HOUSING CHOICE VOUCHER P (S 8 /P B CONTINUED O A

THE LAKELAND HOUSING AUTHORITY

HOUSING CHOICE VOUCHER PROGRAM (SECTION 8 /PROJECT BASE)

CONTINUED OCCUPANCY APPLICATION

If you are elderly or disabled and need reasonable accommodation please call to 863-687-2911

Print Name (Head of Household)

CONTINUED OCCUPANCY APPLICATION

sign

Date

THE INFORMATION YOU PROVIDE WILL BE VERIFIED, (SEE PENALTY OF PERJURY PART 17)

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THE LAKELAND HOUSING AUTHORITY

Application Contents

PART 1 ¨C CONTACT INFORMATION ...................................................................................... 3

PART 2 ¨C HOUSEHOLD COMPOSITION ............................................................................... 4

PART 3 ¨C INTENT TO MOVE .................................................................................................... 5

PART 4 ¨C EMPLOYMENT .......................................................................................................... 5

PART 5 ¨C EARNED INCOME DISALLOWANCE (EID) ......................................................... 6

PART 6 ¨C OTHER INCOME ....................................................................................................... 7

PART 7 ¨C STUDENTS ................................................................................................................. 8

PART 8 ¨C CHILD SUPPORT ...................................................................................................... 9

PART 9 ¨C REGULAR CONTRIBUTIONS & GIFTS ................................................................ 9

PART 10 ¨C ZERO INCOME ........................................................................................................ 9

PART 11 ¨C FINANCIAL ACCOUNTS/ASSETS ..................................................................... 10

PART 12 ¨C CHILDCARE ........................................................................................................... 11

PART 13 ¨C MEDICAL EXPENSES .......................................................................................... 11

PART 14 ¨C CRIMINAL HISTORY / SCREENING ................................................................. 13

PART 15 ¨C STATEMENT OF FAMILY OBLIGATIONS ....................................................... 14

PART 16 ¨C GENERAL INFORMATION .................................................................................. 15

PART 17 ¨C FAMILY MEMBER/HOUSEHOLD CERTIFICATION ....................................... 16

PART 18 ¨C AUTHORIZATION FOR THE RELEASE OF INFORMATION ....................... 17

PART 19 ¨C HUD 9886 ............................................................................................................... 18

PART 20 ¨C WHAT YOU SHOULD KNOW ABOUT EIV ....................................................... 20

PART 21 ¨C HUD 52675 ............................................................................................................. 22

PART 22 ¨C SUPPLEMENT TO APPLICATION ..................................................................... 24

CONTINUED OCCUPANCY APPLICATION

THE INFORMATION YOU PROVIDE WILL BE VERIFIED, (SEE PENALTY OF PERJURY PART 17)

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THE LAKELAND HOUSING AUTHORITY

PART 1 ¨C CONTACT INFORMATION

Date Received

(LHA Only)

Head of Household Name:

Current Address:

Cell or Home Phone Number:

Work Phone Number:

Email Address:

Message Phone Number:

Mailing Address (if different from above):

City:

_ State:

Zip Code:

IMPORTANT: The Housing Authority is now using HUD¡¯s centralized Enterprise Income Verification (EIV) system to

validate and compare tenant-reported information with EIV data. This system will validate identification of all family

members, previous housing assistance; any debts owed to other housing agencies, and will provide us with information

related to income from all family members. It is important that you provide accurate information to prevent disqualification

from the program.

CONTINUED OCCUPANCY APPLICATION

THE INFORMATION YOU PROVIDE WILL BE VERIFIED, (SEE PENALTY OF PERJURY PART 17)

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THE LAKELAND HOUSING AUTHORITY

PART 2 ¨C HOUSEHOLD COMPOSITION

All households must fully complete this section. Complete this table for ALL family members currently residing in your household.

HOUSEHOLD MEMBER

NAME

RELATIONSHIP

TO HEAD OF

HOUSEHOLD

SELF

1.

GENDER

(Male/Female)

SOCIAL

SECURITY

NUMBER

DATE OF

BIRTH

CURRENT

AGE

DISABLED

(Yes/No)

US

Citizens/Eligible

Immigrant

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

? M

?

F

? Y

?

N

? Y

?

N

Is anyone in your household (including you) expecting a baby? ? YES

MARITAL

STATUS

(Married/

Single)

? NO

If yes, please provide doctor¡¯s statement/hospital record.

Name of the Person expecting the baby:

2.

Due Date:

Has anyone in the household (including you) changed their first name or last name since the last household re-examination?

? YES ? NO

if yes, please provide a current copy of the new social security card.

Previous name of Person:

CONTINUED OCCUPANCY APPLICATION

THE INFORMATION YOU PROVIDE WILL BE VERIFIED, (SEE PENALTY OF PERJURY PART 17)

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THE LAKELAND HOUSING AUTHORITY

PART 3 ¨C INTENT TO MOVE

Do you intend to move when your lease expires? ? YES

? NO

If yes, you must pick up a Transfer Packet in our office and complete it to include any notices to vacate unit (Notices to or from landlord).

If no, is the landlord requesting a rent increase?

? YES ? NO

If yes, have landlord provide written notice of the increase request.

PART 4 ¨C EMPLOYMENT

Is any household member 18 years + employed? ? YES

?

NO

If yes, list each employed family member and attach copies of four (2) consecutive pay stubs or a payroll log from the employer verifying salary and/or wages dated

within the last 60 days.

Is any household member 18 years + employed receiving any tips? ? YES ? NO

If yes, is the income from tips included on your W-2? ? YES ? NO

If yes, please return a signed certified estimate of tips received from the prior year and tips anticipated to be received in the coming year.

HOUSEHOLD MEMBER

NAME

OCCUPATION

EMPLOYER PHONE

NUMBER

EMPLOYER NAME & ADDRESS

EMPLOYER CONTACT

NAME (Supervisor, payroll

or human resources)

Phone:

Fax:

Phone:

Fax:

Phone:

Fax:

HIRE DATE

HOURS

WORKED

(Weekly)

HOURLY RATE /

SALARY AMOUNT

PAYMENT FREQUENCY

(weekly, Bi-weekly, BiMonthly, Monthly, Annually)

TIPS/BONUS/OVERTIME

(Specify per week, month,

year)

SELF-EMPLOYMENT - Is any adult (18 years +) family member in the household self-employed? ? YES ? NO

If Yes, Please provide last year IRS tax return form 1040 filed with IRS with all attachments. If an audit was conducted for the previous fiscal year, please provide a copy of the

audited financial statement. If not audited, please provide a statement of income and expenses.

HOUSEHOLD MEMBER NAME

NAME OF BUSINESS

CONTINUED OCCUPANCY APPLICATION

TYPE OF BUSINESS

BUSINESS START

DATE

ESTIMATED ANNUAL

INCOME

THE INFORMATION YOU PROVIDE WILL BE VERIFIED, (SEE PENALTY OF PERJURY PART 17)

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