMPLOYMENT
We are required to verifY, through the Employer, the termination of employment for all applicants and/or tenants
in, our low-rent housing program. We ask your cooperation in supplying this required information. In no even
should the employee fill out this form . The timekeeper, bookkeeper, or accountant should fill out this form.
Employer/ Company N a m e : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Address:
-------------------------------------Termination Date:
Hire Date:
- - - - - - - - - - - - - - -- - -
Last Date Employee Actually Worked _ _ _ _ _ _ _ __
Will the employee receive any additional pay for unused annual or sick leave?
0
Yes
0No
If the answer to the above is yes, state the amount the employee will receive. $- - - - - - Will the employee receive any additional paychecks for any worker's compensation?
DYes
0No
If yes, give the name and address of the company through which this may be verified:
Company Name:
Telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address:
-------------------------------------
Reason for Termination:
D Employee Quit
D Lack of Work
0
0
Terminated for Cause
Other
If terminated for lack of work or other, do you anticipate rehiring this employee?
If yes, when?
0
Yes
0
No
--------------------------------------
Printed Name(fitle of Authorized Representative
Phone
Signature of Authorized Representative
Date
OHAUSEONLY
Complex: - - - - - - - - - - - - -
Verified By: - - - - - - - - - - -
Section 8:
------------Admission & Occupancy:
Spoke With: - - - - - - - - - - Date:
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407} 894-7172 • TDD: (407) 894-9891 Rela®
www. orl - oh a .or ~:
t
-
("':\. -~
C>RLA.NDC> HOUSING A.UTHC>RITV
ATTENTION
CURRENT CHILD SUPPORT PAYMENT HISTORY
THIS FORM DOES NOT HAVE TO BE NOTARIZED
Each family member that has a child or children must submit a separate history from the head of
household. You must provide verification for EACH CHIL support case.
Florida payment histories may be obtained from family services located at:
ORANGE COUNTY COURTHOUSE
425 N. Orange Avenue ROOM 320
Orlando, FL 32801
407-836-2059
Hours of operations
Mon- Fri: 7:30am to 4:00pm
(A FEE WILL BE ASSESSED BY THE CHILD SUPPORT AGENGY)
If your case NOT in Orange County or Florida, you must provide proof from the state from where, you are
receiving child support. If you are not receiving child support, and you have an open case from another state,
please obtain proof from that state you are not receiving child support.
·······································································································································
ATENCION
istorial de Pagos de Pension Alimenticia
Por cada menor en el grupo familiar usted debeni proveer historial de pagos de pension alimenticia. Historial de
pagos de pension alimenticia se puede obtener en la siguiente direccion:
ORANGE COUNTY COURTHOUSE
425 N. Orange Avenue ROOM 320
Orlando, FL 32801
407-836-2059
Hours of operations
Mon- Fri: 7:30am to 4:00pm
(La Agencia de Pension Alimenticia cobrara una tarifa por la verificacion.)
Si usted no tiene un caso abierto debe obtener una certificacion de dicha oficina.
Si su caso no es en estado de la Florida debe presentar la prueba del estado o pais en el que esta registrada la
pension alimenticia. Si usted no recibe pagos de pension alimenticia pero tiene un caso abierto en otro estado o
pais, por favor obtengo la verificacion ese estado que usted no recibe pension alimenticia.
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300 Fax; (407) 894-7172 •
www .orl -oha .o ro
TDD#: 407/894-9891
• Relay#: 711
~e
ORLANDO HOUSING AUTHORITY
CHILD SUPPORT AFFIDAVIT
The following applicant has applied with the Orlando Housing Authority, for Public Housing and/or Section 8
Program. Our agency is required to conduct a third party verification of all applicants applying for or living in
federally assisted housing.
Please list all children living in your household .
I , - - - - - - - - - - - - - ' do herby swear or affirm that I DO/DO Not receive child support for:
Applicant
1.
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
2.
3.
4.
5.
6.
7.
8.
9.
10.
6.®
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172• TDD: (407) 894-9891 Relay#: 711
www.orl -oha.or::
ORLANDO HOUSING AUTHORITY
STATEMENT OF IRREGULAR NON-VERIFIED INCOME
*This form is to be completed if you are paid in cash or are self-employed*
AMB: ____________________
ELEPHONE:_ _ _ _ __
I CERTIFY THAT MY AVERAGE WEEKLY [ ], BI-WEEKLY []BI-MONTHLY []OR MONTHLY []
COME FROM _ _ _ _ _ _ _ _ _ _ _ IS$___________
(Source of Income)
PLEASE CHECK ONE OF THE FOLLOWING
[]LAWNCARE
[ ]FAMILY MEMBER
[]TIPS
[ ] COSMETOLOGY
[]DAY WORK
[ ]CHILD SUPPORT
[]OTHER: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
IF THE SOURCE IS A FAMILY MEMBER:
RELATIONSHIP:_ _ _ _ _ _ _ _ __
NAME:--------------------------
TELEPHONE NUMBER: _____________________
Date
Signature- Section 8/ Public Housing Resident
I understand that the United States Code Title 18 (Crimes and Criminal Procedures) Section 1001, makes it a criminal
offense to make a willfully false statement or representation concerning any matter within the jurisdiction of any department
or agency of the United States, and further, that failure to correctly state my income is considered fraud and may result in
termination of my housing assistance or removal from the waiting list for cause.
NOTARY
WITNESS
SEAL:
PRINT NAME
-------------------------
NAME
SIGNATURE
DATE
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300 •
Fax#: 407/894-7172
wn w .orl-{)ha.org
•
TDD#: 407/894-989 1 • Relay#: 711
~a
ORLANDO HOUSING AUTHORITY
Client#:
-------------------
FINANCIAL ASSISTANCE
To:
The Orlando Housing Authority
Choose one of the following:
D
I certify that my husband, wife, domestic partner, fiancee, boyfriend, girlfriend,
does not live with me, and that I am not receiving any monies from anyone
outside of my household for support of myself and/or my children. I further agree
that if anyone returns or moves in, or if I receive any monies, child support,
and/or alimony from him/her, it will be reported to the Management office
immediately.
D
I certify that I reside with my husband, wife, domestic partner, fiancee, boyfriend,
or girlfriend. I am not receiving any monies from anyone outside of my
household for support of myself and/or my household.
I understand that the United States Code, Title 18 (Crimes and Criminal Procedures)
Section 1001 provides that it is a criminal offense to make a false, fictitious, or fraudulent
statement or entry, in any matter, to a department or agency of the United States; and
shall be fined not more than $10,000 or imprisoned for not more than five years, or both.
I further understand that according to my lease, the Housing Authority may terminate my
tenancy if false statements have been made.
Applicant's Name:
Address:
Telephone No:
Signature:
Witness:
HOUSING AUTHORITY STAFF
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax#: 407/894-7172 • TDD#: 407/894-9891
ww"' o rl-,)h.t.of'.!
• Relay#: 711
b. (i;r
ORLANDO HOUSING AUTHORITY
FOOD STAMPS/CASH ASSISTANCE VERIFICATION (TANF)
We are required by Federal Law to certify the income of all members of families:
1. Applying for admission as residents for low-income housing, which we operate.
2. To reexamine the income of these families once each year while in residency.
Occupancy is restricted to low-income families as established by HUD with rent based on the
amount of the family income.
To comply with this Federal requirement, we are asking your cooperation in supplying
verification from the Department of Children and Families (DCF).
'You must rovide a rintout for food stam s and cash assistance (TANF)."
VERIFICACION DE CUPONES DE ALIMENTO/ASISTENCIA
EN EFECTIVO (TANF)
La ley Federal nos requiere certificar los ingresos de todos los miembros del grupo familiar:
1. Que apliquen a Vivienda de bajo ingreso, la cual nosotros operamos.
2. Reexaminar el ingreso de esta familia una vez al afio durante su residencia en el
programa.
La ocupaci6n esta restringida a familias de bajos recursos como lo establece HUD con la renta
basada en la cantidad de ingreso del grupo familiar.
Para cumplir con el requisito Federal, le solicitamos su cooperaci6n supliendo la verificaci6n del
Departamento de Nifios y Familia (DCF).
Debe proveer un historial de sus Cupones de Alimentos y Asistencia en efectivo (TANF).
http://www .mvflorida.cornlaccessflorida
or
DEPARTMENT OF CHILDREN AND FAMILIES (DCF)
Orange County ACCESS Center
6218 W Colonial Drive
Suite#240
Orlando, FL 32818
Phone: (866) 762-2237 Fax: (866) 735-2469
390 1 . Burnby Avenue, Orlando, Florida 32803 • Tel#: 407/ 895-3300 • Fax#: 407/894-7 172 • TDD#: 407/894-989 1
'"'·w.orl-olta .o r~"'
• Relay#: 711
C>RLA.NDC> HOUSING A.UT+-tC>RITV
DECLARATION OF ASSETS
Oient Must Bring Proo(o(Each Asset
Do you or any family members have an account?
(
) YES
or
(
) NO
NameofbanWcremtUJrion: _______________________________________________________________
Checking Account Balance$_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Savings Account Balance $________________________________
Do you or any family members have a whole life insurance policy?
Whole Life Policy (
) YES or (
) NO
(
) YES
Term Life Policy (
or
(
) YES
)NO
or
(
)NO
If any cash value; how much? $_______________________________
Do you or any family members have stocks or bonds?
(
) YES
or
(
) NO
Company Name:
Value of investment$______________
Company Name: ___________________________
Value of investment $- - - - - - - - -
Do you or any family members have treasury bills, CD's, or money market funds? ( ) YES or ( ) NO
Value ofFunds $
Type_ _ _ _ _ _ _ _ _ _ __
Value ofFunds $_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Type_ _ _ _ _ _ _ _ _ _ _ __
Do you or any family members have rental property?
(
) YES
or
(
) NO
Ifyes; provide a letter from your realtor stating the market value of the property
Amount of rent received monthly $
Market value of property $_______
Do you or any family members have any retirement or pension funds?
Value of retirement$
(
) YES
or
(
) NO
Value of pension$_ _ _ _ _ _ _ _ _ __
Do you or any family members expect to receive a lump sum of payments?
Source of payment
(
) YES
or
(
) NO
Amount expected$_______________
Do you or any adult family members have any personal items that you hold as investments? ( ) YES or ( ) NO
(Examples ....antique car, coins, or stamp collections, etc..)
Item type_________________
Value ofItem______________
Item type_ _ _ _ _ _ _ _ _ _ _ _ _ __
Value ofItem______________
The above statements are full, true and complete to the best of my knowledge. I understand that the United States Code, Title 18 (crimes and
criminal procedures) Section 1001 makes it a criminal offense to make a willfully false statement or representation concerning any matter within the
jurisdiction of any department or agency of the United States.
Date
Signature
**ALL .4DCLTS HOCfiEIIOLJ> .\JEJ/BERS A (iE
390 N. Bumby Avenue, Orlando, Florida 32803
•
r,y.-t.YD 0 /.DER Jlt.:ST SJG.\' .4 FORJ.I
Tel#: 407/895-3300 • Fax#: 407/894-7172
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•
TDD#: 407/894-9891
• Relay#: 711
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C>RLA.NDO HOUSING A.UTHORITV
CHILD CARE VERIFICATION
TO WHOM IT MAY CONCERN: Public Housing Authorities are required by Federal Law to verify any Child
Care costs paid by their applicants so that the costs may be taken into consideration when the rent is computed
for the family. You will note that the head of household has signed a release below, giving you permission to
provide us this information.
Sincerely,
Orlando Housing Authority
Th1s Portion is to be com
VERIFICATION:
I certify that I provide care for_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___, (name of
children) cared for who reside in the household of the person signing release below.
I care for the children so that a family member can: (check as applicable)
In the year beginning _ _ _ _ and ending
o Go to School
o Work
I will be caring for the child(ren)
- - - - - - - - - w e e k s per year. My rate of pay is$
o every two weeks
D once a month
o once a week
hours per week,
per hour, and I will be paid:
Care during the week will be offered as follows:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
hours
hours
hours
hours
hours
hours
hours
Name: - - - - - - - - - - - - - - - - - - - - D a t e _ _ _ _ _ _ _ _ _ __
Signature- - - - - - - - - - - - --r=======r Phone# __________
AX ID#/SS# _ _ _ _ _ _ _ _ _ __
Title:
TENANT/APPLICANT RELEASE
I , - - - - - - - - - - - - - - - - ' hereby authorize the release of the requested information.
- - - - - - - - - - - - - - - - - - - - - - - - D a t e : _ _ _ _ _ _ _ _ _ _ _ __
Signature
PENALTIES FOR MISUSING THIS CONSENT: ntle18, 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 of the United States Government. HUD and any owner (or any employee of HUD 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 this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any
information under false pretenses concerning an applicant or participant may be subjected to a misdemeanor and fined not more than $5000. 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security
number are contained in the Social Security act (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/894-1500
v.. ""'~ .orf-<)h..t
Fax: (407) 894-7172 •
Llfl:'
TDD#: 407/894-9891
• Relay#: 711
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ORLANDO HOUSING AUTHORITY
AUTHORIZATION
For Release of Information
I, _ _ _ _ _ _ _ _ _ _ _ _(Legal name), do hereby authorize any agencies, offices, groups, organizations or
business firms to release to the Orlando Housing Authoritv any information or materials which are deemed
necessary to complete and verify my application for participation and or to maintain my continued assistance
under the Section-S Housing Assistance Program, Section 8 Voucher Program, and/or Low-Income Housing
Programs. These organizations are to include, but are not limited to: financial institutions, Employment Security
Commission; past or present employers; Social Security Administration; welfare and food stamp agencies;
Veteran's Administration; court clerks; utility companies; Workmen's Compensation Payers; hospitals; public
and private retirement systems; law enforcement agencies; attorneys, credit providers, and banks.
I understand that the Department of Housing and Urban Development (HUD) may conduct computer-matching
programs in order to verify the information supplied on my application or recertification. It is understood and
agreed that this authorization or the information obtained with this use may be given to and used by HUD in the
administration and enforcement of program rules and regulations and that HUD may in the course of its duties
obtain such information from other Federal, State or local agencies, including State Employment Security
Agencies; Department of Defense: Office o f Personnel Management, the Social Security Administration, and State
welfare and food stamp agencies.
It is with my understanding and consent that a photocopy of this authorization may be used for the purposes stated
above.
Signed: X_______________________________________
Social Security Number:----------
Date: ----------------
f*AL L ADULTS HOUSEHOLD MEMBERS AGE 18 AND OLDER MUST SIGN A FOR~]
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300 • Fax#: 407/894-7172
\\ \~\\ .orl-oha.oro
•
TDD#: 407/894-9891
• Relay#: 711
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~
ORLANDO HOUSING AUTHORITY
TAX RETURN VERIFICATION
We are required by Federal Law to certify the income of all members of families:
1. Applying for admission as residents for low-income housing, which we operate.
2. To reexamine the income of these families once each year while in residency.
To comply with this Federal requirement, we are asking your cooperation in supplying
verification from the Internal Revenue Service (IRS).
• If you filed taxes the previous year, you must provide a copy of the tax
return transcript.
• If you did not file, you must provide a Verification o(Non-Filing from
the IRS.
There are four (4) ways to obtain this information:
1.
2.
3.
4.
Go online: www.irs.gov and click on Order a Return or Account Transcript;
Call IRS 1-844-545-5640 ; For Appointments in Maitland call 321-441-2586
Mail the IRS Form 4506-T (or Form 4506-T-EZ), Request for Transcript ofTax Return
Office addresses 850 Trafalgar Ct. Maitland, FL 32751. Monday-Friday 8:30am-4:30pm
NOTE: If the transcripts are mailed to your home, it could take 5-10 days for delivery.
VERIFICACION DE IMPUESTOS
La ley Federal nos requiere certificar los ingresos de todos los miembros del grupo familiar:
1. Que apliquen a Vivienda de bajo ingreso, la cual nosotros operamos.
2. Reexaminar el ingreso de esta familia una vez al afio durante su residencia en el programa.
La ocupaci6n esta restringida a familias de bajos recursos como lo establece HUD con la renta basada en
la cantidad de ingreso del grupo familiar.
Para cumplir con el requisito Federal, le solicitamos su cooperaci6n supliendo la verificaci6n del
Departamento de Rentas Internas (IRS).
•
•
Si usted completo y/o sometio impuestos el pasado afio, usted debeni proveer copia de Ia
transcripcion de los impuestos.
Si usted NO completo y/o sometio impuestos el pasado afio, entonces debera proveer una
verificacion de no-completado del IRS.
Hay 4 maneras de obtener esta informacion:
1. Vaya online: ~nnr.irs .gol_ y presione el bot6n de ordenar una transcripci6n de los lmpuestos.
2. Uamar 1-844-545-5640 y seguir las instrucciones en el telefono: Para Cita 321-441-2586
3. Enviar por correo la Forma de IRS 4506-T (o la Forma IRS 4506-T-EZ)- Solicitud de la Transcripci6n
de los lmpuestos
4. Oficina Local, 850 Trafalgar Ct. Maitland, FL 32751. Monday-Friday from 8:30am-4:30pm.
Nota: Si la transcripci6n es enviada por correo a su casa, tome en cuenta que se tardara de 5 a 10 dias en
recibirla.
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax; (407) 894-7172 • TDD #: 407/894-9891 • Relay#: 711
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ORLANDO HOUSING AUTHORITY
TO ALL PUBLIC HOUSING & SECTION 8 APPLICANTS
The Violence Against Women Act (VAWA) and Justice Department Reauthorization Act of
2005 protects qualified applicants for HUD assisted housing programs from adverse actions
solely as a result of being a victim of domestic violence, dating violence or stalking.
A qualified applicant may be a person who is a victim of actual or threatened domestic violence,
dating violence or stalking and who was involved in a domestic violence incident that is directly
related to the denial of admission to public housing and/or Section 8 Program.
If you believe you are a victim of domestic violence you may request the Certification
information and a Certification Form under VA W A. Please send your request to:
Orlando Housing Authority
390 North Bumby Avenue
Orlando, Florida 32803
Attn: Admissions & Occupancy
If you have any additional questions, feel free to contact the undersigned at 407-894-1500 Ext
5301 or 5302.
Sincerely,
T i.
;ffMf<'l(
T.L. Mungen, PHM/COS
Admissions & Occupancy Manager
390 N. Bumby Avenue, Orlando, Florida 32803
• Tel#: 407/895-3300 • Fax#: 407/894-7172
www.orl-oha.oro
TDD#: 407/894-9891
• Relay#: 711
ORLANDO HOUSING AUTHORITY
A TODOS LOS SOLICITANTES DE VIVIENDA PUBLICA Y DEL
PROGRAMA DE SECCION 8
El Acta de Violencia Contra Las Mujeres (AVCM) y e! Acta de Re-Autorizaci6n del
Departamento de Justicia de 2005 protege a las solicitantes que cualifiquen para los Programas
de HUD de Asistencia de vivienda, de acciones adversas solamente como resultado de haber sido
victima de violencia domestica, citas violentas o asecho.
Un solicitante cualificado pudiera ser una persona que es victima o ha sido amenazado do
violencia domestica, citas violentas o ha sido asechada y que ha estado envuelta en incidents
violentos que estan directamente relacionados con la negaci6n de admisi6n a vivienda publica
y/o al programa de Secci6n 8.
Si usted cree que es una victima de violencia domestica, pudiera solicitar la informacion de
Certificaci6n y una Forma de Certificaci6n bajo VA W A. Favor de enviar su requerido a:
Orlando Housing Authority
390 North Bumby Avenue
Orlando, Florida 32803
Attn: Admissions & Occupancy
De tener preguntas adicionales, puede comunicarse con la persona abajo firmante a 407-8941500 Ext. 5301 o 5302.
A tentamente,
T !.
!lfM~I(
T.L. Mungen, PHM/COS
Admissions & Occupancy
390 N. Bumby Avenue, Orlando, Florida 32803
• Tel#: 407/895-3300 • Fax#: 407/894-7172
www .orl -oha.orrr
TDD#: 407/894-9891
• Relay#: 711