5700 R Street Lincoln, NE 68505 Phone: 402-434-5500 Fax: 402-434-5502 TDD: 1-800-545-1833 ext 875 www.L-Housing.com

APPLICATION for Housing Choice Voucher and/or Lincoln Housing Authority Owned or Managed Properties

LHA Form #101

Revision 07/2012

APPLICATION PLEASE CHECK YOUR SELECTIONS BELOW If you are uncertain about which property might be right for you, please discuss it with an Application Clerk, consult the LHA brochure or the LHA website at L-Housing.com. 0 Housing Choice Voucher Program, sometimes referred to as Section 8, is our largest rental subsidy program. With a voucher you must find a rental unit to rent within Lincoln that will pass LHA inspection. LHA will pay a portion of rent and you will pay a portion of rent based on your income. LHA will check criminal history. LHA Properties: LHA will check landlord references, credit history, criminal history and may require an in-home visit prior to approving an application. 0 Public Housing (Scattered sites located throughout Lincoln) see page 6 in the LHA brochure Spacious two, three, four and five bedroom homes and duplexes located throughout Lincoln. Some two bedroom units are wheelchair accessible. Applicants must meet income guidelines. Rent is based on income. Security deposit is $150. Small pet allowed with additional $300 pet deposit. 0 Arnold Heights (Neighborhood located off Northwest 48th Street) see page 7 in the LHA brochure Two, three and four bedroom duplexes just minutes from downtown Lincoln. Very reasonably priced with lots of green space for families. Deposit is one month’s rent. Small pet allowed with additional $300 pet deposit. You must have enough income to pay the monthly rent or have a Voucher. 0 Northwood Terrace and Heritage Square Apartments (22nd & Y and 23rd & W) see page II in the LHA brochure Reasonably priced studio, one, two and three bedroom apartments located close to the University of Nebraska. No pets allowed. Deposit is one month’s rent. You must have enough income to pay the monthly rent or have a Voucher. 0 Lynn Creek Apartments (9th & Garber Ave) see page I0 in the LHA brochure Reasonably priced two bedroom apartments near the Belmont shopping area and close to the University. No pets allowed. Deposit is one month’s rent. You must have enough income to pay the monthly rent or have a Voucher. 0 Prairie Crossing Apartments and Townhomes (33rd & Yankee Hill Road) see page 12 in the LHA brochure One and two bedroom apartments and three bedroom townhomes. Half of the units are available at a reduced Rent to income eligible families through the Tax Credit Program. You must have enough income to pay the monthly rent or have a Voucher. Half of the units are available at market rent. Some accessible one and two bedroom apartments. No pets allowed. Deposit is one month’s rent. Tax Credit Unit 0 Market Rate Unit 0 Wood Bridge Apartments and Townhomes (22nd & Pine Lake Road) see page I3 in the LHA brochure Reasonably priced two bedroom apartments and three bedroom townhomes in South Lincoln near SouthPointe Mall. Half of the units are available at a reduced rent to income eligible families through the Tax Credit Program. You must have enough income to pay the monthly rent or have a Voucher. Half of the units are available at Market Rents. Some accessible two bedroom apartments. No pets allowed. Deposit is one month’s rent. 0 Tax Credit Unit

0 Market Rate Unit

0 Summer Hill Apartments and Townhomes (56th & Union Hill Road) see page 14 in the LHA brochure Two and three bedroom units located just south of Pine Lake Road. Half of the units are available at a reduced rent to income eligible families through the Tax Credit or other LHA programs, and Vouchers are welcome. Half of the units are available at Market Rents. No pets allowed. Deposit is one month’s rent. 0 Tax Credit Unit

0 Market Rate Unit

0 Mahoney Manor Senior Housing (4241 North 61st Street) see page 15 in the LHA brochure Affordable studio, one, and two bedroom apartments for seniors (50+). Waiting List Preference to 62+. Located in the beautiful Havelock area. Some one bedroom accessible units. Applicants must meet income guidelines and be at least 50 years of age to qualify. Rent is based on income. Security deposit is $150. Small pet allowed with additional $300 pet deposit. 0 Crossroads House Senior Housing (1000 0 Street) see page 16 in the LHA brochure Affordable one bedroom apartments for seniors. Some one bedroom accessible units. Applicants must meet income guidelines and be at least 55 years of age. Rent is based on income. Deposit is one month’s rent. Cat allowed with additional $300 pet deposit. 0 Burke Plaza Senior Housing (6721 L Street) see page 17 in the LHA brochure Affordable one bedroom apartments for seniors (62 +)and persons with disabilities. Waiting List preference for seniors. Applicants must meet income guidelines and be at least 62 years of age or disabled to qualify. Rent and deposit is based on income. Small pet allowed with additional $300 pet deposit. Rev 6/12

APPLICATION

I. Lincoln Housing Authority: Preferences Please check any that apply to your situation.

Public Housing, Housing Choice Voucher program and Section 8 properties is eligible for a preference if one of the following is verifiable. 0 Disaster such as flood or fire — unit is not livable. 0 Domestic violence — displaced/homeless by domestic violence- actual or threatened violence against one or more members of the applicant family by a spouse or other member of the applicant’s household. Such applicants must have been forced to move because of domestic violence or lives with a person who engages in domestic violence. Families that become displaced/homeless due to domestic violence must provide documentation from a shelter, case-manager, police reports, protection order or any other credible documentation that substantiates the fact the applicant became displaced/homeless due to domestic violence and the displacement occurred within the last 3 months of the requested preference. Such violence must be recent or continuing. The applicant must certify that the person who engaged in such violence will not reside with the applicant family unless the Housing Authority has given advance written approval. If the family is admitted, the Housing Authority may deny or terminate assistance to the family for breach of the certification. 0 Homeless family or individual lacks a fixed or regular and adequate nighttime residence AND has a primary nighttime Residence that is a supervised public or private operated shelter providing temporary living accommodations; or an institution that provides a temporary residence for persons intended to be institutionalized; such as a nursing care facility or a public or private place not designed for or ordinarily used as regular sleeping accommodation. The acceptable verification must come from a government agency, law enforcement agency, public or private shelter, clergy, or social services agency. Housing Choice Voucher only preferences: (These preferences do not apply to the Public Housing Program) 0 Employment First program or other approved self-sufficiency program — The applicant is current and active in the participation with the Health and Human Services program, Employment First, or in any approved self -sufficiency program. 0 Military: Households who were terminated from the LHA voucher program due to the head of household or spouse being placed in active military duty. 0 Do you have a Nebraska RentWise Certification? Yes No If yes, please submit a copy of the certification to LHA. RentWise is a 12-hour educational program to help renters obtain and keep rental housing. See enclosed brochure and registration form to enroll. Public Housing only preference: (This preference does not apply to the Housing Choice Voucher Program) 0 Working Family: A family with at least one adult member who is currently employed at least 25 hours per week. A selfemployed person will be considered to meet the requirement if the net monthly earnings have equaled or exceeded the dollar value of 25 hours per week at minimum wage. A family whose head or spouse or sole member is age 62 or older or is a person with a disability also qualifies for this preference. This preference does not apply to Mahoney Manor or Burke Plaza. Rev 6/12

APPLICATION If you need us to provide an interpreter check here: PLEASE USE BLACK INK (Please Print All Information Below)

Written Language: Spoken Language: Home Phone: ( ) Cell Phone: ( ) Work Phone: ( )

Head of Household: First

Middle

Last

Residence Address: Street

City

State

Zip Code

Race Codes

Mailing Address: Street

City

State

(If multi-racial, you may use more than one code)

Zip Code

1. White 2. African American 3. American Indian/ Alaska Native

Email Address:

4. Asian 5. Native Hawaiian/ Other Pacific Islander

I. Household Composition: List below all persons who will be staying in your home, listing head of household first. Legal Name (First, Middle, Last)

Age

Date of Birth

1.

/

/

Relation to Head of Household

Social Security Number

HEAD

2.

/

BC

SSC

214

MEI Y/N

BC

SSC

214

MEI Y/N

BC

SSC

214

MEI Y/N

BC

SSC

214

MEI Y/N

BC

SSC

214

MEI Y/N

BC

SSC

214

MEI Y/N

BC

SSC

214

MEI Y/N

/

8.

/

MEI Y/N

/

7.

/

214

/

6.

/

SSC

/

5.

/

BC

/

4.

/

For Office Use Only

Race Hispanic Marital (Use Y/N Status code above)

/

3.

/

Sex

/

Maiden Name of female adult household member(s): Other Names/Social Security #’s used by any/all household members: Explain: Revised 7/3/12

APPLICATION

II. Household Composition

Office Use Only

1. Do you have custody of your minor children?

Yes

No

Non Applicable

Explain the custody arrangements:

If the parent of the minor is not living in the household, list information as follows: Absent Parent Name: Child’s Name: Street Address: City, State, Zip: Telephone #:

Absent Parent Name: Child’s Name: Street Address: City, State, Zip: Telephone #:

2. Is anyone in your household attending any school or education program? Yes

No Full Time Part Time

Student: Student: Student: Student: Student: Student: Student:

School: School: School: School: School: School: School:

3. Will anyone be leaving your household or family within the next 12 months?

Yes

No

Yes

No

If yes, please explain:

4. Will you be adding anyone to your household in the next 12 months? If yes, please explain:

Verification

APPLICATION

III. Employment: Enter earned income that any household member will have within the next year or had in the last year. List most current first.

(Office Use Only)

Person Working:



Employer:

Income Amount:



Position:

Income Per: Hour Hours Per Week:

Week

Month



Income Amount:



Position:

Income Per: Hour Hours Per Week:

Week

Month

Verification



Verification



Verification

City, State, Zip: Telephone:

End Date:

Person Working:



Employer:

Income Amount:



Position:

Income Per: Hour Hours Per Week:

Week

Month

Year Address:



City, State, Zip:

How long have you worked here/received this income?

Telephone:

End Date:

Person Working:



Employer:

Income Amount:



Position:

Income Per: Hour Hours Per Week:

Week

Month

Year Address:



City, State, Zip:

How long have you worked here/received this income?

Telephone:

End Date:

Person Working:



Employer:

Income Amount:



Position:

Income Per: Hour

Week

Month

Year Address:



City, State, Zip:

How long have you worked here/received this income? Start Date:



Year Address:



How long have you worked here/received this income?

Hours Per Week:

Verification

End Date:

Employer:

Start Date:



Telephone:



Start Date:

Verification

City, State, Zip:

Person Working:

Start Date:



Year Address:

How long have you worked here/received this income? Start Date:

Office Income Calculation

End Date:

Telephone:



Subtotal:

$

APPLICATION IV. Income Do you or anyone in your household receive any of the following income? Type Child Support/Alimony Court Order Number

Who Receives Income

Amount

How Often Paid or Received Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Disability, Death Benefits or Life Insurance Dividends

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Educational grants or scholarships (for example: Pell)

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Net Income from a Business, Rental property or Self Employment

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Other cash payments or contributions

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Pensions, Retirement Funds and Annuities

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Public Assistance (ADC, AABD, TANF)

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Social Security

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Supplemental Social Security (SSI)

Source/Company

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Unemployment Compensation

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Veterans Benefits

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

Workers Compensation

Yearly: Monthly: 2 times per month: Weekly: Every Two Weeks:

1. Does any household member receive regular contributions (donations or gifts) from any organization or persons not living in your household? If yes, please explain:

Yes

No

2. Did any household member file a federal income tax return last year?

Yes

No

3. Does any member of the household receive money from someone outside the household to pay bills or living expenses? If yes, please explain:

Yes

No

4. Has anyone in the household applied for any of the following within the last twelve months? Employment, AFDC, unemployment compensation, social security, SSI, pension or disability benefits? If yes, please explain:

Yes

No

If no, please explain:

Calculation/Annual Total (Office Use Only)

APPLICATION

V. Assets List all assets currently held by all household members and the cash value of each. Assets include Checking and Savings Accounts, CDs, Stocks, Bonds, Mutual Funds, Retirement Accounts, Real Estate and any other property held as an investment. Do you or anyone in your household have: Yes No Type





Bank/Source

Owner of Account

Account #



Any Stocks Bonds, or Mutual Funds



Verification



Verification



Verification



Verification



Verification



Verification



Verification



Verification



Verification

Retirement (401K, IRA)





(Office Use Only)

Savings Account

Certificates of Deposit



Calculation/Annual Total

Checking Account





Current balance/value

Life Insurance

Policy Type Term Whole Policy Type Term Whole

Cash



Savings Bonds



List any items not described above.

Subtotal:

APPLICATION

Own equity in Real Estate, rental property, land contracts/contract for deeds or other real estate holding or other capital investments (this includes your personal residence, mobile homes, vacant land, farms, vacation homes, or commercial property)?

Yes

No

Have you sold or given away any assets within the last two years for less than Fair Market Value? Type of Asset: Cash Value: $ Date Sold or Given Away:

Yes

No

VI. Residence: Where have the household members resided? Please check the box indicating all states and/or territories where any household member has resided. In addition, list the household member’s name on the line associated with the state or territory resided in.

State • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire

Who Resided There • • • • • • • • • • • • • • • • • • • •

New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

U.S. Territory • • • • • • • • •

American Samoa Federated States of Micronesia Guam Midway Islands Northern Mariana Islands Puerto Rico Republic of Palau Republic of the Marshall Islands U.S. Virgin Islands

Who Resided There

APPLICATION VII. Criminal and Drug-Related Activity: Answer for ALL Household Members 1. Are you or any other household member a current user or been arrested, ticketed, charged or convicted of possession, using, dealing or manufacturing a controlled substance?

Yes

No

2. Have you or any household member been convicted of methamphetamine production?

Yes

No

3. Are you currently on probation or parole?

Yes

No

Verification

4. Has any household member been arrested, charged, ticketed or convicted of any of the following? Please include both misdemeanors and felonies. Drug related activity including: Sale Manufacture Possession Use of illegal controlled substances

Yes

Alcohol related activity including: Driving under the influence of alcohol Other: Murder/Manslaughter Battery Assault

Yes

Yes

No

No

No

Sexual Assault Sex offender: Is anyone required to register on any state sex offender registry? Child abuse/molestation Burglary Larceny Robbery Vandalism Arson Disturbing the peace/disorderly conduct Other:

If yes was answered to the questions above, complete the following. If you have more than two incidents provide the remaining information on a separate piece of paper. a. Who was charged or convicted?

b. What crime was the charge or conviction for?

c. When was the charge or conviction? Month: Year:

e. Were any of the crimes drug related?

Yes

No

f. If drug related, has that person(s) successfully completed a supervised drug treatment program or is presently enrolled in such a program?

Yes

No

g. If yes, please name the facility:

Yes

No

Yes

No

Yes

No

Yes

No

d. Where did it occur? City:

County:

State:

h. Have you provided a certificate of completion? a. Who was charged or convicted?

b. What crime was the charge or conviction for?

c. When was the charge or conviction? Month: Year:

e. Were any of the crimes drug related?

d. Where did it occur? City:

County:

State:

f. If drug related, has that person(s) successfully completed a supervised drug treatment program or is presently enrolled in such a program? g. If yes, please name the facility: h. Have you provided a certificate of completion?

Office Use Only

APPLICATION VIII. Additional Information Yes

No Have you or has anyone in your household ever received rental assistance or paid rent based on income? What name was used by the person receiving assistance? Address: City State When: Month Day Year Name of Housing Agency Has your rental assistance ever been terminated for fraud, non-payment of rent or failure to re-certify? If yes, please explain.

Have you or has anyone in your household applied or rented with the Lincoln Housing Authority? When: Month Day Year What name was used on the application? What name was used and/or who was the Head of Household? When: Address Have you or has anyone in your household ever been evicted? When: Why Name of Landlord

Address

Do you declare a disability for the purposes of eligibility? Some programs have preferences for persons with disabilities. You are under no obligation to declare this. If yes, provide name and address of doctor who can verify your disability

Would you or any members of your household benefit from a handicapped-accessible unit? Explain:

Do you have a pet? How many:

Type/breed and weight:

Do you or anyone in your household have a vehicle?

Yes

No

Model/Year: License Plate Number:

Do you have a second vehicle?

Yes

No

Model/Year: License Plate Number:

Do you or anyone applying for or receiving help have a guardian, conservator, or individual acting under power of attorney? Yes No Name of person with Guardian, Conservator or Power of Attorney: Name of Guardian, Conservator, or Power of Attorney: Address: Street

City

State

Zip Code

Phone number:

(Include area code)

List any additional information or notes. Describe any additional information not previously covered such as special needs, required bedroom size, etc.

Has someone assisted you in completing this form? Name of person completing form:

Yes

No

APPLICATION

IX. Rental History Attach additional pages if needed List all places each household member has lived in the past five (5) years, beginning with your current address. Current Residence

Who lives here?

Street Address: Dates: Month/Day/Year From: City/State/Zip: To:

Landlord: Address: City/State/Zip: Phone #:

Why do you want to move? Do you

Rent

Previous Residence

Own

Other (explain)

Who lived here?

Street Address: Dates: Month/Day/Year From: City/State/Zip: To:

Landlord: Address: City/State/Zip: Phone #:

Why did you want to move? Did you

Rent

Previous Residence

Own Who lived here?

Landlord: Address: City/State/Zip: Phone #:

Why did you want to move? Rent

Previous Residence

Own Who lived here?

Landlord: Address: City/State/Zip: Phone #:

Why did you want to move? Rent

Rent Amount $

Other (explain)

Street Address: Dates: Month/Day/Year From: City/State/Zip: To:

Did you

Rent Amount $

Other (explain)

Street Address: Dates: Month/Day/Year From: City/State/Zip: To:

Did you

Rent Amount $

Own

Other (explain)

Rent Amount $

APPLICATION

X. Rights and Responsibilities I/We certify that all information given to the Lincoln Housing Authority is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements I/we give to the Housing Authority may be punishable under Federal Law. I/We also understand that false statements or information will be grounds for denial of your application, termination of housing assistance and/or termination of tenancy. I/We understand that this is an application for assistance and signing this application does not bind the Housing Authority to offer rental assistance nor does it bind me/us to accept any assistance offered. I/We have no objection to inquiries for the purpose of verifying the facts herein stated. I/We have received, read and understand the HUD fact sheet “Applying for HUD Housing Assistance.” I/We authorize you to verify the above information through a consumer reporting agency. (This agency is Tenant Data Services Inc. (800) 228-1837. The function of this agency is to track and maintain records such as your resident conduct and personal credit history. Tenant Data Services Inc. also will obtain a credit report on all applicants for Lincoln Housing Authority owned/ managed properties.) Authorization to Release Information Your signature on this form and the signature of each member of your household who is 18 years of age or older authorizes the Housing Authority of the City of Lincoln, NE, to use this authorization and the information obtained with it, to administer and enforce rules and policies. Any individual or organization, including any governmental agency may be asked to release information. Information may be requested from but is not limited to: banks and other financial institutions, courts, law enforcement agencies, credit bureaus, landlords, past and present employers, medical providers, educational institutions, Veterans Affairs, Social Service Agencies, utility companies, unemployment benefits, pensions/annuities, child care providers, neighbors and the U.S. Post Office. By signing this form, I authorize the above persons, firms or corporations to make available any documents or record to the Housing Authority of the City of Lincoln for inspection and copying. Signature of Head of Household

Print Name

Date

Signature of Spouse/Co-Applicant

Print Name

Date

Signature of Other Adults/Co-Applicant

Print Name

Date

LANGUAGE IDENTIFICATION FLASHCARD

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2010

LANGUAGE IDENTIFICATION FLASHCARD

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LANGUAGE IDENTIFICATION FLASHCARD LANGUAGE IDENTIFICATION FLASHCARD

1. Arabic 2. 4. Cambodian 3. Armenian Bengali 1. 2. Armenian 3. Arabic Bengali 4. Cambodian 5. Chamorro 2. Armenian 1. 3. Arabic Bengali 4. Cambodian 5. Chamorro

2010

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Chamorro Motka ya yangin manaitai pat ûntûngnu' Chinese Označite ovaj čitate ili agovorite Zaškrtněte tutokvadratić kolonku,ako pokud čtete hovořítehrvatski česky. jezik. 8.Croatian Chinese 9. Czech Chinese 6. Simplified Cocher ici si vous lisez ou parlez le français. French 7.8.13. Traditional Croation Chinese 5. Chamorro Motka i kahhon ya yangin ûntûngnu' manaitai pat ûntûngnu' kumentos Chamorro. Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. 8.Croatian Zaškrtněte tuto kolonku, pokud a hovoříte 9. Czech Chinese QUmditbJÇ ak'kaan ñ¨g®b/b' enHparlez ebIčtete /leñkfrançais. /an …niXofčesky. aXPasa 4. C 10. Dutch Kruis vakje als u ou Nederlands kunt lezen spreken. e‡oµe . Cocher ici si vous lisez 13. French 6. Simplified 7. Traditional 5. Chamorro Motka i kahhon ya yangin ûntûngnu' manaitai pat ûntûngnu' kumentos Chamorro. 9. Czech Chinese Chinese Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. 8.Croatian Zaškrtněte tuto aan kolonku, pokud čtete kunt a hovoříte česky. 10. Dutch 9. Czech Kruis dit vakje als u Nederlands lezen of spreken. Cocher ici si vous lisez ou parlez le français. 13. French 7.14. Traditional 6. Simplified Kreuzen Sie dieses Kästchen an, wenn Sie Deutsch lesen oder sprechen. German 10. Dutch Chinese Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. Chinese 8.Croatian Zaškrtněte tuto aan kolonku, pokud čtete kunt a hovoříte česky. 9. Czech 10. Dutch Kruis dit vakje alsread u Nederlands lezen of spreken. 11. English Mark this if you speak 6. Simplified Cocher ici si vous lisez ouorparlez leEnglish. français. 13. French Kreuzen Sie dieses Kästchen an,ûntûngnu' wenn Sie Deutsch sprechen. 14. German 5. C Motka ibox kahhon ya yangin manaitailesen pat oder ûntûngnu' kumentos Chamorro. 7. Traditional Chinese Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. 8.Croatian 11.Chinese English Zaškrtněte tutoifaan kolonku, pokud čtete a hovoříte česky. 9. Czech 10. Dutch 11. English Kruis ditici vakje alsread u ou Nederlands kunt lezen of spreken. Mark this box you orparlez speak Cocher si dieses vous lisez leEnglish. français. 13. Kreuzen Sie Kästchen an, wenn Sie Deutsch lesen oder sprechen. 14. French German Greek 7.15. Traditional Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. 8.Croatian Zaškrtněte tuto kolonku, pokud čtete a hovoříte česky. 12.Chinese Farsi 9. Czech 10. Dutch Kruis this dit vakje alsread u Nederlands kunt lezen of spreken. 11. English Mark box ifaan you speakleEnglish. 12. Farsi Cocher si dieses vous lisez ouorparlez français. 13. French 7. Traditional Kreuzenici Sie Kästchen an, wenn Sie Deutsch lesen oder sprechen. 6. S 15. Greek 14. German Chinese Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. Zaškrtněte tuto kolonku, pokud čtete a hovoříte česky. 8.Croatian 9. Czech C 10. Dutch 13. French Kruis ditici vakje alsread u ou Nederlands kunt lezen of spreken. 16. Haitian 12. Farsi 11. English Mark this box ifaan you orparlez speak Cocher si dieses vous lisez leEnglish. français. 13. French DEPARTMENT OF COMMERCE Kreuzen Sie Kästchen an, wenn Sie Deutsch lesenU.S.oder sprechen. 14. German 15. Greek Economics and Statistics Administration Make kazye sa a si ou li oswa ou pale kreyòl ayisyen. Creole U.S. CENSUS BUREAU 9. Czech Zaškrtněte tuto kolonku, pokud čtete a hovoříte česky. 16.German Haitian Označite ovaj govorite jezik. 8.Croatian 10. Dutch Kruis this dit vakje uako Nederlands kunt lezenhrvatski of spreken. 11. English Mark box kvadratić ifaan youalsread or čitate speakili English. 12. Farsi 14. U.S. DEPARTMENT OF COMMERCE Kreuzen Sie dieses Kästchen an, wenn Sie Deutsch lesen oder sprechen. 14. German Economics and Statistics Administration Make kazye sa a si ou li oswa ou pale kreyòl ayisyen. 15. Creole Greek U.S. CENSUS BUREAU 8.Croatian Označite ovaj kvadratić ako čitate ili govorite hrvatski jezik. Zaškrtněte tuto kolonku, pokud čtete kunt a hovoříte česky. 16. Haitian 7. Tr 10. Dutch 9. Czech Kruis dit vakje u Nederlands lezen of spreken. English Mark this box ifaan youalsread or speak English. U.S. DEPARTMENT OF COMMERCE 11. 12. Farsi 15. Greek Kreuzen Sie sa dieses Kästchen Sie Deutsch lesen oder sprechen. C 14. Economics and Statistics Administration 15. German Greek Make kazye a si ou li oswaan, ou wenn pale kreyòl ayisyen. Creole U.S. CENSUS BUREAU 17. Hindi 10. Dutch Kruis dit vakje u Nederlands kunt lezen of spreken. 16. Haitian Zaškrtněte tutoifaan kolonku, pokud čtete a hovoříte česky. 9. Czech 11. English Farsi Mark this box youalsread or speak English. U.S. DEPARTMENT OF COMMERCE 12. 16. Haitian 15. Greek Economics and Statistics Administration Make kazye sa a si ou li oswa ou pale kreyòl ayisyen. 17.Creole Hindi Creole U.S. CENSUS BUREAU 9. Czech Zaškrtněte tuto kolonku, pokud čtete a hovoříte česky. 16.English Haitian 10. Dutch 11. Kruis this dit vakje u Nederlands kunt lezen of spreken. Mark box ifaan youalsread or speak English. U.S. DEPARTMENT OF COMMERCE 12. Farsi 17. Hindi Economics and Statistics Administration 15. Greek Make kazye sa a si ou li oswa ou pale kreyòl ayisyen. 17. Hindi Creole Označite ovaj akothiab čitate ililus govorite U.S. CENSUS BUREAU Kos lub voj no yogkvadratić koj paub twm hais Hmoob.hrvatski jezik. 18. Hmong 8.Cr 16. Haitian 11. English Mark this box if you read or speak English. 10. Dutch Kruis dit vakje aan als u Nederlands kunt lezen of spreken. U.S. DEPARTMENT OF COMMERCE 12. Farsi 18. Make kazye sa yog a si ou oswatwm ou pale ayisyen. Statistics Administration Creole 17.Hmong Hindi Kos lub voj no kojlipaub thiabkreyòl hais lus Hmoob. Economics andU.S. 18. Hmong CENSUS BUREAU 10. Dutch Kruis dit vakje aan als u Nederlands kunt lezen of spreken. 16. Haitian 12. Farsi 11. English Mark this box if you read or speak English. U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration Make kazye sa a si ou li oswa ou pale kreyòl ayisyen. Creole 17.Hungarian Hindi Kos lubmeg voj ezt no yog koj paub twm thiab hais lus Hmoob. 18. Hmong Jelölje a kockát, ha megérti vagy beszéli a magyar nyelvet.U.S. CENSUS BUREAU 19. 19. Hungarian Farsi Zaškrtněte pokud čtete a hovoříte 9. C U.S.česky. DEPARTMENT OF COMMERCE 12. 11. English Mark this box iftuto you kolonku, read or speak English. Economics and Statistics Administration 17. Hindi Jelölje a kockát, ha megérti vagy beszéli a magyar nyelvet.U.S. CENSUS BUREAU 19. Kos lubmeg voj ezt no yog koj paub twm thiab hais lus Hmoob. 18. Hungarian Hmong 11. English Mark this box if you read or speak English. U.S. DEPARTMENT OF COMMERCE 12. Farsi

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26. Kos lubmeg vojezt no ayog koj paub twm thiab lus Hmoob. 18.Portuguese Hmong Jelölje kockát, ha megérti vagyhais beszéli a magyar nyelvet. 19. 20. Hungarian Ilocano Markaam daytoy nga kahon no makabasa wenno makasaoka iti Ilocano. Assinale este quadrado se você lê ou fala português. 27. 26. Portuguese Jelölje meg ezt a kockát, ha megérti vagy beszéli a magyar nyelvet. 19.Romanian Hungarian Marchi questa casella se legge parla italiano. 21. 20. Italian Ilocano Markaam daytoy nga kahon noomakabasa wenno makasaoka iti Ilocano. Assinale este quadrado se você lê ou fala português. 26. Portuguese 27. Jelölje meg ezt a kockát, ha megérti vagy beszéli a magyar nyelvet. 19.Romanian Hungarian 20. Ilocano Markaam daytoy nga kahon no makabasa wenno makasaoka iti Ilocano. Marchi questa casella se legge o parla italiano. 21. Italian Assinale este quadrado se você lê ou fala português. 26. Portuguese 28. �ометьте этот квадратик, еслиLANGUAGE вы читаете илиIDENTIFICATION говорите по-русски.FLASHCARD 27. Russian Romanian 20. Japanese Ilocano Markaam daytoy nga kahon no makabasa wenno makasaoka iti Ilocano. 22. Marchi questa casella se legge o parla italiano. 21. Italian Assinale este quadrado se você lê ou fala português. 26. Portuguese 27. Romanian 20. IIocano 28. Russian �ометьте этот квадратик, если вы читаете говорите по-русски. 20. Ilocano Markaam daytoy nga kahon no makabasa wennoили makasaoka iti Ilocano. Marchi questa casella se legge o parla italiano. 21. Italian 22. Japanese 1. A .á«Hô©dGeste çóëàJ hCG CGô≤Jse âæc ™HôŸG ‘ áeÓY ™°V Assinale quadrado vocêGPE lêG ou fala Gòg português. 26. Portuguese 27. Romanian 29. Serbian 28. Russian �ометьте этот квадратик, если вы читаете или говорите по-русски. 21. Italian Marchi questa casella se legge o parla italiano. 21. Italian 23. Korean 22. Japanese Assinale este quadrado se você lê ou fala português. 26. Portuguese 27. Romanian 28. Russian �ометьте этот квадратик, если вы читаете или говорите по-русски. 29. Serbian 22. Japanese Marchi questa casella se legge o parla italiano. 21. Italian 22. Japanese 23. Korean Assinale este quadrado se você lê ouвы falaчитаете português. 26. Portuguese 28. Russian 27. Romanian �ометьте этот квадратик, говорите по-русски. Označte tento štvorček, ak vieteесли čítať alebo hovoriťили po slovensky. 30. Slovak 29. Serbian 2. A 23. Korean

2004 Census Test

2010

22. Japanese

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24. Laotian 23. Romanian Korean Assinale este quadrado se você lê ou fala português. 26. Portuguese 27. 28. Russian �ометьте этот квадратик, если вы читаете или говорите по-русски. 29. Serbian Označte tento štvorček, ak viete čítať alebo hovoriť po slovensky. 30. Slovak 22. Japanese 24. Laotian 23. Korean Assinale este quadrado se você lê ou fala português. 24. Laotian 26. Portuguese 27. Romanian 28. Russian 29. Serbian �ометьте этот квадратик, если вы читаете или Marque casilla si leeak o habla español. 31. Označteesta tento štvorček, viete čítať alebo hovoriť po говорите slovensky. по-русски. 30.Spanish Slovak 25. Polish 23. Korean Prosimy o zaznaczenie tego kwadratu, jeżeli posługuje się Pan/Pani 3. 25. Polish 24. Romanian Laotian Assinale este quadrado se vocêесли lê ouвы falaчитаете português. 26. Portuguese 27. językiem polskim. 28. Russian �ометьте этот квадратик, или говорите по-русски. 29. Slovak Serbian Označteesta tento štvorček, viete čítať alebo hovoriť po slovensky. 30. Marque casilla si leeak o habla español. 31. Spanish 23. Korean 26. Portuguese Prosimy zaznaczenie kwadratu, posługuje się Pan/Pani U.S. DEPARTMENT OF COMMERCE 26. 24. Laotian Assinaleoeste quadradotego se você lê ou jeżeli fala português. Portuguese 25. Polish 27. Romanian Economicsпо-русски. and Statistics Administration 28. Russian �ометьте этот квадратик, если выmarunong читаете или językiem polskim. Označte tento štvorček, čítať hovoriť po говорите slovensky. 30. Slovak 29. Serbian U.S.Tagalog. CENSUS BUREAU 32. Markahan itong kuwadrado kung kayo ay alebo magbasa o magsalita ng Marque esta casilla si leeak o viete habla español. 31.Tagalog Spanish 24. Laotian 27. Romanian Prosimy o zaznaczenie tego kwadratu, jeżeli posługuje się Pan/Pani U.S. DEPARTMENT OF COMMERCE 27. 25. Romanian Polish 28. Russian �ометьте этот квадратик, если вы читаете или говорите по-русски. 29. Serbian Economics and Statistics Administration Označte esta tento štvorček, čítať hovoriť po slovensky. 30.Tagalog Slovak 4. językiem polskim. Marque casilla si leeak o viete habla español. 31. Spanish Markahan itong kuwadrado kung kayo ay alebo marunong magbasa o magsalita ng U.S.Tagalog. CENSUS BUREAU 32. 24. Laotian Prosimy o zaznaczenie tego kwadratu, jeżeli posługuje się Pan/Pani 28. Russian 25. Polish Romanian U.S. DEPARTMENT OF COMMERCE 27. 28. Russian �ометьте этот квадратик, если вы читаете или говорите по-русски. 29. Serbian językiem polskim. Economics and Statistics Administration Označte tento štvorček, čítať alebo hovoriť po slovensky. 30. Slovak Marque esta casilla si leeakkung o viete habla español. 31. Spanish Markahano itong kuwadrado kayo ayjeżeli marunong magbasa o magsalita ng CENSUS Tagalog. 32.Thai Tagalog U.S. BUREAU 33. Prosimy zaznaczenie tego kwadratu, posługuje się Pan/Pani 25. Polish U.S. DEPARTMENT OF COMMERCE 29. Serbian językiem polskim. 28. Russian 29. Serbian �ометьте этот квадратик, если выmarunong читаете или Economicsпо-русски. and Statistics Administration Označte tento štvorček, akkung viete čítať hovoriť po говорите slovensky. 30. Slovak Marque esta casilla si lee o habla español. Markahan itong kuwadrado kayo ayalebo magbasa o magsalita U.S. ng CENSUS Tagalog. 31. Spanish Tagalog BUREAU 32. Prosimy o zaznaczenie tego kwadratu, jeżeli posługuje się Pan/Pani 5. Motka i kahhon ya yangin ûntûngnu' manaitai pat ûntûngnu' kumentos Chamorro. 33. Thai U.S. DEPARTMENT OF COMMERCE 25. Polish językiem polskim. 30. Slovak Economics and Statistics Administration 28. Serbian Russian �ометьте этот квадратик, если вы читаете или по-русски. 29. Označte tento štvorček, viete čítaťay alebo hovoriť po говорите slovensky. Slovak BUREAU 30. Markahan kuwadrado kayo marunong magbasa o magsalita U.S. ng CENSUS Tagalog. 32. Tagalog Marque'i esta casilla si leeakkung o'oku habla 31. Spanish Maaka heitong puha ni kapau ke español. lau pe lea fakatonga. 34. Tongan 33. Thai

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U.S. DEPARTMENT OF COMMERCE

Economics and Statistics Administration 31. Spanish Označte tento štvorček, čítať alebo hovoriť po slovensky. Slovak 29. Serbian U.S. CENSUS BUREAU 30. Marque casilla si leeakkung o viete habla español. 31. Spanish Markahanesta itong kuwadrado kayo ay marunong magbasa o magsalita ng Tagalog. 32. Tagalog 33. Thai Maaka 'i he puha ni kapau 'oku ke lau pe lea fakatonga. 34. Tongan 29. Serbian 30. Slovak Označte tentocasilla štvorček, čítať alebo hovoriť po slovensky. 32. Tagalog Marque si leeakkung o viete habla español. 31. Spanish Markahanesta itong kuwadrado kayo ay marunong magbasa o magsalita ng Tagalog. 32. Tagalog 33. Thai Maaka 'i he ni kapau 'okuвиkeчитаєте lau pe lea �ідмітьте цюpuha клітинку, якщо абоfakatonga. говорите українською мовою. 35. 34. Ukranian Tongan

Označte tento štvorček, čítať hovoriť po slovensky. Marque esta casilla si leeakkung o viete habla español. Markahan itong kuwadrado kayo ayalebo marunong magbasa o magsalita ng Tagalog. Maaka 'i he puha ni kapau 'oku ke lau pe lea fakatonga. �ідмітьте цю клітинку, якщо ви читаєте або говорите українською мовою. Označte tento štvorček, hovoriť po slovensky. Marque esta casilla si leeako viete hablačítať español. Markahan itong kuwadrado ayalebo marunong magbasa o magsalita ng Tagalog. Maaka 'i he puha ni kapaukung 'okukayo ke lau pe lea fakatonga. �ідмітьте цю клітинку, якщо ви читаєте або говорите українською мовою. Markahan itong kuwadrado kayo ay marunong magbasa o magsalita ng Tagalog. Marque casilla lee kung o'oku habla Maaka 'iesta heцю puha ni sikapau keespañol. lau pe lea fakatonga. �ідмітьте клітинку, якщо ви читаєте або говорите українською мовою. Markahan itong kuwadrado kayo ay marunong magbasa o magsalita ng Tagalog. Marque esta casilla si lee kung o habla español. Maaka 'i he puha ni kapau 'oku ke lau lea fakatonga. �ідмітьте цю клітинку, якщо ви читаєте або говорите українською мовою. XinOznačite ñaùnh daáuovaj vaøokvadratić oâ naøy neáuako quyùčitate vòpebieá t ñoï c vaø noùi hrvatski ñöôïc Vieäjezik. t Ngöõ . ili govorite Markahan itong kuwadrado ay marunong magbasa o magsalita ng Tagalog. Maaka 'i he puha ni kapaukung 'okukayo ke lau pe lea fakatonga.

�ідмітьте цю клітинку, якщо ви читаєте або говорите українською мовою.

Xin ñaùnh daáu vaøo oâ naøy neáu quyù vò bieát ñoïc vaø noùi ñöôïc Vieät Ngöõ.

Markahan itong kuwadrado kung kayo ay marunong magbasa o magsalita ng Tagalog.

Maaka 'i he puha ni kapau 'okuви keчитаєте lau pe lea fakatonga. українською мовою. �ідмітьте Xin ñaùnh цю daáuклітинку, vaøo oâ naøякщо y neáu quyù vò bieáабо t ñoïговорите c vaø noùi ñöôïc Vieät Ngöõ. DB-3309

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Zaškrtněte tuto kolonku, pokud a hovoříte česky. Maaka 'i heцю puha ni kapau 'okuви ke lau pečtete lea fakatonga. �ідмітьте клітинку, якщо читаєте або мовою. Xin ñaùnh daáu vaøo oâ naøy neáu quyù vò bieát ñoïговорите c vaø noùiукраїнською ñöôïc Vieät Ngöõ .

U.S. DEPARTMENT OF COMMERCE

Maaka 'i he puha ni kapau 'oku ke lau pe lea fakatonga.

Economics and Statistics Administration

U.S. CENSUS BUREAU

6. S C

30. Slovak 33. Thai 31. Spanish 32. Tagalog 33. Thai 34. Tongan 35. Ukranian 30. Slovak 7. Tr 31. Spanish 34. Tongan 32. Tagalog 34. Tongan 33. Thai 36. 35. Urdu Ukranian C 32. Tagalog 31. Spanish 35. Ukranian 33. Thai 34. Tongan 35. Ukranian 36. Urdu 31. Spanish 32. Tagalog 33. Thai 36. Urdu 34. Tongan 35. Ukranian 37. 36.Vietnamese Urdu 8.Cr 32. Tagalog 33. Thai 34. Tongan 37. Vietnamese 35. Ukranian 36. Urdu 37. Vietnamese 32. Thai Tagalog 33. 34. Tongan 36. Urdu 38. Yiddish 35. Ukranian 38. 37. Yiddish Vietnamese 9. C 34. Tongan 33. Thai 35. Ukranian 36.Yiddish Urdu 37. Vietnamese 38. 33. Thai

OMB Control # 2502-0581 Exp. (07/31/2012) Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form. Applicant Name: Mailing Address: Telephone No:

Cell Phone No:

Name of Additional Contact Person or Organization: Address: Telephone No:

Cell Phone No:

Email Address (if applicable): Relationship to Applicant: Reason for Contact: (Check all that apply)



Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent

Assist with Recertification Process Change in lease terms Change in house rules Other:___________________________

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you. Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law. Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-55, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Check this box if you choose not to provide the contact information.



Signature of Applicant



Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501·3520). The public reporting burden is estimated al 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information . Providing the information is basic to the operations of the HUD Assisted·Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102·55, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. Form HUD- 92006 (05 /09)