Emergency HOME TBRA Sample Application - HUD Exchange



PURPOSE:In the memorandum, “Suspensions and Waivers to Facilitate Use of HOME-Assisted Tenant-Based Rental Assistance (TBRA) for Emergency and Short-term Assistance in Response to COVID-19 Pandemic,” issued on April 10, 2020, as amended (the “April 2020 TBRA Memo, as amended”), HUD provided HOME statutory suspensions and regulatory waivers to permit a Participating Jurisdiction (PJ) to use HOME tenant-based rental assistance (TBRA) funds to facilitate urgent housing assistance to families experiencing financial hardship due to the coronavirus (COVID-19) pandemic. To facilitate the development of emergency TBRA programs, HUD permits PJs, among other items, to provide TBRA to eligible tenants who already occupy their units, allow for self-certification of income for households affected by the pandemic, pay for utility services, and waive HQS inspections. APPLICABILITY:This Emergency HOME TBRA Sample Application may be used by PJs to implement their local programs in response to the pandemic. The sample form assumes the use of all available waivers related to emergency TBRA as outlined in the April 2020 TBRA Memo, as amended. It may be used both for existing tenants seeking assistance to remain in a unit they already occupy or for households seeking a new unit to rent. In all cases, consistent with the waivers, applicants must be experiencing financial hardship as a result of the pandemic. This includes (a) individuals and families that have lost employment or income either permanently or temporarily due to the COVID-19 pandemic and (b) homeless individuals and families who are applying for admission to a HOME funded emergency TBRA program. This form must be kept as a record in the tenant/project file. TIMEFRAME: This sample form is valid between April 10, 2020 and September 30, 2021, the extended waiver period set forth in the April 2020 TBRA Memo, as amended.DISCLOSURE:This sample form is provided as a guide and should be adapted to include the PJ’s policy and procedures regarding emergency TBRA. Depending upon the PJ’s program design and application intake process, this form may need to be adapted in various ways including:Text highlighted in yellow indicates a PJ should update the form with specific local information (such as the name of the PJ or subrecipient administrator of the program). Once done, the highlighting should be removed. The “Sample” watermark should also be removed. To remove the watermark, go to the Design Ribbon and select the dropdown “Watermark” box. Then select “Remove Watermark.”This document can be converted to a “fillable form” for electronic completion or printed for completion by hand. The grey shading of the text fields and check boxes do not print in hard copy. To convert the document into a fillable form, go to the Developer Ribbon at the top of the MS Word window and select “Restrict Editing.” (How to add the Developer Ribbon to Word.) In the dialogue area on the right of the screen, check the box for “Allow only this type of editing in the document.” Then select “Filling in forms” from the drop-down menu. Finally, select the button for “Yes, Start Enforcing Protection.” Already Housed v. New Tenants – The sample application anticipates programs serving both households seeking new units (e.g. homeless families) and those seeking assistance for their existing unit. Part B of the application is only applicable to tenants who are already housed and could be removed for programs focusing on households seeking new units.Local Preferences – If the local PJ has established preferences or “set asides” within its emergency TBRA program, for example prioritizing households with a permanent job loss versus temporary reduction in hours, it should identify those in Section III of the application. There is no HOME requirement that a PJ identify any such local preferences or set asides, so if this is not part of the local program design, Section III can be removed and the remaining sections renumbered.Types of Assistance – PJs should adapt Section IV to reflect the types of assistance they will offer in their local emergency TBRA program. For example, while the COVID-19 waivers allow a PJ to pay past due rent or utilities (and associated late fees) that were otherwise originally due on or after January 27, 2020, if a PJ is only structuring their program to provide ongoing rent or utility assistance, then the references to back rent and utilities would need to be removed. If the local emergency TBRA program is exclusively focused on tenants seeking assistance for their current units, then references to security and utility deposit assistance should be removed.Section V through VII effectively embed the previously published HOME Sample Self-Certification of Annual Income Form into the sample application rather than requiring an applicant to fill out several forms. If the PJ is going to use that form in a stand-alone manner, then these sections could be removed. Please note whether using the stand-alone form or the sample application, both assume the PJ is using the Part 5 (aka “Section 8”) definition of income. PJs adopting the IRS 1040 adjusted gross income definition will need to update either sample form accordingly.While Part B of this sample application assumes the applicant already occupies the unit to be assisted, it could be adapted into a stand-alone document to collect information about the unit and financial provisions of the lease once a unit is identified by households seeking a new unit. Section XI is also being published as a stand-alone document. It represents one approach PJs might use to assess the condition of units absent an in-person HQS inspection. Other approaches might include PJ drive-by assessments, searches of local information from other recent inspections (e.g. if the jurisdiction has a rental licensing requirement that includes periodic inspections), etc.Instructions: All applicants must complete Part A and Part C of this application. Applicants who already occupy their unit (i.e. seeking assistance to remain in place) must also complete Part B.Part – A (To be completed by all applicants)I. Applicant InformationFull Name: FORMTEXT ?????Telephone Number: FORMTEXT ?????Email: FORMTEXT ?????Cell Phone Number: FORMTEXT ?????Current Legal Address (Street, Apt./Unit#): FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????Mailing Address (if different): FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip Code: FORMTEXT ?????II. Eligibility/Financial HardshipHOME-funded emergency TBRA is limited to applicants experiencing financial hardship defined by HUD as either:Loss of income (including job loss) due to the COVID-19 pandemic or Experiencing homelessnessCheck all that apply: FORMCHECKBOX – Loss of income FORMCHECKBOX – HomelessIf the applicant has experienced financial hardship as a result of the COVID-19 pandemic, the applicant must describe how the household’s financial situation has changed. Please describe whether household has lost employment or experienced reduced income, identify dates in which these incidents occurred, and indicate if these losses are expected to be temporary or permanent. If an applicant is homeless, please describe when/how they lost housing (e.g. fled domestic violence) and where they currently reside (e.g. shelter). Describe the financial hardship: FORMTEXT ?????Is the applicant household currently receiving any form of rental assistance (e.g. housing choice voucher/Section 8, state/local rent assistance, private assistance such as from a nonprofit, faith-based organization, etc.)? FORMCHECKBOX – Yes FORMCHECKBOX – NoHas the applicant household already received any publicly or privately funded assistance toward rent and/or utilities? (TBRA cannot pay any costs, like back rent/utilities, that have already been paid by another source.) FORMCHECKBOX – Yes FORMCHECKBOX – NoIf yes to either, please describe: FORMTEXT ?????III. Priorities for AssistanceThe following categories or households have been designated as priorities for assistance. Indicate which, if any, apply to the household : FORMCHECKBOX – Preference#1 FORMCHECKBOX – Preference#2IV. Type of TBRA AssistanceIndicate whether assistance is sought for the applicant’s existing unit or to lease a new unit. FORMCHECKBOX – Existing Unit – Household is applying for assistance for a rental housing unit they currently occupy and have an existing lease (If yes, complete Part B of this application and include copy of executed lease). FORMCHECKBOX – New Unit – Household is applying for assistance for a rental housing unit that they do not currently occupy.Please indicate which forms of assistance are needed by the applicant. FORMCHECKBOX – Past Due/Delinquent Rent$ FORMTEXT ????? currently owed, late since: FORMTEXT ?????Including late fees in accordance with tenant’s lease of $ FORMTEXT ????? FORMCHECKBOX – Ongoing Monthly Rent FORMCHECKBOX – Past Due/Delinquent Utilities (electric, fuel, water/sewer) FORMCHECKBOX – Utility reconnection/service restoration fees/costs FORMCHECKBOX – Ongoing Monthly Utilities (electric, fuel, water/sewer) FORMCHECKBOX – Security Deposit (new units only) FORMCHECKBOX – Utility Deposit (new units only)V. Household Information If more than 6 household members, please add additional sheet for Sections V through VII.HouseholdMember #Name(Last, First, MI)Relationship to Head of Household(spouse, child, etc.)Birth Date(mm/dd/yyyy)*StudentY/NPart/Fulltime1 FORMTEXT ?????Head of Household FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????*Note: Students do not qualify for HOME assistance unless the individual meets one of the exemptions below. Check all that apply: FORMCHECKBOX Student is a dependent member of the household (e.g. will occupy unit with parent(s)/guardian(s)) Student is FORMCHECKBOX Over age 24 FORMCHECKBOX Veteran of the US Military FORMCHECKBOX Married FORMCHECKBOX Has dependent child(ren) FORMCHECKBOX Student is not eligible to be claimed as the dependent of any other individual (e.g. was emancipated as a minor, aged out of foster care, etc.) VI. Household IncomePlease provide all income/earnings information for each household member (HH Mbr#) below. Anticipate the annual income for the next 12 months by converting current income to an annual figure by multiplying income by the frequency with which it is received while factoring in amounts that will terminate before the end of the next 12 months. For example, multiply weekly income by 52; bi-weekly income (received every other week) by 26; semi-monthly income (received twice each month) by 24; and monthly income by 12. A full-time student, 18 years or older (excluding the head of household or spouse) should exclude earnings in excess of $480 for annual income. Leave blank those that do not apply. To determine the total income for the household, add all columns on the last row of this chart.Income SourcesHH Mbr #1(Head of HH)HH Mbr #2HH Mbr #3HH Mbr #4HH Mbr #5HH Mbr #6Unemployment Compensation – (include regular unemployment, Pandemic Unemployment Assistance and Pandemic Emergency Unemployment Compensation)*Exclude Federal Pandemic Unemployment Compensation and Lost Wages Supplemental Payment Assistance $ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Wages, Salary, Overtime, Hazard Pay, Commissions, Fees, and Bonuses (before payroll deductions)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Net income from business and self-employment (include income earned as an independent contractor and “Gig Economy” jobs such as Etsy, Amazon, eBay, Uber, Lyft, Instacart, Grub Hub, Door Dash, etc.)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Interest, dividends, and other net income of any kind from real or personal property (include rental income)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Social Security (including disability and supplemental; include gross amount prior to any Medicare premiums)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Retirement/Pension/Insurance Policy/Annuities$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Disability or Death Benefits (disability compensation)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Worker’s Compensation and Severance Pay$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Welfare Assistance Payments (e.g., Temp. Assistance to Needy Families)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Regular pay, special pay, and housing allowance for the Armed Forces (exclude military hazard pay)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Veterans Administration (VA) Benefits (exclude deferred disability benefits)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Adoption Assistance Payments (exclude amount in excess of $480 annually)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Alimony or Child Support (include only amounts expected)$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Re-occurring cash gifts from private/nonprofit/charity or friends/family who will not reside in the housing unit$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Other (please describe): FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Total Income for each HH Member$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Total Household Income$ FORMTEXT ?????VII. Household AssetsAnnual income includes income derived from assets to which household members have access. Interest or dividends earned are counted as income even when the earnings are reinvested. This type of information can be obtained by contacting the financial institution that holds the asset. Using the categories below, report the type of asset(s) held by each member of the household and the income derived from the assets (report annual figures only). If the asset does not generate income, report ZERO. If the household member does not have assets, leave BLANK. Calculate the total income from assets for the household on the last row of this chart.Household Member #Assets to be reported include all of the following:Checking, Savings, Mutual Funds, Money Market Account(s), Equity in Rental Property, Retirement and Pensions, 401(K)(s), Stocks, Bonds, Treasury Bills, Certificate(s) of Deposit, Annuities, Revocable Trust(s), Mortgage(s) and/or Deed(s) of Trust, Whole Life Insurance policy, Lump-sum inheritance, Lottery Winnings, Insurance Settlements, Personal property held as an investment (e.g., antiques, gems, jewelry, art, etc.)Cash Value of AssetInterest/Dividends earned on the Assets1 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????2 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????3 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????4 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????5 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????6 FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????HouseholdMember #Assets Disposed of in Last 24 Months:Assets given away for less than the fair market value in the last 24 months with value greater than $1,000, (e.g., sale/gift of home)Cash Value of Disposed Asset(s)Income from Disposed Asset(s) FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????Total Value of AssetsTotal Income from Assets$ FORMTEXT ?????$ FORMTEXT ?????***To be completed by Program Administrator only.***Step 1: If Total Value of Assets exceeds $5,000, multiply total by 0.06% (passbook savings rate): $ FORMTEXT ????? = Imputed IncomeStep 2: Enter Greater of Total Income from Assets or Imputed Income: $ FORMTEXT ?????Step 3: Add Total Household Income from Section VI with result from Step 2: $ FORMTEXT ????? = Gross Household IncomeUse space below to explain any adjustments/corrections to applicant-completed information: FORMTEXT ?????VIII. Conflict of InterestThis HOME TBRA program is funded by the PJNAME {e.g. City of Acme} and administered by PJ/SUBRECIPIENT {e.g. Housing All Peoples}. The program is subject to conflict of interest rules intended to ensure all applicants are treated fairly and no one, by virtue of their position, unduly influences the selection or assistance approval process. Applicants must declare whether or not they, or any member of their household, has a potential conflict of interest by checking one of the statements below: FORMCHECKBOX – I am not an employee, agent, consultant, officer, or elected official or appointed official of the PJNAME or of the SUBRECIPIENT, nor am I the immediate family member of nor do I have business ties with any such person. FORMCHECKBOX – I cannot check the box above and do have a potential conflict of interest as described in the space below. (Note, having a potential conflict does not automatically disqualify an applicant but triggers additional reviews which may determine that no conflict exists, that a conflict exists and that an exception will be sought from HUD, or that the applicant is conflicted and may not be assisted.)Describe potential conflict of interest (if applicable): FORMTEXT ?????Part – B(To be completed only by applicants who already occupy the unit to be assisted)IX. Current Lease & Landlord InformationProperty Owner/Landlord: FORMTEXT ?????Lease Expiration (mm/dd/yyyy): FORMTEXT ?????Property Management Company (if applicable): FORMTEXT ?????Monthly Rent:$ FORMTEXT ?????Telephone: FORMTEXT ?????Back Rent Due:$ FORMTEXT ?????Submit a copy of your lease with this application.X. Utility ServicesIndicate which utility services are used in the unit. If the utility service is included in the rent under the lease, check “owner paid.” If the utility service is paid directly by the tenant, check “tenant paid.”Owner PaidTenant PaidUtility Service ProviderElectricity FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Fuel (e.g. gas) FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Water/Sewer FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????XI. Unit Condition ChecklistHOME funded emergency rental assistance requires assisted units to meet certain basic housing quality standards. Due to social distancing, in lieu of inspections by the Program Administrator, applicants should complete the following checklist about their unit.Is the housing unit free of the following health and life safety conditions?YesNoUnknownExposed bare wires or openings in electrical panels, outlets, or junction boxes? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Leaking water, puddling, or ponding on or near any electrical apparatus or outlet? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Evidence of mold or mildew, especially in bathrooms and/or air outlets? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Strong propane, natural gas, or methane gas odors? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Strong sewer odors? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Any physical/structural defect(s) that pose a tripping risk in the unit or in common stairways or hallways? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Evidence of rodent and/or insect infestation, especially in areas of food storage/prep? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Any sharp edge or physical/structural defect(s) that could cause bodily harm (e.g., cuts, skin puncture, etc.)? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Are common areas accessible to the tenant free of the following health and life safety conditions?Emergency exit(s) that cannot be used/accessed for any reason? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Missing exit signs or exits signs that are not clearly illuminated? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX An elevator(s) misaligned with the floor by more than ? inch? (e.g. the elevator(s) does not level as it should) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Flammable materials that are improperly stored? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other: Free of any other general defect(s) or hazards that pose a health and/or safety risk. If no, explain: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Does the housing unit contain the following basic livability features?YesNoUnknownWorking/operable lock(s) on all windows and doors that can be reached from the outside? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX At least one working smoke detector on each level of the unit, including the basement? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Lights that work in all common hallways and interior stairwells? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Ceilings, walls, and floors in good condition? (no large cracks, holes, bulging, chipped/peeling plaster/paint, etc.) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX A living room? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX At least two electrical outlets, or one outlet and a permanent overhead light fixture?At least one window? (all windows must be in good condition) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX A kitchen? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Storage, preparation, and serving space for food?At least one electrical outlet and one permanent light fixture?A working stove (or range) and oven? (tenant owned/supplied is acceptable)A refrigerator that keeps temperatures low enough that food does not spoil?A sink with hot and cold water? (a bathroom sink will not satisfy this requirement) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX A bathroom? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX A window that opens and/or a working exhaust fan?A flush toilet that works?A sink and tub/shower with hot and cold water? (a kitchen sink will not satisfy this requirement)At least one permanent overhead or wall light fixture? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other rooms? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX At least one operable window in every room used for sleeping? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Please use space below to clarify, elaborate, or add information about the condition of the unit: FORMTEXT ?????Part – C (To be completed by all applicants)XII. Beneficiary Intent to Participate and CertificationI/we intend to participate in the emergency HOME Tenant-Based Rental Assistance program. I/we understand that: FORMCHECKBOX – I/we may be required to provide access to the unit for purposes of a physical inspection, including a lead-based paint visual inspection, prior to approval; FORMCHECKBOX – I/we will be required to execute a three-party Rental Assistance Contract with the property owner and the PROGRAMADMINISTRATOR {e.g. PJ or Subrecipient as applicable}; FORMCHECKBOX – My/our current lease will be modified to include certain protections under the Violence Against Women Act (VAWA); and FORMCHECKBOX – In no case will the term of assistance under the program extend beyond September 30, 2021.I/we certify under penalty of perjury that the above information is complete and accurate to the best of my/our knowledge. I/we understand that Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony and assistance can be terminated for knowingly and willfully making a false or fraudulent statement to a department of the United States Government. I/we understand that additional state or local civil and/or criminal penalties may also apply to the submission of materially false or incomplete information. I/we agree to provide any additional documentation required by the program administrator to document my/our household income and/or any other eligibility criteria.__________________________________Head of Household Signature FORMTEXT ?????Print Name FORMTEXT ?????Date (mm/dd/yyyy)__________________________________Other Adult Household Member Signature FORMTEXT ?????Print Name FORMTEXT ?????Date (mm/dd/yyyy)__________________________________Other Adult Household Member Signature FORMTEXT ?????Print Name FORMTEXT ?????Date (mm/dd/yyyy)__________________________________Other Adult Household Member Signature FORMTEXT ?????Print Name FORMTEXT ?????Date (mm/dd/yyyy)__________________________________Other Adult Household Member Signature FORMTEXT ?????Print Name FORMTEXT ?????Date (mm/dd/yyyy)__________________________________Other Adult Household Member Signature FORMTEXT ?????Print Name FORMTEXT ?????Date (mm/dd/yyyy)Remember to submit:Copy of leaseCopy of any delinquent utility billsProperty Owner Certification (if already completed) ................
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