Application Package for Public Housing

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Application Package for Public Housing
FOR OFFICE USE ONLYoz/16
Application Number:
Date:
ORLANDO HOUSING AUTHORITY
PUBLIC HOUSING/ ADMISSION APPLICATION
Name(first) _ _ _ _ _ _ _ _ __,___ _ Middle _ _ _ _ _ _ _ _ _ LastName _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Apt.# _ _ _ _ _ _ _ _ __
City _ _ _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ _ _ _ _ _ Zip Code _ _ _ _ _ __
Phone # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Work/Message Phone#_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
NAME OF PERSON WE MAY CONTACT IF WE CANNOT REACH YOU:
I
NAME
0 Yes 0
I
RELATIONSHIP
•
Do you Speak English?
•
Name of English Speaking Contact person {IF AVAILABLE):
PHON"
No If not what language do you speak? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I
NAME
I
ADDRESS
RELATIONSHIP
I
I
ADDRESS
PHONE#
HOUSEHOLD COMPOSITION: (LIST ALL PERSON .INCLUDING YOURSELF, WHO WILL BE PART OF THE HOUSEHOLD)
Member No.
last
Name of Family Member {List Head first)
Middle
First
Relation
to Head
Soc. Sec.#
Date of
Birth
AGE
SEX
HEAD
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Do you expect changes in the number of person in your household
0 Yes
explain:
Is any member ofthe household a full time student over 18 years of age?
HouseHold#
*Race
(May use More
* Hispanic/
Ethnicity
•u.s
Citizen
0
0
No
Yes
0
If yes,
No If yes, list names :
Race Code:
* Place of Birth
City, State, Country
1- ·--·····-·- .;...cr,_.h__:.:.:
am'.:·...o.::..:".,:.'e:...,l:_......................;....c::.o:_:::
d.e
:=································:'······v.:.../,____:N:............. ;.................................
1.
1. WHITE
.. ..........................................
2. BLACK
2.
3. AMERICAN INDIAN/NATIVE ALASKAN
3.
4 . ASIAN
5. NATIVE HAWAIIAN/PACIFIC ISLANDER
4.
···-···--··-······;-··--····--····--··········-
5.
+-············--···························+········ ...................... ........... ····-·-···--·-····-··--
·+·-························-···················+·····-···········----·· ·······-
6.
*Hispanic/Ethnicity Code:
7.
8.
-···-····-··--···- ····-······-········-···--······················-·····- + ···············-·······················-·····+··-····················
9.
+·-···············-·······-···-·-·····-········-·-·········-··························-·-···············-·····-········-········
-1
--·-····-··-··· -·-·····-···-·-···-······-·····-······-· -+··-················-························- -+--·--················· ·+·····-·············--·····-·······-····-········-·······--····························-··-······································· ...... 1
10.
.1. HISPANIC
2. NON-HISPANIC
DISABLED
Y/N
*This informati on is req uired, 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 Genera l Counse l of HUD has ruled that th e regulation issued on behalf of the Secretary requiring collection of racia l and ethnic data has the force and effect of law and takes
precedence over any conflicting Stat e 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 MEMBERS: (EXAMPLE : MFTP, GA, SOCIAL SECURITY, SSI DISABILITY COMPENSATION, ALI MONY,
CHILD SUPPORT DIVIDENDS PENSIONS TRUST FUNDS ANNUITIES INCOME FROM RENTAL PROPERTY AND ARMED FORCES RESERVES)
'
'
'
'
SOURCE
GROSS EARNINGS
HOUSEHOLD MEMBER
Per Year
$
Per Year
$
Per Year
$
ASSETS OF ALL HOUSEHOLD MEMBERS: (EXAM PLE, SAVINGS AND CHECKING ACCOUNTS, SAVINGSCERTIFICATES , CREDIT UNION SHARES, MONEY MARKET
FUNDS STOCKS BONDS IRA ACCOUNT)
'
'
NAME AND ADDRESS OF BANK/FINANCIAL INSTITUTION
ACCOUNT NO.
AMOUNT
HOUSEHOLD MEMBER
•
Do you curre ntly own real estate DYes
DNo
If ye s, please state location and value of property _ __ _ _ _ __ _ _ _ _ __
•
Have you so ld or transferred real estate within the last 12 months? DYes
DNo
If yes, when? _ _ _ _ _ _ _ _ _ _ _ _ __
Do you have life insurance7 DYes DNo If yes, list company name, address policy# and loan value :
•
POLICY NO.
ADDRESS
COMPANY NAME
LOAN VALUE
DEDUCTIONS:
1. Do you pay for childcare while a family member is employed or attending school? DYes DNo
Name of family member(s) employed or attending school _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
U~childcarepro~de~sname: _ _ _ _ _ _ _ __ __ _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __ _ __ _~
AddressandZipCode : _ _ _ _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Cost$
per
(week, month, year etc.)
Telephone number:
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?
~Yes ~Nolfye~expla 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 No D
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 D
NoD If yes, list name and address of pharmacy or medical
provder :_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
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 D
NoD
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
2.
DNo If yes, list name of household member and relationship to head of household :
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 service _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
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 charge 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 _ _ _ _ _ _ _ _ _ _State _ _ _ _ _ _ _ _ _ _ _ _ __
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 _ _ _ _ _ _ _ County _ _ _ _ _ _ _ _ _ _ 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?
DYes DNo. If yes, state name and address of probation/parole officer: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Dates of probation/parole: f r o m - - - - - - - - - - - - - - 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 condition : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
9.
If you are age 62 or older, would you prefer to live in housing designated specifically for seniors? Yes D
NoD
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 hou seho ld EVER received housing assistance through a Federally Subsid ized hou si ng
program anywhere? Yes D
NoD If yes, where and wh e n - - - - - - - - - - - - - - - - - - - - - - -
Did anyone help you fill out this application? Yes D NoD
If ye s, plea se provide the following:
Full Name : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Signature _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ __ _
Title/Relationship _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ Date : _ _ _ _ _ _ _ _ _ _ _ _ __
1/WE UNDERSTAND THAT THIS IS NOT A CONTRACT AND DOES NOT BUIND 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 STATEMTNS 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 A P P L I C A N T - - - - - - - - - - - - - - - - - - - - DATE _ _ _ _ _ _ _ _ _ _ _ __
SIGNATUREOFSPOUSE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE _ _ _ __ _ _ _ _ _ _ __
SIGNATURE OF OTHER
ADULT HOUSEHOLD M E M B E R - - - - - - - - - - - - - -- - --
DATE _ _ _ _ _ __ _ _ _ __ _
SIGNATURE OF OTHER
ADULT HOUSEHOLD MEMBER _ __ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE _ _ _ _ _ _ __ _ __ __
INTERVIEWEDBY _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ DATE _ _ _ _ __ _ _ _ _ _ ____
ORLANDO HOUSING AUTHORITY
OPTIONS TO BE COVERED WITH APPLICATION
Date:
APPLICANT CAN NOT SPECIFY ANY ONE COMPLEX.
Applications are placed in our community-wide central file by bedroom size, preference/priority,
date and time.
When the applicant's name reaches the top of the list and a vacancy occurs, he or she is offered the
first unit that is available in accordance with our "first come first served" policy.
If the applicant refused the unit offered, he or she must notify this office in writing within ten (10)
days.
Applicant
Eligibility Specialist
Applicant
••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••
NOTIFICATION OF RENT OPTIONS IN PUBLIC HOUSING:
Applicants have a choice of two rent options as listed below:
Flat Rent- Rent set by the Orlando Housing Authority based on the rent charged to
comparable unassisted units in the housing market area. This rent will remain until the
next scheduled re-exam.
2. Income-Based Rent- Pay thirty percent (30%) of your adjusted income for rent.
3. Special Rent- Rent for Individuals residing in Orlando Housing Authority property to
provide special services.
1.
Applicant/Tenant
Date
Applicant/Tenant
Date
Eligibility Specialist
®
390 N. Bum by Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: ( 407) 894-7172 • TDD: ( 407) 894-9891 Relay#: 711
Revised 02/ 16
www.orl-oha.org
l
(5\. =- "'
Community Service/Self-Sufficiency Requirement Summary and Certification
Community Service
Community service is defined as “the performance of voluntary work or duties that are a public benefit, and that serve to
improve the quality of life, enhance resident self-sufficiency, or increase resident self-reasonability in the community.
Community Service is not employment and may not include political activities.
Requirement
The Quality Housing and Work Responsibility Act (QHWRA) of 1998 requires that all not-exempt public housing adult
resident (18 years or older) contribute eight (8) hours per month of community service (volunteer work) or participate in
eight (8) hours of training, counseling, classes or other activities that help an individual toward self-sufficiency and
economic independence. This is a requirement of Public Housing Lease.
Exempt Residents
Residents that are exempt from the program work/sufficiency requirement include persons who are:
• 62 years of age or older
• Has a disability that prevent him/her from being gainfully employed
• Is the caretaker of a disabled person
• Is working at least 28 hours per week
• Is participating in a welfare to work program
Non-compliance or Resident and/or Family Member(s)
•
•
If OHA finds family to be non-compliant, OHA will enter into an agreement with the Head of Household, or the
Head of Household and the non-compliant member, to make up the sufficient house over the next twelve (12)
month period.
If, at the next annual recertification, a family is not compliant, the lease will not be renewed and the entire family
will have to vacate, unless the non-compliant member agrees to move out of the unit.
I/We have read and understand the contents of the Community Services/Self Sufficiency Summary.
I /We understand that this is a requirement of the Quality Housing and Work Responsibility Act (QHWRA) of 1998 and
that if I/We do not comply with this requirement, the lease will be terminated.
_____________________________________
_______________
Head of household
______________________________________
Other Adult household member
______________________________________
Other Adult household member
Date
_______________
Date
_______________
Date
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax: (407) 894-7172 • TDD#: 407/894-9891 • Relay#: 711
www.orl-oha.org
ORLANDO HOUSING AUTHORITY
Landloi•(l Refe1•ence Foi"In
Client Name: _ __ _ _ _ _ _ _ _ Client Number: _ _ _ _ _ _ _ _ Date: _ _ _ __
I authorize the Orlando Housing 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
To be Completed By Landlord
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
2.
Rent is generally paid: DOn Time
DNo
Monthly rent amount: _ _ _ __
DOccasionally Late
DOften Late
3. Did resident, their guest, or family damage the apartment or the property? DYes
DNo
Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
4.
Does the resident have pets? DYes
DNo
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
7.
Did the resident give you proper notice to vacate? DYes
8. Will you rent to this person again? DYes
9.
Is this a Public Housing Community? DYes
DNo
DNo Comments: _ _ _ _ __
DNo
Comments : _ _ _ _ _ _ _ _ _ _ __
DNo If yes, name of PHA: _ _ _ _ _ _ __
10. Any additional comments/information: _ _ _ _ _ _ _ __ __ _ __ __ _ _ __
Person Completing Form:
Name/Title
Signature
Date
Phone
··................................................................Refurn··completea·roriil'to:······.. ······· ...................................... ·········
Admissions and Occupancy Department
Orlando Housing Authority
Phone: (407) 894-1500 ext.5301 or 5302
If by mail: 390 N. Bumby Ave., Orlando, FL 32803
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
www.orl-oha,org
ORLANDO HOUSING AUTHORITY
Fm•Jnulario lle J•efeJ•encia llel}n•oilietau•io
Nombre del Cliente: _ _ _ _ _ _ _ _ _ __
Fecha: _ _ _ _ _ _ ___
Numero del Cliente: _ _ __
Autorizo a Ia Autoridad de Vivienda de Orlando, sus subsidiarias o su gesti6n a investigar mi historial de alquiler.
La investigaci6n puede incluir, pero nose limita a, las preguntas a continuaci6n:
Firma del Aplicante
Fecha
Para ser completado por el proprietario
Su inquilino ha aplicado para el alquiler de Ia Autoridad de Vivienda de Orlando. Como parte del proceso de
calificaci6n, se requiere una referenda del propietario actual del solicitante y Ia informacion basica solicitada a
continuaci6n.
Direcci6n: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Fecha de residencia: Fecha de movimiento: _ Fecha de salida:_ Numero de ocupantes: _ _ _ _ _ _ _ _ __
1.
LEI residente pag6 su alquiler a tiempo? OSi
ONo Cantidad de renta mensual: _ _ _ _ _ _ _ ___
2.
Generalmente Ia renta es pagada: OA tiempo
OA veces
3.
LEI residente, sus invitados o familiares han hecho dafios el apartamento o Ia propiedad?
OA menudo tarde
Commentarios: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
4.
Tiene el residente mascotas? OSi ONo
5.
A habido quejas ruidos, disturbios u otras preocupaciones en referenda a este residente o Ia familia
OSi
ONo Comentarios: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
6.
Hay cualquier aviso legal servido a este residente? OSi
ONo Comentarios: _ _ _ _ _ _ _ _ _ __
7.
El residente dara aviso apropiado para desocupar? OSi
ONo
8.
Le rentarfa a esta persona otra vez? OSi
9.
Es esta una comunidad de vivienda publica? OSi
ONo Comentarios : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
ONo
Si afirmativo, nombre Ia vivienda publica :
10. Cualquier comentario adicional/informaci6n:
Persona Completando este Formulario
Nombre/Tftulo
Firma
Fecha
Telefono
Devuelva el formulario completado a:
Departamento de Admisiones and de Ocupaci6n
Orlando Housing Authority
Phone: (407) 894-1500 ext.5301 or 5302
If by mail: 390 N. Bumby Ave., Orlando, FL 32803
6. ®
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
Rev. 02/16
www.orl-oha.org
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)
PHA requesting release of information; (Cross out space if none)
(Full address, name of contact person, and date)
exp. 1/31/2014
IHA requesting release of information: (Cross out space if none)
(Full address, name of contact person, and date)
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 of salary and wages from current or previous employers; (2)
HUD 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
information from the U.S. Social Security Administration and the
U .S. Internal Revenue Service. The law 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 theHA 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 oflnformation to be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of 1974, 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 of determining 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 improperuses of the income information that is obtained based on the
consent form . Private owners may not request or receive
information authorized by this form.
Who Must Sign the Consent Fot·m: 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.
OMB CONTRO L NUMBER: 2501-0014
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PHA-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 of 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 of retirement income as referenced at Section 61 03(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). I understand that income information obtained from these
sources will be used to verify information that I provide in
determining 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, 7420.8, & 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 HOD'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 consent form expires 36 months after signed.
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 Famil y 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 auth01i zed to collect this
infonnation by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civi l Rights Act of 1964 (42 U.S. C. 2000d),
and by the Fair Housing Act (42 U.S.C. 360 1-19). 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 infonnation are being collected by HUD to detennine 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 appropiiate Federal , State, and local agencies,
when relevant, and to civil, criminal , or regu latory 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 inf01mation
requested by the HA, including all Social Secuiity Numbers you, and all other household members age six years and older, have and
use. Giving the Social Security Numbers of all house~old members six years of age and older is mandat01y, and not providing the
Social Security Numbers wi ll affect your eligibili ty. Failure to provide any of the requested information may res ult in a delay or
rejection of your eligibility approva l.
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.
Origi nal is retained by the requesting organization.
Ref. Handbooks 7420.7, 7420.8, & 7465 .1
form HUD-9886 (07/14)
Departamento de Vivienda
Autorizaci6n para divulgar informacion/
Aviso sobre Ia Ley de Confidencialidad
y Desarrollo Urbano de los EE.UU.
enviado al Departamento de Vivienda y Desarrollo Urbano (HUD) de los EE.UU.
y a Ia Oficina/Autoridad de Vivienda (HA)
Oficina de Vivienda Publica (PHA) que solicita Ia divulgacion de informa cion.
(Tache Ia casilla si no corresponde.)
(Escriba Ia direccion completa, el nombre del repre sen tante y Ia fecha.)
Oficina de Vivienda Publica y para
Comunidades lndigenas
Oficina de Vivienda para Comunidades lndigenas (IHA) que
solicita Ia divulgacion de informacion. (Tache Ia casilla si no
corresponde.) (Escriba Ia direccion completa, el nombre
del representante y Ia fecha.)
Orlando Housing Authority
390 N. Bumby Ave.
Orlando, FL32803
Autoridad: La Seccion 904 de Ia Ley Stewart B. McKinney de Enmiendas a Ia
Se exige que los solicitantes o receptores de asistencia con arreglo a los
Asistenc ia para las Personas sin Hogar de 1988, en su fonna erunendada porIa
siguientes programas fmnen este fonnulario de consentimiento :
Seccion 903 de Ia Ley de Vivienda y Desarrollo Comunitario de 1992 y Ia
Vivienda publica de alquiler de propiedad de una PHA.
Seccion 3003 de Ia Ley General de Conciliacion del Presupuesto de 1993. Esta
Oportunidades de adquisicion de vivienda propia para entrega lla ve en
ley se encuentra en Ia Seccion 3544 del Titulo 42 del Codigo de los EE.UU.
Dicha ley exige que usted Iinne un fonnulario de consentimiento en virtud del
cual autoriza ( l) al Departamento de Vivienda y Desarrollo Urbano (Department
of Housing and Urban Development, en adelante HUD) y a Ia Oficina/Autoridad
de Vivienda (Housing Agency/ Authority, en adelante HA) para solicitar
verificaciones de los sueldos y salaries devengados de empleadores actuates o
anteriores; (2) al HUD y a Ia HA para solicitar infonnacion sobre reclamaciones
de pago de salaries o indemnizacion
por desempleo a Ia entidad estatal
encargada de mantener dicba infonnacion; y (3) al HUD para solicitar cierta
infonnacion sobre Ia declarac ion de renta a Ia Administracion de Seguridad
Social (Social Security) y al Servicio de Rentas lnternas de los EE.UU. (IRS). La
ley exige adetm\s una verificacion independiente de Ia infonnacion sobre
mano de tipo [[[ (alquiler con opcion de compra) .
Oportunidad de adquisicion de vivienda propia con un sistema de ayuda
mutua.
Vivienda alquilada segun las disposiciones de las Secciones 23 y 19(c).
Pages de asistencia para vivienda segun las disposiciones de Ia Seccion
23.
Vivienda de propiedad de una HA para alquiler a comunidades indigenas.
Certificado de alquiler segt1n las disposiciones de Ia Seccion 8 de Ia Ley
de Viviendade los EE .UU. de 1937.
Cupon de alquiler segt1n las disposiciones de Ia Seccion 8.
Rebabilitacion moderada segun las disposiciones de Ia Seccion 8.
Omision de Ia firma del formulario de consentimiento: Si usted no fmna el
ingresos . Por lo tanto, el HUD o Ia HA puede so licitar informacion a
formulario de consentimiento se le puede revocar su idoneidad o se le pueden
instituciones fmancieras para verificar su idoneidad y el monte de los beneficios.
suspender los beneficios de vivienda, o ambas cosas. La revocacion de Ia idoneidad
Finalidad: A I fmnar este fonnulario de consentimiento, us ted autoriza al HUD y
o Ia suspension de los beneficios esta sujeta al procedirniento de presentacion de
a Ia HA mencionada para solicitar infonnacion sobre sus ingresos a las fuentes
quejas de Ia HA y de audiencia informal indicados en Ia Secci6n 8.
citadas en el fonnulario. Ambos organismos necesitan esa informacion para
verificar su ingreso familiar con el fin de cerciorarse de que usted reune las
Fuentes de acopio de informacion :
condiciones para recibir beneficios de asistencia para conseguir viv ienda y que
Entidades estatales de acopio de informacion sabre salaries . (Este
esos beneficios se fijen en el monte correcto. Tanto e l HUD como Ia HA pueden
consentirniento se lim ita a Ia indemnizaci6n por concepto de salario y desempleo
participar en programas electronicos de concordancia con estas fuentes para
que se me ha pagado periodicamente en los ultimos 5 aiios cuando he recibido
beneficios de asistencia para conseguir vivienda.) Administracion de Seguridad
verificar su idoneidad y el monte de los beneticios.
Social de los EE .UU. (solamente el HUD). (Este consentimiento se limita a Ia
formas de empleo de Ia informacion obtenida: Se exige que el HUD proteja
infonnacion sobre salario y empleo independiente y sobre el pago de ingreso de
Ia infonnacion obtenida sobre ingresos, de confonnidad con Ia Ley de
jubilacion, citados en Ia Seccion 6 103(l)(7)(A) del Codigo del Servicio de Rentas
Confidencialidad de 1974, Seccion 552a del Titulo 5 del Codigo de los EE .UU.
El HUD puede divulgar infonnacion (distinta de
Ia correspondiente a
lntemas de los EE .UU.)
Servicio de Rentas Intemas de los EE .UU . (IRS) (solamente el HUD). (Este
declaraciones de renta) para ciertas clases de usa ordinaria, par ejemplo, a otros
consentimiento se lim ita al ingreso no !aboral [por ejemplo, intereses y
organismos gubemamentales con fmes de aplicacion de Ia ley, a organ ismos del
dividendos] .)
gobiemo federal con fm es de detenninacion de Ia idoneidad para el empleo, y a
Tambien se puede obtener infonnacion directamente de : (a) los empleadores
las HA con el objeto de detenninar el manto de Ia asistencia para conseguir
actuates y anteriores, sobre sue ldos y salaries y (b) las instituciones fmancieras,
vivienda. Tambien se exige que Ia HA proteja Ia infonnacion sabre ingresos que
sobre ingresos no laborales (por ejemplo, intereses y di videndos). Ten go
obtenga, de confonnidad con cualquier ley estatal de confidencialidad aplicable
entendido que Ia intonnacion sobre ingresos obtenida de estas fuentes se
al caso. Los empleados del HUD y de Ia HA pueden estar sujetos a sanc iones par
empleara para veriticar Ia intonnacion proporc ionada por mi, con el fm de
divulgacion no autorizada o par uso impropio de Ia infonnacion sabre ingresos
detenninar mi idoneidad para participar en los programas de asistencia para
obtenida con el fomJUlario de consentimiento. Los propietarios particulares no
conseguir vi vienda y el monte de los beneticios. Por lo tanto , este tonnulario de
pueden solicitar ni recibir informacion autorizada por este formulario .
consentimiento so lamente autoriza Ia di vulgacio n de infonnacion directamente
Quien debe firmar el formulario de consentimiento : Cada familiar res idente
de los empleadores y las instituc iones financieras por cua lquier periodo de los
en Ia propiedad mayor de 18 aiios debe tinnar el fonnulario de consentimiento.
ultimos 5 aiios cuando he recibido bendicios de asistencia para conseguir
Es precise obtener Ia tinna de nue vas adultos que ingresen a Ia residencia o de
vivienda.
quienes cumplan 18 aiios.
La organizacion solicitante guarda el original.
Pagina I de 2
Formulario HUD-9886-Spanish (7/94)
Ref. Manuales 7420.7, 7420.8 y 7465.1
Consentintiento: Doy mi consentintiento para permitir que el HUD o Ia HA soliciten y obtengan informacion sobre ntis ingresos de las fuentes
citadas en este formulario con el fin de verificar mi idoneidad y el monto de los beneficios de conforntidad con los programas de asistencia
para vivienda del HUD. Tengo entendido que las HA que reciban informacion sobre ntis ingresos por medio del presente formulario de
consentintiento no pueden emplearla para denegar, reducir o suspender Ia asistencia sin efectuar primero una verificacion independiente del
monto correspondiente, si realmente tuve acceso a los fondos y cuando se recibieron. Ademas, se me debe dar Ia oportunidad de refutar esas
determinaciones.
Este formula rio de consentintiento se vence 36 meses despues de firmarlo .
Firrnas:
Jefe de familia
Fecha
No . del seguro soc ial (si existe) del jefe de familia
Otro familiar mayor de 18 aiios
Fecha
Conyuge
Fecha
Otro familiar mayor de 18 aiios
Fecha
Otro familiar mayor d~ 18 aiios
Fecha
Otro familiar mayor de 18 aiios
Fecha
Otro familiar mayor de 18 aiios
Fecha
Otro familiar mayor de 18 aiios
Fecha
Aviso sobre Ia Ley de Confidencialidad. Autoridad: El Departamento de Vivienda y Desarrollo Urbano (HUD) est<\ autorizado para acopiar esta
informacion en virtud de Ia Ley de Vivienda de los EE.UU. de 1937 (Seccion 1437 et seq . del Titulo 42 del Codigo de los EE.UU.), el Titulo VI de Ia
Ley de Derec hos Civiles de 1964 (Seccion 2000d del Titulo 42 del Codigo de los EE.UU.) y Ia Ley de Vivienda Justa (Seccion 3601-19 del Titulo 42
del Codigo de los EE.UU.). La Ley de Vivienda y Desarrollo Comunitario de 1987 (Seccion 3543 del Titulo 42 del Codigo de los EE.UU.) exige que
los solic itantes y pat1icipantes presenten el numero de seguro soc ial de cada familiar mayor de seis aiios de edad. Finalidad: El HUD usa Ia
infonnacion sobre sus ingresos y otra infonnacion acopiada para detenninar su idoneidad, el tamaiio apropiado de las habitaciones y el manto que
pagara su familia por alquiler y servicios publicos. Otros usos: el HUD usa Ia informacion sobre su ingreso familiar y otra informacion acop iada para
ayudar a administrar y supervisar los programas de ·vivienda realizados con asistencia de ese organismo, proteger el inten!s financiero del Gobiemo o
verificar Ia exactitud de Ia infonnac ion proporc ionada. Esta infonnacion puede divulgarse a entidades federates, estatales y locales idoneas, cuando
proceda, y a investigadores y fiscales encargados de tramitar casos civiles y penates y asuntos nonnativos. De lo contrario, Ia informacion nose
revelan\ ni divulgara fuera del HUD, excepto en los casas pennitidos o exigidos porIa ley. Sancion: Usted debe proporcionar toda Ia infonnacion
solicitada porIa HA, incluso el nt'unero de seguro social que tengan o usen usted y todos los demas familiares mayo res de seis aiios de edad. Es
obligatotio dar el nt'unero de seguro social
d~
todos los familiares mayores de seis aiios de edad; su otnision afectara su idoneidad . La omision de
cualquier parte de Ia infonnacion solicitada puede hacer que se demore o deniegue Ia aprobacion de su soli citud por razones de idoneidad.
Sanciones por el uso indebido del presente formulario de consentimiento:
El HUD, Ia HA y cualqu ier propi etatio (o empleado del HUD, Ia HA o el propietatio) pueden es tar sujetos a sa nc iones por divulgacion no autorizada
o por uso indeb ido de Ia infonnacion acopiada con el presente fonnulari o
d~
consentimiento.
El uso de Ia infonnac ion acopiada con el fonnulario HUD-9886 se limita a los fines citados en el mismo . Cualquier persona que, a sab iendas
0
intencionalmente, so licite, obtenga o revel e infonnacion de manera fraudulenta sobre un so lic itante o participante puede estar suj eta a acusacion por
deli to menor y a imposicion de una multa maxima de $5.000.
Cualquier solici tante o partic ipante afectado porIa divul gac ion negl igente de infonnac ion puede inicia r una acc ion ci vil por daiios y petjuicios contra
el oficial o funcionatio del HUD, Ia HA o el propietario responsable de Ia divulgac ion no autotizada o deluso indebido, o buscar otra indemnizacion
por pat1e d~ ellos, segt'tn proceda.
Este documento es traducci6n de un documento jurfdico expedido par el Departamento de Vivienda y Desarrollo Urbano
(HUD), el cua/ proporciona esta traducci6n solamente a modo de conveniencia para que le ayude a usted a comprender sus
derechos y obligaciones. La version en ingles es el documento oficial, legal y que rige. Esta traducci6n no constituye un
documento oficial.
La organizaci6n solicitante conserva el original.
Pagina 2 de 2
Formulario HUD -9886-Spanish (7/94)
Ref. Manuales 7420.7, 7420.8 y 7465.1
~gy
DECLARATION OF SECTION 214 STATUS
Notice to applicants and tenants: In order to be eligible to receive the housing assistance
sought, each applicant for or recipient of housing assistance must be lawfully within the
United States . Please read the Declaration statement carefully and sign and return to the
Housing Authority's Admissions Office. Please feel free to consult with an immigration
lawyer or other immigration expert of your choosing.
I,
certify, under penalty of perjury, that to
the best of my knowledge, I am lawfully within the United States because:
[ ]
OR:
[ ]
OR:
[ ]
I am a citizen by birth, naturalized citizen or national of the United States.
I have eligible immigration status and I am 62 years of age or older (attach proof of age).
I have eligible immigration status as checked below (see reverse side of this form for
explanations). Attach INS document(s) evidencing eligible immigration status and
signed verification consent form.
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
Immigrant stah1s under #I 00 I (a)( 15) or l Ol(a)(20) of the INA
Permanent residence under #249 of INA
Refugee, asylum or conditional entry status under #207, 208 or 203 of the
INA
Parole status under #212(d)(f) of the INA
Threat to life offreedom under #243(h) of the INA
Amnesty under #254 of the INA
Signature of Family Member
Date
[ ]
Check box if signature of adult residing in the unit is responsible for a child named on
statement above.
HA:
Enter INS/SAVE Primary Verification # _ _ _ _ _ _ _ _ _ Date_ _ __
Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and
willfully makes or uses a document or writing containing any false, fictitious or fraudulent
statement or entry, in any manner within the jurisdiction of any department or agency of
the United States, shall be fined not more than $10,000 or imprisoned for not more than five
years, or both.
[See reverse side for footnotes and instmctions]
The following footnotes pertain to noncitizens that declare eligible immigration status in
one of the following categories:
Eligible immigration status and 62 years of age or older: For noncitizens who are 62 years of
age or older or who will be 62 years of age or older and receiving ass istance under a Section 214
covered program on June 19, 1995. If you are eligible and elect to select this category, you must
include a document providing evidence of proof of age. No further documentation of eligible
immigration status is required.
Immigrant status under 101(a)(15) or 101(a)(20) of It~ A: A noncitizen lawfully admitted for
permanent residence, as defined by 101 (a)(20) of the Immigration and Nationality Act (INA), as
an immigrant, as defined by 10l(a)(15) of the INA
(8 U.S.C. 1101(a)(20) and 1101(a)(l5), respectively [immigrant status]. This category includes a ·
noncitizen admitted under 210 or 210A of the INA (8 U.S .C. 1160 or 1161), [special agricultural
worker status] who has been granted lawful temporary resident status.
Permanent residence under 249 ofiNA: A noncitizen who entered the U.S. before January 1,
1972, or such later date as enacted by law, and has continuously maintained residence in the U.S.
since then, and who is not ineligible for citizenship, bur who is deemed to be lawfully admitted
for pe1manent residence as a result of an exercise of discretion by the Attorney General under 249
of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].
Refugee, asylum or conditional entry status under 207, 208 or 203 ofiNA: A noncitizen who
is lawfully present in the U.S. pursuant to an admission under 207 of the INA (8 U.S.C. 1157)
[refugee status]; pursuant to the granting of asylum (which has not been terminated under 208 of
the INA (8 U.S .C. 1158) [asylum status]; or as a result of being granted conditional entry under
203(a)(7) of the INA (U.S.C. 1153(a)(7) before April! , 1980, because of persecution or fear of
persecution on account of race, religion or political opinion or because of being uprooted by
catastrophic national calamity [conditional entry status].
Parole status under 212(d)(5) ofiNA: A noncitizen who is lawfully present in the U .S. as a
result of an exercise of discretion by the Attorney General for emergent reasons or reasons
deemed strictly in the public interest under 212(d)(5) of the INA (8 U.S.C. 1182(d)(5) [parole
status].
Threat to life or freedom under 245(a) of INA: A noncitizen who is lawfully present in the
U.S. as a result of the Attorney General's withholding deportation under 243(h) of the INA (8
U.S.C. 1253(h)) [threat to life or freedom].
Amnestv under 245(a) of the INA: A noncitizen lawfully admitted for temporary or permanent
residence under 245(a) of the INA (8 U.S.C. 1255(a)) [amnesty granted under INA 245(a)].
Instructions to Housing Authority: Following verification of status claimed by persons
declaring eligible immigration status (other than for noncitizens age 62 or older and receiving
assistance on June 19, I 99 5), the HA must enter INS/SAVE Verification Number and date that
it was obtained. An HA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first
name, middle initial(s) and last name. Place an "x" in the appropriate boxes. Sign and date at
bottom page. Place an "X" in the box below the signature if the signature is by the adult
residing in the unit who is responsible for the child.
DECLARATION OF SECTION 214 STATUS
Notice to applicants and tenants: In order to be eligible to receive the housing assistance
sought, each applicant for or recipient of housing assistance must be lawfully within the
United States. Please read the Declaration statement carefully and sign and return to the
Housing Authority's Admissions Office. Please feel free to consult with an immigration
lawyer or other immigration expert of your choosing.
I,
certify, under penalty of perjury, that to
the best of my knowledge, I am lawfully within the United States because:
[ ]
OR:
[ ]
OR:
[ ]
I am a citizen by birth, naturalized citizen or national of the United States.
I have eligible immigration status and I am 62 years of age or older (attach proof of age).
I have eligible immigration status as checked below (see reverse side of this form for
explanations). Attach INS document(s) evidencing eligible immigration status and
signed verification consent form.
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
Immigrant status under # 1001 (a)( 15) or 101 ( a)(20) of the INA
Permanent residence under #249 of INA
Refugee, asylum or conditional entry status under #207, 208 or 203 of the
INA
Parole status under #212(d)(f) of the INA
Threat to life of freedom under #243(h) of the INA
Amnesty under #254 of the INA
Signature of Family Member
Date
[ ]
Check box if signature of adult residing in the unit is responsible for a child named on
statement above.
HA:
Enter INS/SAVE Primary Verification # _ _ _ _ _ _ _ _ _ Date_ _ __
Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and
willfully makes or uses a document or writing containing any false, fictitious or fraudulent
statement or entry, in any manner within the jurisdiction of any department or agency of
the United States, shall be fined not more than $10,000 or imprisoned for not more than five
years, or both.
[See reverse side for footnotes and instmctions]
The following footnotes pertain to noncitizens that declare eligible immigration status in
one of the following categories:
Eligible immigration status and 62 years of age or older: For noncitizens who are 62 years of
age or older or who will be 62 years of age or older and receiving assistance under a Section 214
covered program on June 19, 1995. If you are eligible and elect to select this category, you must
include a document providing evidence of proof of age. No further documentation of eligible
immigration status is required.
Immigrant status under 101(a)(15) or 101(a)(20) of INA: A noncitizen lawfully admitted for
permanent residence, as defined by 10l(a)(20) ofthe Immigration and Nationality Act (INA), as
an immigrant, as defined by 101(a)(15) of the INA
(8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a
noncitizen admitted under 210 or 21 OA of the INA (8 U.S.C. 1160 or 1161), [special agricultural
worker status] who has been granted lawful temporary resident status.
Permanent residence under 249 ofiNA: A noncitizen who entered the U.S . before January 1,
1972, or such later date as enacted by law, and has continuously maintained residence in the U.S.
since then, and who is not ineligible for citizenship, bur who is deemed to be lawfully admitted
for permanent residence as a result of an exercise of discretion by the Attorney General under 249
of the INA (8 U.S .C. 1259) [amnesty granted under INA 249].
Refugee, asylum or conditional entry status under 207, 208 or 203 ofiNA: A noncitizen who
is lawfully present in the U.S . pursuant to an admission under 207 of the INA (8 U.S.C. 1157)
[refugee status] ; pursuant to the granting of asylum (which has not been terminated under 208 of
the INA (8 U.S.C. 1158) [asylum status] ; or as a result of being granted conditional entry under
203(a)(7) of the INA (U.S.C. 1153(a)(7) before April!, 1980, because of persecution or fear of
persecution on account of race, religion or political opinion or because of being uprooted by
catastrophic national calamity [conditional entry status].
Parole status under 212(d)(5) of INA: A noncitizen who is lawfully present in the U.S. as a
result of an exercise of discretion by the Attorney General for emergent reasons or reasons
deemed strictly in the public interest under 212(d)(5) of the INA (8 U.S .C. 1182(d)(5) [parole
status].
Threat to life or freedom under 245(a) of INA: A noncitizen who is lawfully present in the
U.S. as a result of the Attorney General's withholding deportation under 243(h) of the INA (8
U.S.C. 1253(h)) [threat to life or freedom].
Amnestv under 245(a) of the INA: A noncitizen lawfully admitted for temporary or permanent
residence under 245(a) of the INA (8 U.S.C. 1255(a)) [amnesty granted under INA 245(a)].
Instructions to Housing Authority: Following verification of status claimed by persons
declaring eligible immigration status (other than for noncitizens age 62 or older and receiving
assistance on June 19, 1995), the HA must enter INS/SAVE Verification Number and date that
it was obtained. An HA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first
name, middle initial(s) and last name. Place an "x" in the appropriate boxes . Sign and date at
bottom page. Place an "X" in the box below the signature if the signature is by the adult
residing in the unit who is responsible for the child.
DECLARATION OF SECTION 214 STATUS
Notice to applicants and tenants : In order to be eligible to receive the housing assistance
sought, each applicant for or recipient of housing assistance must be lawfully within the
United States . Please read the Declaration statement carefully and sign and return to the
Housing Authority's Admissions Office. Please feel free to consult with an immigration
lawyer or other immigration expert of your choosing.
I,
certify, under penalty of perjury, that to
the best of my knowledge, I am lawfully within the United States because:
[ ]
OR:
[ ]
OR:
[ ]
I am a citizen by birth, nah1ralized citizen or national of the United States .
I have eligible immigration status and I am 62 years of age or older (attach proof of age).
I have eligible immigration stah1s as checked below (see reverse side of this form for
explanations). Attach INS document(s) evidencing eligible immigration stah1s and
signed verification consent form.
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
OR:
[ ]
Immigrant status under # 100 1(a)( 15) or 101 ( a)(20) of the IN A
Permanent residence under #249 of INA
Refugee, asylum or conditional entry status under #207, 208 or 203 of the
INA
Parole status under #212(d)(f) of the INA
Threat to life offreedom under #243(h) of the INA
Amnesty under #254 of the INA
Signature ofFamily Member
Date
[ ]
Check box if signature of adult residing in the unit is responsible for a child named on
statement above.
HA:
Enter INS/SAVE Primary Verification # _ _ _ _ _ _ _ _ _ Date _ _ __
Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and
willfully makes or uses a document or writing containing any false, fictitious or fraudulent
statement or entry, in any manner within the jurisdiction of any department or agency of
the United States, shall be fined not more than $10,000 or imprisoned for not more than five
years, or both.
[See reverse side for footnotes and instmctions]
The following footnotes pertain to noncitizens that declare eligible immigration status in
one of the follo wing categories :
Eligible immigration status and 62 years of age or older: For noncitizens who are 62 years of
age or older or who will be 62 years of age or older and receiving assistance under a Section 214
covered program on June 19, 1995 . Ifyou are eligible and elect to select this category, you must
include a document providing evidence of proof of age. No further documentation of eligible
immigration status is required.
Immigrant status under 101(a)(15) or 101(a)(20) of INA: A noncitizen lawfully admitted for
permanent residence, as defined by 10l(a)(20) of the Immigration and Nationality Act (INA), as
an immigrant, as defined by 101(a)(l5) ofthe INA
(8 U.S .C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a
noncitizen admitted under 210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural
worker status] who has been granted lawful temporary resident status.
Permanent residence under 249 of INA: A noncitizen who entered the U.S. before January 1,
1972, or such later date as enacted by law, and has continuously maintained residence in the U.S.
since then, and who is not ineligible for citizenship, bur who is deemed to be lawfully admitted
for permanent residence as a result of an exercise of discretion by the Attorney General under 249
of the INA (8 U.S .C. 1259) [amnesty granted under INA 249].
Refugee, asvlum or conditional entrv status under 207, 208 or 203 of INA: A noncitizen who
is lawfully present in the U.S . pursuant to an admission under 207 of the INA (8 U.S.C. 1157)
[refugee status] ; pursuant to the granting of asylum (which has not been terminated under 208 of
the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under
203(a)(7) of the INA (U.S.C. 1153(a)(7) before April 1, 1980, because of persecution or fear of
persecution on account ofrace, religion or political opinion or because of being uprooted by
catastrophic national calamity [conditional entry status].
Parole status under 212(d)(5) of INA: A noncitizen who is lawfully present in the U.S. as a
result of an exercise of discretion by the Attorney General for emergent reasons or reasons
deemed strictly in the public interest under 212(d)(5) of the INA (8 U.S .C. 1182(d)(5) [parole
status].
Threat to life or freedom under 245(a) of INA: A noncitizen who is lawfully present in the
U.S. as a result of the Attorney General's withholding deportation under 243(h) of the INA (8
U.S.C. 1253(h)) [threat to life or freedom].
Amnestv under 245(a) of the INA: A noncitizen lawfully admitted for temporary or permanent
residence under 245(a) of the INA (8 U.S.C. 1255(a)) [amnesty granted under INA 245(a)].
Instructions to Housing Authority: Following verification of status claimed by persons
declaring eligible immigration status (other than for noncitizens age 62 or older and receiving
assistance on June 19, 1995), the HA must enter INS/SAVE Verification Number and date that
it was obtained. An HA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first
name, middle initial(s) and last name. Place an "x" in the appropriate boxes. Sign and date at
bottom page. Place an "X" in the box below the signature if the signature is by the adult
residing in the unit who is responsible for the child.
C>RLANDC> H O U S I N G AUTHC>RITV
STUDENT ENROLLMENT VERIFICATION
Student Name: ------------------------------------------------------------Student SS#:--------------------------------------------------------------Student Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
The above names student's family is applying /re-certifying eligibility for housing assistance under a program
ofthe 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 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# : 407/894-71 72
www.orl-oha.org
TDD#: 407/894-989 1
• Relay#: 7 11
b(if
ORLANDO HOUSING AUTHORITY
STUDENT ENROLLMENT VERIFICATION
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 official
School Name: -------------------------------------------------------------School Address: __________________________________________________________
Child's arent 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 Number
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 40 7/895-3300 • Fax#: 407/894-7 172
www.orl-oha.org
TDD#: 407/894-989 1
• Relay#: 7 11
~til
OMB No. 2577-0266
Expires 08/31/2016
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes
per response. This includes the time for respondents to read the document and certify, and any record keeping burden. This
information will be used in the processing of a tenancy. Response to this request for information is required to receive
benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays
a currently valid OMB control number. The OMB Number is 2577-0266, and expires 08/31/2016.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
•
Public Housing (24 CFR 960)
•
Section 8 Housing Choice Voucher, including the Disaster
•
Section 8 Moderate Rehabilitation (24 CFR 882)
•
Project-Based Voucher (24 CFR 983)
~ousing
Assistance Program (24 CFR 982)
'
i
I
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-lis:ted HUD rental assistance programs. This information is
maintained within HUD's Enterprise Income Verification (EIV)! system, which is used by Public Housing Agencies (PH As)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors. , The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD riental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233 .
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights . PHAs are required to provide this notice to all applicants and program participants and you are
required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form .
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e . unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date.
08/2013
Form HUD-52675
OMB No. 2577-0266
Expires 08/31/2016
2
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs .
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants . PHAs will be able to access this information to determine a
family's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements . If the reported information is
accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,
subject to PHA policy.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:
1. To have access to your records maintained by HUD, subject to 24 CFR Part 16.
2. To have an administrative review of HUD's initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request .
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information
about you. The PHA' s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute . HUD's record retention policies at 24 CFR Part 908
and 24 CFR Part 982 provide that the PHA may d1=stroy your records three years from the date your participation in the
program ends. To ensure the availability of your records, disputes of the original debt or termination information must be
made within three years from the end of participation date; otherwise the debt and termination information will be
presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD's EIV system .
However, if you have included th is debt in your bankruptcy f iling and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status .
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute .
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record . If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature
Date
Printed Name
08/2013
Form HUD-52675
OMB No. 2577-0266
Expires 08/31/2016
U.S. Department of Housing and Urban Development
Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to ave rage 7 minutes
per response. This includes the time for respondents to read the document and certify, and any record keeping burden. This
information will be used in the processing of a tenancy. Response to this request for information is required to receive
benefits . The agency may not collect this information, and you are not required to complete this form , unless it displays
a currently valid OMB control number. The OMB Number is 2577-0266, and expires 08/31/2016.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
•
Public Housing (24 CFR 960)
•
Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
•
Section 8 Moderate Rehabilitation (24 CFR 882)
•
Project-Based Voucher (24 CFR 983)
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs . This information is
maintained within HUD's Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors . The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-l isted rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program . This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights . PHAs are required to provide this notice to all applicants and program participants and you are
required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form .
What information about you and your tenancy does HUD collect from the PHA?
The following information is collected about each member of your household (family composition): full name, date of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit :
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such as damages, utility charges, etc.); and
2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you ; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date .
08/2013
Form HUD-52675
OMB No. 2577-0266
Expires 08/31/2016
2
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs .
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants . PHAs will be able to access this information to determine a
family's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements . If the reported information is
accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance,
subject to PHA policy.
How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of
participation date.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights :
1. To have access to your records maintained by HUD, subject to 24 CFR Part 16.
2. To have an administrative review of HUD's initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your record corrected upon written request.
4. To file an appeal request of an initial adverse determination on correction or amendment of record request within
30 calendar days after the issuance of the written denial.
5. To have your record disclosed to a third party upon receipt of your written and signed request .
What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information
about you . The PHA's name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908
and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the
program ends. To ensure the availability of your records, disputes of the original debt or termination information must be
made within three years from the end of participation date; otherwise the debt and termination information will be
presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record .
Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD's EIV system .
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status .
The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.
If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record . If the PHA
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:
I hereby acknowledge that the PHA provided me with the
Debts Owed to PHAs & Termination Notice:
Signature
Date
Printed Name
08/2013
Form HUD-52675
ORLANDO HOUSING AUTHORITY
MOVING TO WORK (MTW) PUBLIC HOUSING AUTHORITY
Summary: Moving to Work (MTW) is a demonstration program for Public Housing Authorities (PHAs) that provides
them the opportunity to design and implement strategies to use Federal dollars more efficiently, help clients find
employ ment and become self-sufficient, and increase housing choices for low-income families . With the Moving to Work
designation, Public Housing Authorities are exempted from many of the Department of Housing and Urban Development
(HUD) rules and have more flexibility with how they use their Federalfimds.
MOVING TO WORK ACTIVITIES THAT AFFECT HOUSING ASSISTANCE
As an Moving To Work agency, the Orlando Housing Authority (OHA) has the opportunity to implement new policies
outside of the usual scope of HUD policies and regulations. Families whose Head or Spouse is Elderly or Disabled are
exempt from the Moving to Work program requirements. In situations where the Head or Spouse is not elderly or
disabled, and the household cannot pay the Minimum Rent, all adult household members who are 18 years or
older will be referred to the Moving to Work Resource Center if they are not employed.
OHA Moving to Work Program Policies Includes But Are Not Limited to the Following:
I. Minimum rent is $225.00- All new residents must pay a minimum of $225.00 for rent. This amount is not based on
your having a job or not. If you have a job when you are assigned a unit and you quit or lose the job once you move-in,
you are still required to pay a minimum of $225.00 toward your rent.
2. Hardship Exemption - Families who demonstrate a hardship in paying their rent can qualify for a temporary waiver.
The income for your household must have decreased due to mitigating circumstances as defined in ORA's Moving to
Work Agreement with the United States Department of Housing and Urban Development (HUD). The Orlando
Housing Authority (OHA) must review and approve your waiver request. If approved, the hardship rent is $100.00.
The family will also be required to participate in the self-sufficiency activities of the Moving to Work Resource Center.
3. Eliminate First $25,000.00 Assets - Assets includes but are not limited to the following: bank accounts, money market
accounts, certificate of deposits, stocks, bonds, etc. Assets less than $25,000.00 will not be included in the calculation
of income to determine your rent. However, you are required to report all assets including but not limited to the
following : bank accounts, property, insurance policies with cash value, etc.
4. Modify Third-Party - The Third Party verification requirements are modified to allow clients to provide proof of
mcome.
5. Exemption for Elderly and/or Disabled Households -Families whose Head or Spouse is Elderly or Disabled will be
recertified every three (3) years.
This is to certify that I have read the above Moving To Work Summary and understand the minimum rent requirements
and hardship exemptions. This form must be signed by all household members 18 years of age and over.
Applicant Signature
Other family member signature
Date
Other family member signature
OHAStalf ____________________________________________
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300
•Fax#: 407/894-7172
www.orl-oha.org
•
TDD#: 407/894-989 1 • Relay#: 7 11
l
~
0.~
ORLANDO HOUSING AUTHORITY
July 28, 2015
Dear OHA Residents or Participants:
RE:
Section 504 Voluntary Compliance Agreement
The purpose of this letter is to provide information about improvements the Orlando Housing Authority
("OHA") has agreed to voluntarily make to its properties, programs and activities. The improvements are
outlined in the Section 504 Voluntary Compliance Agreement with HUD 's Office of Fair Housing and
Equal Opportunity, also known as FHEO.
Section 504 of the Rehabilitation Act of 1973 is a body of law that prohibits discrimination on the basis of
disability in programs or activities, like those ofOHA that receive money from the federal government.
In order to make OHA' s properties and programs more accessible to persons with disabilities, OHA and
FHEO decided to enter a voluntary compliance agreement that clearly outlines how to improve access to
OHA for persons with disabilities by adhering to the following laws: Section 504, the Americans with
Disabilities Act, the Architectural Barriers Act, the Unifonn Federal Accessibility Standards and the Fair
Housing Act.
The following are examples of how OHA will improve access to its properties or programs:
•
•
•
OHA will construct or modify a minimum of 5% or 76 OHA housing units agency-wide into
accessible units (i.e., units that may be approached, entered and used by individuals in a
wheelchair). The construction ranges from minor or moderate modifications to major
rehabilitation. OHA is developing a schedule to implement these changes.
OHA will also modify some of its existing policies including but not limited to the transfer
policy, resident transportation, effective communication and reasonable accommodations.
OHA currently provides training to its employees on the laws pertaining to persons with
disabilities. OHA will supplement its educational program to improve employees' ability to
understand disability-related laws.
The Section 504 VCA is for a minimum term of 3 years during which time, OHA will report its progress
to FHEO. OHA is committed to the implementation of the tenns outlined in the VCA and will continue
to abide by disability-related laws even after the tennination of the agreement.
A copy of the agreement in its entirety is available for review on our website, www.orl-oha.org.
Sincerely,
Print Your Name
VWian 9J'Uf'Ul1
Vivian Bryant, Esq.
President/CEO
Sign Your Name
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel: (407) 895-3300 • Fax (407) 895-0820 • TDD (407) 894 -9891 • Relay#: 711
Page l of2
www.orl-oha.org
ORLANDO HOUSING AUTHORITY
28 de julio de 2015
Estimados residentes o participantes de OHA:
RE:
Acuerdo Voluntario de Cumplimiento de Ia Secci6n 504
El proposito de esta carta es proporcionar infonnacion sobre mejoras que Ia Autoridad de Vivienda de
Orlando (OHA) se compromete a realizar voluntariamente en sus propiedades, programas y actividades.
Las mejoras estim en el Acuerdo del Cumplimiento Voluntario de Ia Seccion 504 con HUD Ia oficina de
Vivienda Justa e Igualdad de Oportunidades, tambien conocido como FHEO.
La Seccion 504 de Ia Ley de Rehabilitacion de 1973 ("Ia Seccion 504") es un cuerpo de ley que prohibe Ia
discriminacion por discapacidad en programas o actividades, como las de OHA que reciben dinero del
gobiemo federal. Para hacer que los programas y propiedades de OHA sean mas accesible a las personas
con discapacidad, OHA y FHEO decidieron entrar en un acuerdo que claramente describe como mejorar el
acceso a OHA para las personas con discapacidades por medio de adhirirse a las siguientes !eyes: Ia
Seccion 504, Ia Ley de Americanos con Discapacidades, Ia Ley de Barreras Arquitectonicas, las Nonnas
Federales de Accesibilidad Unifonnes y Ia Ley de Vivienda Equitativa.
Los siguientes son ejemplos de como OHA mejorara el acceso a sus propiedades o programas:
•
•
•
OHA construira o modificara un minimo de 5% o 76 unidades de vivienda atraves de toda Ia
agencia y las hara accesible (es decir, unidades que puedan abordar, entrar y ser utilizadas por
personas en silla de ruedas). La construccion variara desde modificaciones !eves o moderadas
hasta rehabilitaciones mayores. OHA esta desarrollando una agenda para implementar estos
cambios.
OHA tambien modificara algunas de sus politicas existentes incluyendo pero no limitado a Ia
politica de traslado, transporte de los residentes, comunicacion efectiva y acomodaciones
razonables.
OHA actualmente provee adiestramiento a sus empleados en las !eyes con relacion a las personas
con discapacidades. OHA complementara su programa educativo para mejorar Ia capacidad de
los trabajadores a comprender las !eyes relacionadas con las discapacidades.
El VCA de Ia Seccion 504 dura un periodo minimo de 3 afios durante los cuales, OHA informara de su
avance a FHEO. OHA se compromete a Ia aplicacion de los tenninos expuestos en el VCA y continuara
cumpliendo las !eyes relacionadas con Ia discapacidad, incluso despues de Ia tenninacion del acuerdo.
Una copia del acuerdo en su totalidad esta disponible para revision en nuestro sitio web, www.orl-oha.org.
Sinceramente,
Escriba su Nombre en Letras de Molde
VWian fJJ'u;ant
Lcda. Vivian Bryant
Pres identa/CEO
Finne su Nombre
390 N. Bmnby Avenue, Orlando, Florida 32803 • Tel: (407) 895-3300 • Fax (407) 895-0820 • TDD (407) 894-989 I • Relay#: 7 I I
Page 2 of2
www.orl-oha.org
e
~(!)
~
::::
114
U.S. Department of Housing and Urban Development
Office of Inspector General
Things You
Should Know
Don't risk your chances for Federally assisted housing by providing false, incomplete, or inaccurate
Information on your application forms.
Purpose
This is to inform you that there is certain information you must provide when applying
for assisted housing. There are penalties that apply if you knowingly omit information or give false information.
Penalties
The United States Department of Housing and Urban Development (HUD) places a high
For
priority on preventing fraud. If your application or recertification forms contain false or
Committing incomplete information, you may be:
Fraud
•
•
•
•
•
Evicted from your apartment or house:
Required to repay all overpaid rental assistance you received:
Fined up to S 10,000:
Imprisoned for up to 5 years; and/or
Prohibited from receiving future assistance.
You're State and local governments may have other laws and penalties as well.
Asking
Questions
When you meet with the person who is to fill out your application, you should know what
is expected of you. If you do not understand something, ask for clarification. That person
. can answer your question or find out what the answer is.
Completing
The
Application
Income
When you answer application questions, you must include the following information:
•
•
•
•
•
All sources of money you or any member of your household receive (wages, welfare
payments, alimony, social security, pension, etc.):
Any money you receive on behalf of your children (child support, social security for
children, etc.);
Income from assets (interest from a savings account, credit union, or certificate of deposit:
dividends from stock, etc.);
Earnings from second job or part time job;
Any anticipated income (such as a bonus or pay raise you expect to receive)
Assets
•
•
•
All 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.
Any business or asset you sold in the last 2 years for less than its full value, such as your
home to your children.
The names of all of the people (adults and children) who will actually be living with you,
whether or not they are related to you.
Signing the
Application
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
www.orl-oha.org
U.S. Department of Housing and Urban Development
Office of Inspector General
•
•
•
Do not sign any form unless you have read it, understand it, and are sure everything is
complete and accurate.
When 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.
Information 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.
Re-certifications:
You must provide updated information at least once a year. Some programs
require that you report any changes in income or family/household composition
immediately. Be sure to ask when you must recertify. You must report on recertification forms:
•
•
•
Beware of
Fraud
You should be aware of the following fraud schemes:
•
•
•
•
•
Reporting
Abuse
All income changes, such as increases of pay and/or benefits, change or loss of job and/or
benefits, etc., for all household members.
Any move in or out of a household member; and,
All assets that you or your household members own and any assets that was sold in the last 2
years for less than its full value.
Do not pay any money to file an application;
Do not pay any money to move up on the waiting list;
Do not pay for anything not covered by your lease;
Get a receipt for any money you pay; and,
Get a written explanation if you are required to pay for anything other than rent (such as
maintenance charges).
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 at (800) 347-3735. You can also write to: HUD-OIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington,
DC. 20410. HUD- 1140-0IG THIS DOCUMENT MAY BE REPRODUCED WITHOUT PERMISSION.
Date
Signature of Head of Household
Date
Signature of Other Adult
Date
Signature of Other Adult
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895 -3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
www.orl-oha.org
ORLANDO HOUSING AUTHORITY
Applicant/renant Certification
ATTACHMENT TO FORM HUD-50058
1/We certify that the information given to the Orlando Housing Authority on Household
composition income, net family assets, allowances and deductions is accurate and complete to the
best of myfour knowledge/belief. 1/We understand that I have ten (10) business days in which to
report, in writing, any changes that may occur in my household income and/or composition. The
change must be brought into the office. Facsimile (fax) and phone messages are unacceptable
forms of reporting.
1/We understand that false statements or the giving of false information is punishable under
Federal law. 1/We also understand that false statements or information are grounds for
termination of housing assistance and termination of tenancy.
(*Your signature on this form verifies that you have read and understood the above statements.*)
Signature of Head of Household
Date
Signature of Spouse/Other Adult Member
Date
Signature of Other Adult Member
Date
Signature of Other Adult Member
Date
If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity
National Toll-free Hot Line at 1-800-424-8590.
After verification by this Housing Agency, this information will be submitted to the Department of
Housing and Urban Development on a Form HUD-50058 (Tenant Data Summary), by a computergenerated facsimile or on a magnetic tape. See the Federal Privacy Act Statement for more information
about its use.
®
390 N. Bum by Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
Revised 02/ 16
www.orl-oha.org
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ORLANDO HOUSING AUTHORITY
Certificaciou de Solicitaute/luquiliuo
ADJUNTO AL FOKMULAKIO HUD-5oo5s
YojNosotros certifico que Ia informacion proporcionada a Ia Autoridad de Vivienda de Orlando sabre el
ingreso de Ia composicion del hagar, los bienes netos de Ia familia, contribuciones y las deducciones es
exacta y completa a lo mejor de mijnuestro conocimientojcreencias. YojNosotros entiendo que tengo
diez (10) dias laborables para informar, por escrito, cualquier cambia que pueda ocurrir en los ingresos
del hagar y jo com posicion. El cambia debe ser llevado a Ia oficina. Facsimil (fax) y mensajes de telefono
son formas inaceptables de reportar cam bios.
YojNosotros entiendo que las declaraciones falsas o Ia entrega de informacion falsa son punibles bajo Ia
ley federal. Yojnosotros tambien entiendo que las declaraciones o informacion falsa es motivo para Ia
terminacion de Ia asistencia de vivienda y Ia terminacion del alquiler.
(*Su firma en este formulario verifica que usted ha leido y entendido las declaraciones anteriores. *)
Firma del Jefe de Familia
Fecha
Firma de C6nyugej0tro Miembro Adulto
Fecha
Firma de Otro Miembro Adulto
Fecha
Firma de Otro Miembro Adulto
Fecha
Si usted cree que ha sido discriminado, puede Hamar a Ia Equidad de Vivienda e Igualdad de
Oportunidades Nacional, Hamada gratuita all-800-424-8590.
Tras Ia verificacion por esta Agencia de Ia Vivienda, esta informacion se presentara a! Departamento de
Vivienda y Desarrollo Urbano en un Formulario HUD- 50058 (Resumen de Datos de Inquilino), por un
facsimil generada a computadora o en una cinta magnetica. Consulte Ia Declaracion de Ley Federal de
Privacidad para obtener mas informacion acerca de su usa.
6, ®
390 N. Bum by Ave. Orlando, FL 32803 • Phone: ( 407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
www.orl-oha.org
ORLANDO HOUSING AUTHORITY
APPLICATION/TENANT CERTIFICATION
GIVING TRUE AND COMPLETE INFORMATION
I certify that all the information provided on household composition income, family assets and items for allowances and
deductions is accurate and complete to the best of my knowledge. I have reviewed the application form and the HUD Form
50058 or 50059, whichever applies to me, and certify that the information shown is true and correct.
REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION
I know I am required to report changes in income and any changes in the household size when a person moves in or out of
the unit. I understand the rules regarding guests/visitors and when I must report anyone who is staying with me.
REPORTING ON PRIOR HOUSING ASSISTANCE
I certify that I disclosed whether I received any previous Federal Housing Assistance, and whether or not any money is owed.
I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information, or vacate the
unit in violation of the lease.
NO DUPLICATE RESIDENCE OR ASSISTANCE
I certify that that the house or apartment will be my principal residence and I will not obtain duplicate Federal Housing
assistance while I am on this current program.
COOPERATION
I know I am required to cooperate in supplying all information needed to determine any eligibility, level of benefits, or verify
my true circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I
understand failure or refusal to do so may result in delays, termination of assistance, or eviction.
CRIMINAL AND ADMINISTRATIVE ACTIONS FOR FALSE INFORMATION
I understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State
criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination
of housing assistance and/or termination of tenancy.
SIGNATURE AND DATE OF HOUSEHOLD ADULTS
1.
2.
3.
4.
390 N. Bumby Avenue, Orlando, Florida 32803
Tel#: 407/895-3300 • Fax#: 407/894-7172
www.orl-oha.org
TDD#: 407/894-9891
• Relay#: 711
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ORLANDO HOUSING AUTHORITY
Verification of Employment
Date: _ _ _ _ _ __
Client Number: _ _ _ _ _ _ __
Name of Employee:
AddressofEmployee: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Social Security Number: _ _ _ _ _ _ _ _ _ _ __
Please Complete The Following Information
(This Portion is to be completed by the Employer)
Job Title: _ _ _ _ _ _ _ _ _ _ __
Hire Date: _ _ _ _ _ _ _ _ _ _ __
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: _ _ __
Effective Date: _ _ __ _
Anticipated Pay Increase: Proposed new pay rate$
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 from _ _ _ _ _ _ _ _ _ _ to _ _ _ _ _ _ _ __
NameofEmployer: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Address of E m p l o y e r : - - - - - - - - - - - - - - - - - - - - - - - - - - City _ _ _ _ _ _ _ _ _ _ _ _ State _ _ _ _ _ _ _ _ Zip Code _ _ _ __
Phone ______________ Fax: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
Completed By: _ _ _ _ _ _ _ _ _ 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**
390 N. Bumby Ave. Orlando, FL 32803 • Phone: ( 407) 895-3300 • Fax: ( 407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
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ORLANDO HOUSING AUTHORITY
Verificacion De Empleo
Fecha: _ _ _ _ __
Numero de Cliente: _ _ _ _ _ __
Nombre De Empleado: - - - - - - - - - - - - - - - - - - - - - - - - - Direcci6n de Empleado: - - - - - - - - - - - - - - - - - - - - - - - - - #de Segura Social: _ _ _ _ _ _ _ _ _ _ _ _ __
Por Favor Complete La Siguiente Informacion
(Esta Porci6n Debe Ser Completada Par Empleador)
Titulo de Trabajo : _ _ _ _ _ _ _ _ _ __
Fecha de Contracci6n: _ _ _ _ _ __
Ingreso Bruto:
Numero promedio de horas trabajadas por semana:
Pago por hora: $_ _ _ __
Periodo de pago (Semanal), (Bi-Semanal), (Mensual), (Semi-Mensual): _ _ _ _ _ _ _ _ _ _ _ __
Promedio de horas de tiempo extra:________
Pago: $_ _ _ _ _ _ _ _ __
Promedio de propinas semanales: $
Promedio de comisiones semanales: $_ _ _ _ __
Incremento de sueldo anticipado: Nueva propuesta tarifa de pago: $ _ _ _ _ Fecha efectiva: _ _ _ __
Registro de ganancias: Ingresos brutos del afio pasado: $ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Esta cantidad fue ganada de:
a _ _ _ _ _ _ _ _ __
**Si este empleado es un empleado de temporada, por favor proporcione un salario bruto anual**
(Un ejemplo podria ser un empleado del sistema escolar)
Ingreso Bruto Anual $_ _ _ _ _ _ __
Esta cantidad fue ganada de: _ _ _ _ _ _ _ _ _ _ _ a _ _ _ _ _ _ _ _ _ __
NombredelEmpleador: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ____
Direcci6n de Empleador: - - - - - - - - - - - - - - - - - - - - - - - - - - - - Ciudad _ _ _ _ _ _ _ _ _ _ Estado _ _ _ _ _ _ _ _ _ C6digo Postal _ _ _ _ _ __
Telefono: ____________________ Fax: _ _ _ _ _ _ _ _ _ _ _ _ _ __
Completado Por: _ _ _ _ _ _ _ _ _ _ _ Titulo: _ _ _ _ _ _ _ _ _ Fecha: _ _ _ _ __
Nota lmportante : El C6digo, Titulo 18 (Procedimiento Penal), Secci6n 1001, de Los Estados Unidos hace que sea un
delito penal el hacer deliberadamente una declaraci6n falsa o representaci6n con respecto a cualquier asunto
dentro de Ia jurisdicci6n o agencia de los Estados Unidos.
**POR FAVOR PROPORCIONE LA HISTORIA DE NOMINA Sf LAS HORAS VARIAN**
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
www.orl-oha.org
ORLANDO HOUSING AUTHORITY
Employee Name: - - - - - - - - - - - - - Address:
Social Security No.: - - - - - - - - - - -
-----------------------------------------------------------------------------------VERIFICATION OF TERMINATION OF EMPLOYMENT
vVe are required to verify, through the Employer, the termination of employment for all applicants and/ or tenants
in, our lmv-rent housing progTam. We ask your cooperation in supplying this required information. In no e\Tnt
should the employee fill out this f(mn . The timekeeper, bookkeeper, or accountant should fill out this form .
Employer/ Company Name: - - - - - - - - - - -- - - -- - - - - -- - - -- - - - - - - - Address: - - - - - - - -- - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - Termination Date: - - - - - - - - - - - - -- - -- - - - -
Hire Date:
Last Date Employee Aclually V.,Torked _ _ _ _ _ _ _ __
vVill the employee receive any additional pay for unused annual or sick leave?
D Yes
DNo
If the answer to the above is yes, state the amount the employee vvill receive. $- - - - - - - -
vVill the employee receive any additional paychecks for any worker's compensation?
DYes
D No
If yes, give the name and address of the company through "vhich this may be verified:
Company Name:
Telephone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Address:
Reason for T ermination:
D Employee Quit
D Terminated for Cause
D Lack of vVork
D Other
If terminated for lack of work or other, do you anticipate rehiring this employee?
DYes D No
If yes, when? - - - - - - - - - - - - - - - - -- - -- - - - - - - - - - - - - - - - - - - Prinled Name{ fitle of Autl1orized Representative
Phone
Signalure of Authorized Representative
Date
OHAUSEONLY
VerifiedBy: _ _ _ _ _ _ _ _ _ _ __
Complex: - - - - - - - - - - - - - - - - - Spoke With:
Section 8: - - - - - - - - - - - - - - - Date:
Admission & Occupancy:
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891
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ORLANDO HOUSING AUTHORITY
Nombre de Empleado: _ _ _ _ _ _ _ _ _ _ __
#Segura Social: _ _ _ _ _ _ __
Direcci6n: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
VERIFICACION DETERMINACION DE EMPLEO
Estamos obligados a verificar, a traves del empleador, Ia terminaci6n de empleo para todos los
solicitantes y I o inquilinos de nuestro program a de viviendas de bajo costa. Pedimos su colaboraci6n en
el suministro de esta informacion requerida. En ningun caso debe el empleado completar este formulario.
El cronometrador, contable, o contador debe completar este formulario.
EmpleadorjNombre de Compafiia: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Direcci6n: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Fecha de Contrataci6n: _ _ _ _ _ _ _ _ _ __
Fecha de Terminaci6n: _ _ _ _ __
Ultimo dia que el empleado actualmente trabajo: _ _ _ _ _ _ _ _ __
El empleado recibira algun pago adicional par licencia anual y par enfermedad no utilizada? OSi
DNa
Si Ia respuesta arriba es Si, indique Ia cantidad que el empleado recibira. $_ _ _ _ __
El empleado recibira alglin pago adicional par compensaci6n del trabajador? OSi
DNa
En caso afirmativo, dar el nombre y direcci6n de Ia empresa a traves del cual esto puede ser verificado:
Nombre de Compafifa:
Telefono: _ _ _ _ _ _ _ __
Direcci6n: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Raz6n par Terminaci6n:
DEmpleado Renunci6
DTerminado par Causa
0
Dotros
Falta de Trabajo
Si fue cancelado por falta de trabajo u otros, usted anticipa volver a contratar este empleado? Osi DNa
Encasoafirmativo,cuando? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~
Imprima Nombre/Titulo de Representante Autorizado
Telefono
Firma De Representante Autorizado
Fecha
OHA USE ONLY
Complex: _ __ __ _ _ _ _ _ __
Verified By: _ _ _ _ _ _ _ _ __ _ _
Spoke With: _ _ _ _ _ _ _ _ _ __
Section 8:- - - - - - - - - - - - Admission & Occupancy: _ _ _ _ __
Date:
--------------~
®
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
Revised 07/ 15
www.orl-oha.org
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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 child 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
Man- 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
Historial 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
Man- 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 Flmida 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.
ORLANDO HOUSING AUTHORITY
CHILD SUPI:tORTAFFIDAVrr
I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ , do herby swear or affirm that I DO/DO Not receive child support for:
Applicant
Child' s Name
SS#
DOB
Child' s Name
SS#
DOB
Child's Name
SS#
DOB
Child's Name
SS#
DOB
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.
STATEl\'IENT 01~ AUTHOIUZATION
I,
, authorize the Department of Revenue to release any
information or material which is deemed necessary to complete my determination of eligibility for
participation.
Applicant Signature
Address
SS#
Date
City, State and Zip Code
Phone#
To Be Completed By The Department of Child Support Enforcement, Please Affix or Stamp Below:
) The Above mentioned person HAS/HAS NOT registered with our agency and HAS/HAS NOT received child
support payments
( ) Find Attached record on child support paid to the custodial family for the past 12 months
DOR Representative (Signature)
Date
®
390 N. Bumby Ave. Orla ndo, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172• TDD: (407) 894-9891 Relay#: 711
www.orl-oha .org
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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*
NAME: _ _ _ _ _ _ _ _ __
ELEPHONE: _ _ _ _ __
I CERTIFY THAT MY AVERAGE WEEKLY [],BI-WEEKLY []BI-MONTHLY []OR MONTHLY []
INCOME FROM---------,-- - -- - IS$ _ __ _ __
(Source of Income)
[]DAY WORK
[ ]CHILD SUPPORT
PLEASE CHECK ONE OF THE FOLLOWING
[]TIPS
[ ] COSMETOLOGY
[]LAWNCARE
[ ]FAMILY MEMBER
[]OTHER: _ _ _ _ _ _ _ _ _ _ _ __ _ __ _ _ _ _ _ _ _ _ ___
IF THE SOURCE IS A FAMILY MEMBER:
NAME: _ _ _ _ _ __ _ _ __ _
RELATIONSHIP: _ _ _ _ _ _ _ __
TELEPHONE NUMBER: _ _ _ _ _ _ _ _ _ __
Signature- Section 8/ Public Housing Resident
Date
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.
WITNESS
NOTARY
SEAL: ---------------------------
PRINT NAME
SIGNATURE
NAME
DATE
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300 • Fax#: 407/894-7172
www.orl-oha.org
•
TDD#: 407/894-989 1 • Relay#: 711
b1il
ORLANDO HOUSING AUTHORITY
DECLARACION DE INGRESOS IRREGULAR Y NO-VERIFICADOS
*Este Formulario debe ser completado si usted es pagado en efectivo o es empleado propio*
Nombre: _______________
Telefono: _ _ _ _ _ _ _ _ __
CERTIFICO QUE Ml PROMEDIO DE INGRESO: SEMANAL ( ) BI-SEMANAL ( ) 81-MENSUAL ( ) MENSUAL ( )
De: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Es$ _________________________
(Fuente de Ingreso)
POR FAVOR INDIQUE UNA DE LAS SIGUIENTES
( ) TRABAJO DIARIO
( ) MANUTENCION DE NINOS
( ) PROPINAS
( ) COSMETOLOGIA
( ) CUIDADO DEL CESPED
( ) MIEMBRO DE LA FAMILIA
()OTRO: ____________________________________________________
SI LA FUENTE DE INGRESOS PROVIENE DE UN MIEMBRO DE LA FAMILIA:
NOMBRE: _____________________
RELACION: -------------------------
TELEFONO: ____________________
Firma- Partici ante de Secci6n 8/Residente de Vivienda Publica
Fecha
Entiendo que el C6digo Titulo 18 de Estados Unidos( Crfmenes y Procedimientos Penales) Secci6n 1001, hace que sea un delito penal el hacer
una declaraci6n intencionalmente falsa o representaci6n con respecto a cualquier asunto dentro de Ia jurisdicci6n de cualquier departamento o
agencia de los Estados Unidos, y ademas, que el fall a de declarar correctamente mis ingresos se considera fraude y puede resultar en Ia
terminaci6n de mi asistencia de vivienda o Ia eliminaci6n de Ia lista de espera par causa
TESTIGO
NOT ARlO
SELLO: _ _ _ _ _ _ _ _ _ _ _ ___
IMPRIMA NOMBRE
FIRMA
NOMBRE
FECHA
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172 • TDD: (407) 894-9891 Relay#: 711
Revised 07/ 15
www.orl -oha.org
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ORLANDO HOUSING AUTHORITY
Client #: _ _ _ _ _ _ _ _ _ __
FINANCIAL ASSISTANCE
To:
The Orlando Housing Authority
Choose one of the following:
D
I certify that my husband, wife, domestic patiner, 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
immediate! y.
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:
OHA Representative
390 N. Bumby Avenue, Orlando, Florida 32803 • Tel#: 407/895-3300 • Fax#: 407/894-7 172 • TDD#: 407/894-989 1
www .orl-oha.org
•
Relay#:7 11
b.®
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
program a.
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 his to rial de sus Cupones de Alimentos y Asistencia en efectivo (T ANF).
http://www.mvflorida.com/accessflorida
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
C>RLANDC> HOUSING AUTHC>RITV
DECLARATION OF ASSETS
Client Must Bring Proo(o(Each Asset
Do you or any family members have an account?
(
) YES
or
(
) NO
Name of bank/credit union: --------------------------------------------------------------------Checking Account Balance$_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Savings Account Balance $_____________________________________
Do you or any family members have a whole life insurance policy?
Whole Life Policy (
) YES or
(
) NO
If any cash value; how much?$_______
(
) YES
Term Life Policy
(
or
(
) YES
)NO
or
(
) NO
_ _ _ _ _ _ _ _ _ __
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 of Funds $
Type
-----------------------------
ValueofFunds$ _______________________________ 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 $_ __ _ _ _ _ _ _ _ __
Do you or any adult family members have any personal items that you hold as investments? (
) YES or ( ) NO
(Examples .... antique car, coins, or stamp collections, etc..)
Item type_______________________________
Value ofItem_______________
Item type_______________________________
Value ofItem__________________________
The above statements are full , true and complete to the best of my knowledge. I understand that the United States Code, Title 18 (crimes and
criminal procedures) Section 100 1 makes it a criminal offense to make a willfully false statement or representation concerning any matter within the
jurisdiction of any department or agency of the United States.
Signature
Date
**ALL ADULTS HOUSEHOLD MEMBERS AGE 18 AND OLDER MUST SIGN A FORM
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300
•
Fax#: 407/894-7172
www.orl-oh a.org
•
TDD#: 407/894-9891
•
Relay#: 7 11
~~
CHILD CARE VERIFICATION
TO WHOM IT MAY CONCERN: Public Housing Authorities are required by Federal Law to verify any Chi ld
Care costs paid by their applicants so that the costs may be taken into consideration when the rent is computed
for the family. You will note that the head of household has signed a release below, giving you permission to
provide us this information.
Sincerely,
Orlando Housing Authority
(This Portion is to be com leted by the Child Care Provider
VERIFICATION:
I certify that I provide care for _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, (name of
children) cared for who reside in the household of the person signing release below.
I care for the children so that a family member can: (check as applicable) o Work
In the year beginning _ _ _ _ and ending
, I will be caring for the child(ren)
__________ weeks per year. My rate of pay is$
D once a week
D Go to School
D every two weeks
hours per week,
per hour, and I will be paid:
D once a month
Care during the week will be offered as follows:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
hours
hours
hours
hours
hours
hours
hours
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date _ _ _ _ _ _ _ _ _ _ __
Signature
- - - - - - - - - - - - - - - - - - - - - - - - - Phone# - - - - - - - - - - - - Title:
TENANT/ APPLICANT RELEASE
I, ________________, hereby authorize the release of the requested information.
_________________________ Date: _ _ _ _ _ _ _ _ _ _ _ ____
Signature
PENALTIES FOR MISUSING THIS CONSENT: Title18, Section 1001 of the U.S. Code states that a person is gui lty of a felony for knowingly and wi llingly 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 $5000. Any applicant
or participant affected by negligent disclosure of information may bring civil action for damages and seek other re li ef, as may be appropriate, against the
officer or employee of HUD or the owner responsible for the un authorized disclosure or improper use . Penalty provisions for misusing the social security
number are contained in the Socia l Security act (a) (6), (7) and (8). Violations of these provision s are cited as violations of 42 USC 408 (a), (6), (7) and (8).
390 N. Bumby Avenue, Orlando, Florida 32803
Tel# : 407/894-1 500
•
Fax#: 407/894-7 172
www.orl-oha .org
•
TDD#: 407/894-989 1 • Relay#: 7 11
6-tir
ORLANDO HOUSING AUTHORITY
Verificacion de Cuidado de Nifios
A QUIEN PUEDA INTERESAR: Las Autoridades de Vivienda Publica estan obligadas porIa Ley Federal, a verificar
los costos de cuidado de nifios pagados por sus solicitantes para que los costos sean considerados cuando Ia renta
es calculada para Ia familia. Usted notara que el cabeza de familia ha firmado el comunicado aquf debajo que le da a
usted permiso para proporcionarnos esta informacion.
Sinceramente,
Autoridad de Vivienda de Orlando
VERIFICACION:
Yo certifico que cuido a
(nombre del nifio (s) que
cuide), los cuales residen en el hogar de Ia persona quien firma debajo.
Yo cuido los nifios para que un miembro de Ia familia pueda: (indique el que corresponda)
OTrabajar
Dlr a La Escuela
En el afio empezando ________ y terminando
yo estare cuidando del
nifio(s):
horas a Ia semana,
semanas a! afio. Mi tarifa de pago es de$ _ _ por
hora, y se pagara:
OUna Vez a Ia Semana
OCada Dos Semanas
DUna Vez AI Mes
El cuidado durante Ia semana se ofrecera como sigue:
Lunes:
Martes:
Miercoles:
Jueves:
_ _ _ _ _ horas
_ _ _ _ _ horas
_ _ _ _ _ horas
_ _ _ _ _ horas
Viernes:
Sabado:
Domingo:
Nombre:
Firma:
Titulo:
_ _ _ _ _ horas
_ _ _ _ _ horas
_ _ _ _ _ horas
Fecha:
Telefono: _ _ _ _ _ _ _ __
DIVULftACION INQUJJ,JNO/SOl.. ICI'I'AN'I'E
Yo, _________________ porIa presente autorizo Ia divulgaci6n de Ia informacion
solicitada.
Fecha
Firma
Las sanciones por falta este consentimiento : Titulo 18, Seccion 1001 del Codigo de los Estados Unidos declara que una
persona es culpable de un delito grave por hacer a sabiendas y voluntariamente declaraciones falsas o fraudulentas a
cualquier departamento del Gobierno de Estados Unidos, el HUD y cualquier comprador (o cualquier empleado de HUD o el
propietario) puede ser objeto de sanciones por las divulgaciones no autorizadas o usos indebidos de la informacion
recopilada en base a la forma de consentimiento. El uso de la informacion recopilada sobre la base de este formulario de
verificacion se limita a los fines antes citados. Cualquier persona que solicite a sabiendas o voluntariamente, obtiene, o revela
ninguna informacion de manera fraudulenta en re lacion con un solicitante o participante puede ser sometido a un delito
menor y una multa de no mas de $ 5,000. Cualquier solicitante o participante afectado por la divulgacion negligente de
informacio n puede iniciar una accion civil por daiios y buscan otra forma de reparacion, como puede ser el caso, contra el
funcionario o empleado de HUD o el propietario responsable de la divulgacion no autorizada o uso ind ebido. Disposiciones se
aplican multas por mal uso del numero de seguro social estan contenidas en la Ley de Seguridad Social (a), (6), (7) y (8) .
Violaciones de estas disposiciones se citan como violaciones de 42USC 408 (a), (6), (7) y (8)
390 N. Bumby Ave. Orlando, FL 32803 • Phone: (407) 895-3300 • Fax: (407) 894-7172• TDD: (407) 894-9891 Relay#: 711
www.orl-oha.org
~®
e
-~--
OM'OH I U.ITY
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 Authority 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: -------------------
**ALL ADULTS HOUSEHOLD MEMBERS AGE 18 AND OLDER MUST SIGN A FORM
390 N. Bumby Avenue, Orl ando, Florida 32803
•
Tel#: 407/895-3300 • Fax#: 407/894-7 172
www .orl-oha.org
•
T DD#: 407/894-989 1 • Relay# : 7 11
~e
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.go 1 and click on Order a Return or Account Transcript;
Call 1-800-908-9946 and follow the voice prompts; OR (407) 660-5830
Mail the IRS Form 4506-T (or Form 4506-T-EZ), Request for Transcript ofTax Return
Walk-in, at 850 Trafalgar Ct. Maitland, FL 32751. Monday-Friday from 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 Intemas (IRS) .
•
•
Si usted complet6 y/o someti6 impuestos el pasado afio, usted debeni proveer copia de Ia
transcripci6n de los impuestos.
Si usted NO complet6 y/o someti6 impuestos el pasado aiio, entonces debeni proveer una
verificaci6n de no-completado del IRS.
Hay 4 maneras de obtener esta informacion:
1. Vaya online: ~vww . irs.gO\' y pres ione el bol6n de ordemu- una lranscripci6 n de los Impucslos.
2. Llamar 1-800-908-9946 y seguir las instrucciones en el telefo no; o
3. Envi<u- por correo Ia Forma de IHS 4506-T (o Ia Forma IHS 4506-T-EZ)- Solicitud de Ia Tr<mscripci6 n
de los Impuestos
4. Entrar, at 850 Trafalgar Ct. Maitland, FL 32751. Monday-Friday from 8: 30am-4:30pm.
ola: Si Ia trcmscripci6 n es enviada por con-eo a su casa, tome en cuenla gue sc tcu-dara de 5 a 10 elias en
recibirla.
ORLANDO HOUSING AUTHORITY
LEAD IN WATER NOTIFICATION
The Orlando Housing Authority and Orange County Public Utilities Division are publishing this notice to
inform you of the potential adverse health effects of lead. This is being done even though your water may
not be in violation of the current standards. The Environmental Protection Agency, your Authority and
others are concerned about lead in drinking water. Too much lead in the body can cause serious damage
to the brain, kidneys, nervous system and red blood cells. The greatest risk, even with short-term
exposure, is to young children and pregnant women. Lead in our environment is a public health issue
about which we should all be concerned. Lead is a soft metal, which is now known to be harmful to
human health if consumed or inhaled. Since lead accumulates in the body, its potential for harm depends
upon the level of exposure from all sources.
There are three potential sources for lead to accumulate in the body. The major source is from food and
lead is also inhaled from the air. The other potential source of lead is from your drinking water. Drinking
water produced by Orange County Water Department is below the exposure level established for lead by
the EPA, however tap water may contain lead leached from the pipes in your home. If drinking water is
determined to have high levels of dissolved lead or if there is an abiding suspicion of lead contamination
because of the presence of soft water, lead pipes, lead solder and other lead based plumbing materials,
there are some things you can do to help reduce the risk of exposure. One way is to "flush" each cold
water faucet before use when water stands in the pipes for more than a few hours. Flushing a cold water
faucet means allowing the water to run until it gets as cold as it will get before each use. Normally this
may take two or three minutes. This information has been approved by the United States Environmental
Protection Agency and meets the EPA's public lead notification requirements under Section 1417 of Safe
Drinking Water Act Amendments of 1986.
Certification:
I have received a copy of the Notice entitled "Watch out for Lead Based Paint Poisoning." [ ] yes
Print Full Name of Head of Household
Print Full Name of Other Adult
Signature
Signature
Date
Date
Date
HOUSING AUTHORITY STAFF
390 N. Bumby Avenue, Orlando, Florida 32803
•
Tel#: 407/895-3300
·Fax#: 407/894-7172
www.orl-oha.org
•
TDD#: 407/894-989 1 • Relay#: 7 11
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
OFFICE OF COMMUNITY PLANNING AND DEVELOPMENT
WATCH O UT FOR LEA D BASED PA INT PO ISON ING NOTIFICAT ION
TO: TENANTS OF LOWER PUBLIC HOUSING CONSTRUCTED BEFORE 1978
This building was constructed before 1978; there is a possibility that most of the pain in this building contains lead-based paint.
PLEASE READ THE FOLLOWING INFORMATION CONCERNING LEAD PAINT POISONING .
Sources of Lead Based Paint:
The interiors of older homes and apartments often have layers of lead-based paint on the walls, ceilings, windowsills, doors and
doorframes. Lead-based paint and primers may also have been used on outside porches, railings, garages, fire escapes and
lampposts. When the paint chips, flakes or peels off, there may be a real danger for babies and young children. Children may eat
paint ch ips or chew on painted railings, windowsills or other items when parents are not around. Children can also ingest lead even
if they do not specifically eat paint chips. For example, when children play in an area where there are loose paint chips or dust
particles containing lead, they may get these particles on their hands, put their hands into their mouths, and swallows a dangerous
amount of lead.
2. Symptoms of Lead-Based Paint Poisoning:
Has your child been especially cranky or irritable? Is he or she eating normally? Does your child have stomachaches or is he or she
vomiting? Does he or she complain about headaches? Is your child unwilling to play? These may be signs of lead poisoning. Many
times though, there are no symptoms at all. Lead poisoning can eventually cause mental retardation, blindness and even death.
3. Advisability and Availability of Blood Lead Level Screening:
Many buildings built prior to 1978 contain high levels of lead in the paint. Since you live in a building that was built before 1978,
you should take your child to the doctor or clinic for blood lead level testing. If the test shows that yo ur child has an elevated blood
lead level, treatment is available. Contact your doctor or local health department for help or more information. Lead screening and
treatment are available through the Medicaid Program for those who are eligible.
4.
PHA Responsibilities:
Your housing authority is required to remove flaking, peeling, cracking, and chipping paint when it is
found during unit
a.
inspections and at unit turnover. The housing agency is also required to remove flaking,
peeling paint as soon as
possible after you notify them of the condition.
b.
When you notify your housing agency that your child has a confirmed elevated blood lead level, the
housing authority
is required to test your unit for lead-based paint hazards within five (5) calendar days.
The housing agency is also
required to remove all of the lead-based paint hazards found in your unit
within fourteen (14) calendar days after
positive testing. Your housing agency may choose to transfer or assign you and your family to a previously tested unit
which was found to be lead free of lead-based paint hazards; (b) a unit where lead-based paint hazards have been removed:
or (c) a unit that was built after 1978.
5. Tenant and Homebuyer Responsibilities
a. Notify PHA of Elevated Blood Lead Levels.
As applicants, tenants and homebuyers of lower income public housing, you are advised to contact your doctor or
local
clinic to have your children less than 7 years of age tested for an elevated level. If your child is identified as having an elevated
blood lead level, you should notify the housing authority immediately of the condition so that
it
may
take
the
necessary steps to test your unit for lead-based paint hazards and remove those hazards where
they are found.
b. Notify PHA of Defective Paint
Young children sometime put paint chips in their mouths, or suck their fingers after playing on the floor where
paint
chips may get on their hands. If the unit in which you live have flaking, cracking, chipping, loose or peeling paint you should
notify the management office immediately. The housing authority is responsible for removing
flaking, cracking, chipping,
loose and peeling paint from your unit. However, if the housing authority is unable to
remove the defective paint from your
unit immediately, then there are some things you can do to protect your child.
i.
Cover all furniture and appliances.
ii.
Get a broom or stiff brush and remove the loose pieces of paint from walls, woodwork, window
wells and ceilings. Try to avoid making a lot of dust as you clean up the paint.
iii.
Sweep up all pieces of paint and plaster and put them in a paper bag or wrap them in newspaper
bag and put these packages in the trash can. DO NOT BURN THEM .
iv.
Do not leave paint chips on the floor or in window wells. Damp mop floors and window sills in
and around the work area to remove all dust and paint particles. Keeping these areas clear of paint chips, dust
and dirt is easy and very important.
v.
Do not allow loose paint to remain within your children's reach since children may pick loose
paint off the lower part of the wall and put it in their mouths.
6. Home owner Maintenance and Treatment of Defective Lead-Based Paint Hazards:
Beware that when lead-based paint is removed by scraping or sanding, a dust is created, which may be hazardous. The dust can enter
the body by either breathing or swallowing it. The use of heat or paint removers could create a vapor or fume which may cause
poisoning if inhaled over a long period of time. The removal of lead-based paint should take place when there are not children and
pregnant women on the premises.
I.
Signature of Head of Household
390 N. Bumby Avenue, Orlando, Florida 32803
Tel#: 407/895-3300
Fax#: 407/894-7172
www.orl-oha.org
Date
•
TDD#: 407/894-989 1
• Relay#: 7 11
~~
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!.
;tf«<f(fM
T.L. Mungen, PHM/COS
Admissions & Occupancy Manager
390 N. Bumby Avenue, Orlando, Florida 32803
• Tel# : 407/895-3300 • Fax#: 407/894-7 172
www.o rl-oha.ore.
TDD#: 40 7/894-989 1 • Relay#: 7 11
ORLANDO HOUSING AUTHORITY
A TODOS LOS SOLICITANTES DE VIVIENDA PUBLICA Y DEL
PROGRAMA DE SECCION 8
El Acta de Violencia Contra Las Mujeres (A VCM) 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.L. Mungen, PHM/COS
Admissions & Occupancy
390 N. Bumby Avenue, Orlando, Florida 32803
• Tel# : 407/895-3300 • Fax# : 407/894-7 172
www.orl -oha.o rg
T DD# : 407/894-989 1 • Relay#: 7 11

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