A $23.95 nonrefundable application fee is also required

COMPLIANCE 10400 Detrick Avenue Kensington, MD 20895

Dear Applicant: Please complete the enclosed application and submit all required documentation indicated on the checklist provided. A $23.95 nonrefundable application fee is also required per application, in the form of a personal check or money order. Please Read! To expedite the process please thoroughly read and complete the attached packet.        

If a question does not apply, please place N/A. Do not leave anything blank. If a question requires a yes or no answer, one or the other must be checked. Please do not use whiteout and complete the application in blue ink only. If an error is made, please cross through the mistake with one line and write in the correction. Add all banking and employment information for all adult members. Please be sure that all required documents are signed and dated by all applicants 18 and older. If paid weekly, please provide eight recent consecutive pay stubs and if paid bi-weekly, provide four recent consecutive pay stubs. Please provide the six most recent consecutive bank statements, if you or any member of your household holds a checking account and the most recent statement, if you or anyone in your family holds a savings account or 401k. This includes minors. If you have SSI, Social Security and or Pension you will need to provide a recent statement dated no earlier than March 2015. Please call and have a copy sent to you if you hold an older statement.

Please be aware that this does not guarantee housing. Eligibility is based on household income within the housing program guidelines, three current consecutive years of positive rental history, satisfactory credit report, a clean criminal background check of three years and complete and accurate information provided. Thank you for your continued interest in HOC’s housing programs.

+

For Rent Affordable Homes in Montgomery County

You have been searching for affordable housing in Montgomery County and we may have just what you are looking for in a home. The Housing Opportunities Commission has condos, town homes and single family homes for rent at below market rates. If you meet the income requirements for these programs, you may take advantage of this unique opportunity. These homes are packed with amenities designed to increase your living pleasure and leisure time while allowing you to live affordably in Montgomery County. Features include:   

Wall-to-wall carpeting Fully equipped kitchen and baths Full-sized washer and dryer Household Size 1 2 3 4 5 6 7 8

Minimum Income $32,770 $36,770 $36,770 $38,770 $38,770 $38,770 $40,770 $40,770



 

Recreation facilities (in most communities) Convenience to schools and shopping Prime locations throughout the county

Maximum Income $47,600 $54,400 $61,200 $68,000 $73,450 $78,900 $84,350 $89,800

If you would like to apply for this special affordable housing program, please complete the enclosed application package, provide the requested information and include a $23.95 nonrefundable application fee (per application) in the form of a check or money order: Housing Opportunities Commission Compliance Office 10400 Detrick Avenue Kensington, MD 20895 For further assistance, call 1-866-852-5391 or email [email protected]. Thank you for your interest!

TENANT SELECTION CRITERIA 1.

All applications must provide verification of the following:  Household income within the housing program guidelines.  Three current, consecutive years of positive rental history.  A satisfactory credit report.  A clean criminal background check, for a minimum of three years.  All members of the household are not full-time students. (Note: applies to the Low Income Housing Tax Credit program only).

 Complete and accurate information. 2.

Approved applicants, for which there is no immediate housing, will be placed on a waiting list. Acceptance of an application does not indicate approval for leasing premises.

3.

Any changes in income, assets, address, telephone numbers and/or household composition must be documented and reported to the Compliance Office immediately.

4.

If an applicant cannot be contacted by either telephone or by mail, the application will be considered inactive and removed from the waiting list.

5.

If information provided on the application is found to be incorrect or fraudulent, the application will be rejected.

6.

H.O.C. reserves the right to close the waiting list when appropriate.

7.

NO PETS PERMITTED, unless permitted under an approved ADA accommodation.

All applications must be accompanied by a $23.95 nonrefundable application fee.

TENANT SELECTION CRITERIA 1.

All applications must provide verification of the following:  Household income within the housing program guidelines.  Three current, consecutive years of positive rental history.  A satisfactory credit report.  A clean criminal background check, for a minimum of three years.  All members of the household are not full-time students. (Note: applies to the Low Income Housing Tax Credit program only).

 Complete and accurate information. 2.

Approved applicants, for which there is no immediate housing, will be placed on a waiting list. Acceptance of an application does not indicate approval for leasing premises.

3.

Any changes in income, assets, address, telephone numbers and/or household composition must be documented and reported to the Compliance Office immediately.

4.

If an applicant cannot be contacted by either telephone or by mail, the application will be considered inactive and removed from the waiting list.

5.

If information provided on the application is found to be incorrect or fraudulent, the application will be rejected.

6.

H.O.C. reserves the right to close the waiting list when appropriate.

7.

NO PETS PERMITTED, unless permitted under an approved ADA accommodation.

All applications must be accompanied by a $23.95 nonrefundable application fee.

 Checklist of items that must be submitted with your application ENCLOSED FORMS: _____ RELEASE OF PERSONAL INFORMATION signed by all adult household members. _____ EMPLOYER INFORMATION – Provide the requested employer information for all household members 18 years or older, employed full or part-time, for the purpose of determining the family’s eligibility for continued housing assistance.

COPIES OF: _____ BIRTH CERTIFICATE or legal form of identification for all household members. _____ SOCIAL SECURITY CARDS for all household members. _____ EMPLOYMENT INCOME – at least four (4) current, consecutive pay stubs if paid bi-weekly or eight if paid weekly, for each household member who is 18 years or older and employed full or part-time. If a member is self-employed, a Schedule C from the most recent tax year must be submitted in lieu of pay stubs. _____ BENEFIT INCOME – Current benefit letter from all sources of income such as: Pensions or Retirement Accounts Social Services 240-777-3100 or 3240 Social Security www.ssa.gov Disability Veterans Administration 202-872-1151 Civil Service Annuity Unemployment Benefits 301-929-4350 Severance Benefit Letter Workman’s Compensation _____ SUPPORT PAYMENTS – Current verification of support payments received in the form of a court order, notarized agreement or printout from agency responsible to distribute funds, including: Child Support  Alimony  Family or Friend Support _____ STUDENT STATUS – Verification of full-time student status for household members 18 years of age or older. This would be from the registrar’s office, school dean, counselor or advisor. _____ TAX RETURN – If you are self-employed, current Federal Income Taxes with W-2 forms for the past two years. _____ ASSET VERIFICATION – for ALL household members such as: _____ Savings – Most recent bank statement for savings account(s) including Certificates of Deposit (CDs), Time Deposits and Money Market accounts. _____ Checking – Printout indicating account balance for the last 6 months. _____ Investments – Most recent statement for investments such as stocks, bonds and mutual funds. Including IRA, 401(K), 403(b) and 457 Deferred Compensation. _____ Real Estate, Limited Partnership and Trust – Verification of ownership, a fair market value from a recent appraisal or licensed realtor AND a statement with the mortgage balance. Provide documentation of income derived from the asset. _____ Sold Assets – Verification of assets sold or gifted within the past two years.

COMPLIANCE DIVISION 10400 Detrick Ave Kensington, Maryland 20895-2484 1-866-852-5391

OPPORTUNITY HOUSING RENTAL APPLICATION

No Pets

Please print clearly and complete all blanks. I. APPLICANT INFORMATION Applicant Name

Soc Sec #

Applicant E-Mail Address Co-Applicant Name

Soc Sec #

Co-Applicant E-Mail Address Current Address City

State

Home # Own ( )

Zip Code

Work # Rent ( )

Cell/Other

From (Month/Year)

to

Current Rent/Mortgage Payment $

per month # of Bedrooms

Current Landlord

Phone

Landlord Address City

State

Emergency Contact Person

Zip Code

Relationship

Emergency Contact Address City Home #

State Work #

Zip Code Cell/Other

FOR OFFICE USE ONLY: Date: Recommended Property/Program:

TC --- OVER ---

(2015)

Page 2 of 6

II. RENTAL HISTORY List all previous addresses for the last three (3) years - most recent first. From (Mo/Yr)

To

Monthly Rent $

# of BRs

Address City

State

Landlord

Zip code Phone

Landlord Address Landlord City

State

Zip code

Name of Lessee Reason for Moving From (Mo/Yr)

To

Monthly Rent $

# of BRs

Address City

State

Landlord

Zip code Phone


State

Zip code

Name of Lessee Reason for Moving From (Mo/Yr)

To

Monthly Rent $

# of BRs

Address City

State

Landlord

Zip code Phone


State

Zip code

Name of Lessee Reason for Moving

(2015)

Page 3 of 6

III. OCCUPANTS - Please list all persons who will live with you. Date of Birth

Place of Birth

Relationship

Name

Date of Birth

Place of Birth

Relationship

Name

Date of Birth

Place of Birth

Relationship

Name

Date of Birth

Place of Birth

Relationship

Name

Date of Birth

Place of Birth

Relationship

Name

Date of Birth

Place of Birth

Relationship

Don’t leave blank

Name

Are you anticipating any changes in your household composition during the next six (6) months ?

If yes, please describe

IV. INCOME AND ASSETS

Don’t leave blank

APPLICANT

CO-APPLICANT

Employment

$

per

Employment

$

per

Benefits

$

per

Benefits

$

per

Child Support

$

per

Child Support $

per

Other income

$

per

Other income $

per

Total income

$

Total income $

Asset (type/value)

Asset (type/value)

Asset (type/value)

Asset (type/value)

Asset (type/value)

Asset (type/value)

Are the assets (as defined below) of the entire household more than $5000?

[ ] Yes

[ ] No

Have you disposed of any assets at less than fair market value within 24 months?

[ ] Yes

[ ] No

Assets Include: Cash in savings/ checking accounts, trusts, equity in real estate or capitol investments, stocks, bonds, CDs, money market accounts, IRAs, retirement and pension funds.

--- OVER ---

Page 4 of 6

V. CURRENT EMPLOYMENT INFORMATION Name of Head of Household _____________________________________________________________________ Applicant's Employer

Phone

Employer's Address Current Position Current Wages $

Date Employed per hour

week

bi-weekly month year (circle one)

Name of Co-Head ______________________________________________________________________________ Co-Applicant's Employer

Phone


Date Employed per

hour

week


List additional employment for any adult household members Name of Other Adult ___________________________________________________________________________ Other Employer

Phone



week


Name of Other Adult ___________________________________________________________________________ Other Employer

Phone



week


(2015)

Page 5 of 6

VII. PREVIOUS EMPLOYMENT HISTORY

Name of Head of Household: Previous Employer: Dates Employed:

From (Mo/Yr):

To (Mo/Yr):

From (Mo/Yr):

To (Mo/Yr):

From (Mo/Yr):

To (Mo/Yr):

From (Mo/Yr):

To (Mo/Yr):

Name of Co-Head: Previous Employer: Dates Employed:

Other Adult: Previous Employer: Dates Employed:

Other Adult: Previous Employer: Dates Employed:

VII. STUDENT STATUS Are all members of the household full-time students?

Yes

No

IF YES to above, answer the following questions: Are any full-time student(s) married and filing a joint tax return?

Yes

No

Are any student(s) enrolled in a job-training program receiving assistance under the Job Training Partnership Act (federal, state or local)?

Yes

No

Are any full-time student(s) TCA or a Title IV recipient?

Yes

No

Are any full-time student(s) a single parent living with his/her minor child who is not a dependant on another’s tax return (other than a parent)?

Yes

No

--- OVER ---

Page 6 of 6

VII. AREAS OF INTEREST Location(s) Preferred:

□ □ □ □

All areas will be considered Boyds / Clarksburg Gaithersburg / Montgomery Village Germantown / Damascus

□ □ □ □

Olney / Brookeville Potomac / Bethesda Rockville Silver Spring / Burtonsville

VIII. VEHICLES Make/Model/Year

Tag #

State

Make/Model/Year

Tag #

State

IX. EMPLOYEE DISCLOSURE Are you currently an HOC employee?

[ ] Yes

[ ] No

Is anyone in your immediate family currently an HOC employee?

[ ] Yes

[ ] No

Name of family member currently employed at HOC

I/We understand that any or all of the information given here be used by the landlord and/or its Agent to determine my/our reputation for meeting my/our financial obligations and my/our respect for the property of others. I/We freely give my/our consent to HOC to consult with any of the persons/companies named or not named who have direct knowledge of my/our financial reliability. I/We, the undersigned applicant(s), affirm under the penalties of perjury that my/our answers to the foregoing questions are true and correct to the best of my/our personal knowledge, information and belief and that I/we have not knowingly withheld any fact or circumstance which would, if disclosed, affect my/our application unfavorably. I/We, the undersigned Applicant hereby consent to HOC making inquiries with the individuals and institutions listed by Applicant, solely for the purposes of obtaining references and verifying the information provided by the Applicant. Applicant hereby acknowledges payment of a Non-refundable Fee in the amount of twenty three dollars and ninety-five cents ($23.95). Applicant Signature

Date

Co-Applicant Signature

Date

Other Adult Signature

Date


Date

MUST BE SIGNED BY ALL HOUSEHOLD MEMBERS 18 AND OVER (2015)

Personal Declaration Lease #_______________

THIS IS AN IMPORTANT DOCUMENT

Este documento contiene información muy importante. Si no entiende el ingles, por favor buscar un tracuctor. Dáy lá mót tái lièu rát quan trong. Nèu có vi náo khóng doc dúóc tièng anh, xin nno ngúoi khác dien dum snag tièng vièt. This form must be completed in your own handwriting before submitting to HOC for your annual recertification. You must use the correct legal name for each member of your household as it appears on the Social Security card. PLEASE PRINT LEGIBLY. I.

HOUSEHOLD COMPOSITION: List all persons who will be living in your home, listing head of household first. Marital Status

Name Head

Relationship to Head

M-Marreid D-Divorced S-Single L-Legal Separation W-Widowed

Birth Date

Age

Social Security #

Student

Y/N

SELF

Co-H

3. 4. 5. 6. 7. 8.

Is this the entire household to occupy the unit? If no, list and explain:

Yes

No

No one else can join the household without prior management approval. Do you plan to have anyone living with you in the future not listed above? Yes No If yes list and explain:

Have there been any changes in this household since the previous certification? If yes, what were the changes?

Yes

If separated or divorced, list name and address of spouse/ex-spouse as follows: NAME

NAME

STREET ADDRESS

STREET ADDRESS

CITY, STATE, ZIP

CITY, STATE, ZIP

SOCIAL SECURITY # (If known)

SOCIAL SECURITY # (If known)

HOC Opportunity Housing Rental Application (2015)

No

Does any member of your household have a disability? Yes No If yes, would any member of your household benefit from accessible features in the unit? If yes, describe:

II.

Yes

TOTAL HOUSEHOLD INCOME: List all monies earned or received from full or part time employment by everyone living in your household. This includes money from wages, selfemployment, child support, unemployment compensation, contributions, social security, disability payments (SSI), workers compensation, retirement benefits, public assistance, veteran’s benefits, rental property income, stock dividends, income from bank accounts, alimony and other sources.

Household Member Name

Employer Name & Address

Total Gross Income

Source of Income Wages Unemployment Disability Child Support Alimony Pension/Annuity Military Pay

Self-Employed / Business Social Security / SSI Workman’s Comp Veteran’s Benefits TANF / Public Assistance $ from Friends / Relatives Other Income

□ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □ □

Source: Source: Source: Source: Source: Source: Source:

III.

No

Weekly Monthly Annual Weekly Monthly Annual Weekly Monthly Annual Weekly Monthly Annual Weekly Monthly Annual Weekly Monthly Annual Weekly Monthly Annual

ASSETS: Do you or a family member have any of the following assets? Please answer yes or no to all. Checking Accounts

Yes

No

Stocks or Bonds

Yes

No

Savings Accounts

Yes

No

Mutual Funds

Yes

No

Certificates of Deposit

Yes

No

Trust Accounts

Yes

No

IRA

Yes

No

Life Insurance

Yes

No

Other Retirement Funds

Yes

No

Real Estate

Yes

No

List bank name, account number and current balance for bank accounts for ALL household members: Bank Name Bank Name Bank Name Bank Name Bank Name Bank Name

Account #

Amount $

Account #

Amount $

Account #

Amount $

Account #

Amount $

Account #

Amount $

Account #

Amount $


Real Estate Property: Do you own any property? If yes, type of property: Location of property: Appraised Market Value: Mortgage or outstanding loans balance due: Amount of annual insurance premium: Amount of most recent tax bill:

Yes

No

$ $ $ $

Have you sold/disposed of any property in the last two years? If yes, type of property: Market Value when sold/disposed: Amount sold/disposed for: Date of transaction:

Yes

No

$ $

Have you disposed of any other assets in the last 2 years (property in the last two years? (Example: Given away money to relatives, set up Irrevocable Trust Accounts, etc.) Yes No If yes, describe the asset: Date of disposition: Amount disposed: $ Do you have any other assets not listed above (excluding personal property)? If yes, please list:

Do you own a car? Yes

No

Model/Year IV.

Tag #

Yes

No

Do you own a second car? Yes

No

Model/Year

Tag #

GENERAL INFORMATION: Does anyone outside your household pay for any of your bills or give you money? Yes If yes, explain:

No

Have you or any other adult members ever used any name(s) or Social Security number(s) other than the one you are currently using? Yes No If yes, explain below and give the number:

Have you or anyone in your household ever been involved, charged, arrested and/or convicted of any crime other than traffic violations? Yes No If yes, explain:

Have you ever committed fraud in a federally assisted housing program or been requested to repay money for knowingly misrepresenting information for such housing programs? Yes No If yes, explain:


V.

Household Student Status Verification: Will all of the persons in the household be or have been full-time students during five calendar months of this year or plan to be in the next calendar year at an educational institution (other than a correspondence school) with regular faculty and students? Yes No IF YES, ANSWER THE FOLLOWING QUESTIONS: Are any full-time student(s) married and filing a joint tax return?

Yes

No

Are any student(s) enrolled in a job-training program receiving assistance under the Job Training Partnership Act (federal, state or local)?

Yes

No

Are any full-time student(s) TCA or a Title IV recipient?

Yes

No

Are any full-time student(s) a single parent living with his/her minor child who is not a dependant on another’s tax return (other than a parent)?

Yes

No

ALL ADULT HOUSEHOLD MEMBERS 18 YEARS AND OLDER OF THIS HOUSEHOLD MUST SIGN BELOW CERTIFYING THE ABOVE INFORMATION PERTAINING TO THEM IS TRUE AND CORRECT. I do hereby swear and attest that all of the information above about me is true and correct. I also understand that all changes in the income of any member of the household as well as any changes in the household members must be reported to HOC IN WRITING IMMEDIATELY, within 5 business days of the change. Work ( Signature of Head of Household

Date

Date

)

Home/Cell (

)

E-mail Address of Co-Head of Household Work (

)

Signature of Other Adult (18 Yrs Or Older)

Date

Telephone Numbers


Date

Telephone Numbers

Work (

Work ( Date

Date

)

)

Home/Cell (

)

Home/Cell (

)

Home/Cell (

)

Home/Cell (

)

Telephone Numbers Work (


)

Telephone Numbers

E-mail Address for Head of Household


Home/Cell (

Telephone Numbers Work (

Signature of Spouse/Co-Head of Household

)

)

Telephone Numbers

NOTE: Section 1001 of Title 18 of the U. S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.


AUTHORIZATION FOR RELEASE OF INFORMATION All household members age eighteen (18) years or older must complete this form. CONSENT I authorize and direct any Federal, State or local agency, organization, business or individual to release to the Housing Opportunities Commission any information or materials needed to complete and verify my application for participation and/or to maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-income Public and Indian Housing and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies. INFORMATION COVERED I understand that depending on program policies and requirements, previous or current information regarding my household or me may be needed. Verifications and inquiries that may be requested include, but are not limited to: Identity and Marital Status Medical/Child Care Allowances

Employment, Income and Assets Credit and Criminal Activity

Residence/Rental Activity

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program. GROUPS AND INDIVIDUALS THAT MAY BE ASKED The groups or individuals that may be asked to release the above information (depending on program requirements) include, but are not limited to: Previous and Current Landlords (Including Public Housing Agencies) Courts and Post Offices Schools and Colleges Law Enforcement Agencies Support and Alimony Providers Welfare Agencies Past and Present Employers

Social Security Administration Medical and Child Care Providers Veterans Administration Retirement Systems Banks and Other Financial Institutions Credit Providers and Credit Bureaus Utility Companies State Unemployment Agencies

COMPUTER MATCHING NOTICE AND CONSENT I understand and agree that HUD or the Public Housing Authority may conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. HUD may in the course of its duties exchange such automated information with other Federal, State or local agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; The Social Security Agency; and State welfare and food stamp agencies. NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506-T, “Request For Transcript Of Tax Return” FORM MUST BE PREPARED AND SIGNED SEPARATELY. CONDITIONS I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect for one year and one month (13 months) from the date signed. Head of Household (Print Name)

Signature

Social Security #

Date

Spouse/ Co-Head (Print Name)

Signature

Social Security #

Date

Other Adult (Print Name)

Signature

Social Security #

Date


Signature

Social Security #

Date


Signature

Social Security #

Date


RELEASE OF PERSONAL INFORMATION In consideration of my application for housing with the Housing Opportunities Commission, I hereby authorize a review and examination of any and all arrest, trial and other criminal records made available to HOC or its agents for the purposes of determining my suitability for housing. I authorize HOC to conduct credit and rental history checks and reference checks with such persons as employers, social workers, case workers, counselors, landlords, probation and parole officers, clergy, and others as may be determined. It is understood that HOC will not disclose or provide the information I have authorized HOC to obtain to others but will utilize the material solely in determining my suitability for housing. I agree to release HOC from any and all claims, damages, losses and expenses arising out of the utilization of any information which is made available to it in connection with my application for housing. I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect for a year and one month from the date signed.

With the exception of “Race” all items must be complete. Otherwise the form will be returned for completion.

I hereby certify that the information I am providing on this form is accurate and complete to the best of my knowledge. Signature

Printed Name

Date

(Last

First

Middle)

Other names you may have used: Social Security Number:

Date of Birth:

Place of Birth: Current Address:

Previous Address:

Race (Voluntary): Do you have any prior criminal convictions?

Yes

No

Do you have any prior arrests and/or charges?

Yes

No

(PLEASE ACKNOWLEDGE CHARGES THAT WERE NOLLE PROSEQUI OR CHARGES DROPPED)

If yes, please describe:

Are there any outstanding warrants for your arrest?

Yes

No

RELEASE OF PERSONAL INFORMATION In consideration of my application for housing with the Housing Opportunities Commission, I hereby authorize a review and examination of any and all arrest, trial and other criminal records made available to HOC or its agents for the purposes of determining my suitability for housing. I authorize HOC to conduct credit and rental history checks and reference checks with such persons as employers, social workers, case workers, counselors, landlords, probation and parole officers, clergy, and others as may be determined. It is understood that HOC will not disclose or provide the information I have authorized HOC to obtain to others but will utilize the material solely in determining my suitability for housing. I agree to release HOC from any and all claims, damages, losses and expenses arising out of the utilization of any information which is made available to it in connection with my application for housing. I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect for a year and one month from the date signed.

With the exception of “Race” all items must be complete. Otherwise the form will be returned for completion.

I hereby certify that the information I am providing on this form is accurate and complete to the best of my knowledge. Signature

Printed Name

Date

(Last

First

Middle)

Other names you may have used: Social Security Number:

Date of Birth:

Place of Birth: Current Address:

Previous Address:

Race (Voluntary): Do you have any prior criminal convictions?

Yes

No

Do you have any prior arrests and/or charges?

Yes

No

(PLEASE ACKNOWLEDGE CHARGES THAT WERE NOLLE PROSEQUI OR CHARGES DROPPED)

If yes, please describe:

Are there any outstanding warrants for your arrest?

Yes

No

APPLICANT/TENANT CERTIFICATION Giving True and Complete Information: I/We certify that all information provided on household composition, income, family assets and is accurate and complete to the best of my knowledge. I have reviewed the application and certify that the information show is true and correct. Reporting Changes in Income or Household Composition: I know I am required to report immediately in writing any 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 guest/visitor and I must report when someone moves into my unit. I understand that if I do not report these changes, I am subject to repayment of monies owed to HOC. I understand that failure to repay could result in termination of housing assistance or termination of tenancy. Reporting on Prior Housing Assistance: I certify that I have disclosed where 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 the house or apartment will be my principal residence and that I will not obtain duplicate Federal housing assistance while I am in this current program. I will not live anywhere else without notifying Housing Opportunities Commission immediately in writing. I will not sublease my assisted residence. Cooperation: I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled appointments for certification or recertification, 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. All adult household members eighteen (18) years or older must sign and date this form.

Head of Household Signature

Date

Spouse / Co-Head Signature

Date


Date


Date


Date


Date


STATEMENT OF SELF-EMPLOYMENT EARNINGS Date Sent: Sent By: Title:

Name

Lease #

Address

I, ______________________________________________, do hereby certify that I am self-employed and my business is _______________________________.

I estimate

that my gross annual income before expenses for the next twelve (12) months will be $__________________.

My net income for the next twelve (12) months will be

$___________________. My expenses are as follows:

Supplies

$

Rental Fee

$

Gas

$

Other, please specify

$

I certify that the above information is true and correct. Signature: _________________________________

Date: ________________



CERTIFICATION OF ZERO INCOME (To be completed by adult household members only, if applicable.)

1. I hereby certify that I do not individually receive income from any of the following sources: a. Wages from employment (including commissions, tips, bonuses, fees, etc.); b. Income from operation of a business; c. Rental income from real or personal property; d. Interest or dividends from assets; e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death benefits; f. Unemployment or disability payments; g. Public assistance payments (TANF, TCA, etc.); h. Periodic allowances such as alimony, child support, or gifts received from persons not living in my household; i.

Sales from self-employed resources;

j.

Any other source not named above.

2. I currently have no income of any kind and there is no imminent change expected in my financial status or employment status during the next 12 months. 3. I will be using the following sources of funds to pay for rent and other necessities: ________________________________________________________________ Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.

Signature of Applicant/Tenant

Printed Name of Applicant/Tenant

Date



STUDENT VERIFICATION THIS SECTION TO BE COMPLETED AND EXECUTED BY STUDENT This Student Verification is being delivered in connection with the undersigned's eligibility for residency at the following address:

Student Address

Head of Household

City

State

Zip Code

I hereby grant disclosure of the information requested below from ___________________________________ Name of Educational Institution

Student Signature

Date

Student Printed Name

Student ID#

Housing Opportunities Commission Compliance Office 10400 Detrick Avenue Kensington, MD 20895

Return Form to:

OR

FAX Attn: Compliance Office (301) 949-1433

THIS SECTION TO BE COMPLETED BY EDUCATIONAL INSTITUTION The above-named individual has applied for residency or is currently residing in housing that requires verification of student status. Please provide the information requested below: Is the above-named individual a student at this educational institution? If so, part-time or full-time?

PART-TIME

YES

NO

FULL-TIME

If full-time, the date the student enrolled as such: _______________________________________ Expected date of graduation: __________________________________ I hereby certify that the information supplied in this section is true and complete to the best of my knowledge.

Signature

Date

Printed Name

Telephone #

Title Educational Institution



A $23.95 nonrefundable application fee is also required

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