PINELLAS COUNTY HOUSING AUTHORITY PUBLIC HOUSING APPLICATION

Rainbow Village Apartments 12301 134th Avenue North Largo, FL 33774 Phone: (727)581-4793 Rainbow Village Fax: (727)585-3891

Low Income Public Housing Pre-application APPLICATION INSTRUCTIONS PLEASE READ CAREFULLY INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED 1. To be eligible, applicant must: A. Meet the definition of family as defined by Pinellas County Housing Authority's Admissions and Continued Occupancy Policy. B. Applicant must have annual income within the limits established and determined by HUD. C. Must be a U.S. Citizen or possess an eligible immigration status as determined by the INS. D. Must not owe any monies to any Housing Authority or other federally subsidized rental program. E. Must not be engaged in any illicit drug or related criminal activity or violent criminal activity. 2. Applications will be entered onto a computerized site-based waiting list in the order in which the applications are received and reviewed for completeness in accordance with local preferences. 3. Make sure you provide a Social Security number and date of birth for yourself and each family member. If a member of your household has not been issued a Social Security number, write NONE in the box for Social Security number. Make sure you provide your complete address and phone number. Any changes in family composition, income, or address must be submitted in writing to the property(s) of your choice. 4. Make sure that you disclose all income from all family members including assets or bank statements. th

5. This application may be returned via U.S. Mail to Rainbow Village Apartments 12301 134 Ave North Largo, Florida 33774 for processing. If you are a person with disabilities, you may seek assistance with completion of this application at the property. Applications are date and time stamped of acceptance. Please indicate with an (X) your choice. _________ Rainbow Village at 12301 134th Avenue N, Largo - (727)581-4793

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PINELLAS COUNTY HOUSING AUTHORITY PUBLIC HOUSING APPLICATION

 HEAD OF HOUSEHOLD INFORMATION Last Name __________________________ First Name ____________________ Middle Initial ____ Social Security Number ___________________________ Male/Female _____ CHECK ONE:  Hispanic or Latino  Non-Hispanic or Latino Are you disabled? Yes No FOR HUD STATISTICAL PURPOSES ONLY- (Check one of each) CHECK ONE:  White  Black/African American  American Indian/Alaska Native  Asian  Native Hawaiian/Other Pacific Islander Date of Birth ____/_____/______ (mm/dd/yyyy) Place of Birth _________________________ Are you a U.S. Citizen? Yes No Occupation______________________________________________________________________ Full-Time Student Yes No How many in your household? _______  INFORMATION ON OTHER FAMILY MEMBERS: (PLEASE USE BACKOF THIS PAGE FOR ADDITIONALHOUSEHOLD MEMBERS)

Legal Name 1 2 3 4 5 6

Male / Female

Social Security Number

Type of Member (Spouse, Child)

Student

Disabled

Race

DOB

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PINELLAS COUNTY HOUSING AUTHORITY PUBLIC HOUSING APPLICATION

 SOURCE(S) OF FAMILY INCOME: CHECK ALL THAT APPLY AND STATE AMOUNT: HOUSEHOLD MEMBER

Employment Income (MONTHLY)

TANF /DCF

CHILD SUPPORT (MONTHLY)

SOCIAL SECUITY BENEFITS

UNEMPLOYMENT

ALL OTHER INCOME

1. 2. 3.

 CONTACT INFORMATION: Mailing Address: __________________________________________________________________________________ __________________________________________________________________________________ (City) (State) (Zip Code) Telephone number __________________________ Alternate Telephone Number ________________ Email Address ________________________  LOCAL PREFERENCES There are three possible rankings for which you may qualify. Written documentation will have to be provided when you are interviewed and before any offers for housing are made. Please answer the questions as they apply to you and your household members. 1) Working Families Is a member of the applicant family, over the age of 18, working, attending an educational or training institution? □‫‏‬Yes □ No 2) Elderly, Disabled, Handicapped Is head of household, or spouse, 62 years of age or older?

□ Yes

□ No

Is the head of household, or spouse disabled, receiving social security disability, or SSI disability benefits, or other payments based on the individual's inability to work? □ Yes □ No Is the head of household, or spouse handicapped?

□ Yes □ No

3) Natural Disaster/Displacement Is the applicant family displaced by a declared Natural Disaster such as flood, hurricane, earthquake, etc.? □ Yes □ No 4) No Preference □ None of the above preferences apply to me or members of my household

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PINELLAS COUNTY HOUSING AUTHORITY PUBLIC HOUSING APPLICATION

 GENERAL INFORMATION: 1. Have you or anyone in your household ever been arrested or convicted of a drug related crime or violent criminal activity?

Yes No

2. Have you ever been evicted from a public housing program?

Yes No

3. Have you ever received assistance from a federally assisted Housing Authority?

Yes No

If yes, have you ever committed any fraud in a federally assisted Housing Authority or ever been requested to repay money for knowingly misrepresenting information for such Housing program?

Yes No

4. Are any members of the household currently or in the pass been subject to a lifetime sex offender registration program in any state

Yes

No

I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE. I understand that submission of false information or misrepresentation may result in loss of eligibility to participate in the Public Housing Program. Date _______________

Signature of Head of Household________________________________________

Date _______________

Signature of Spouse__________________________________________________

Date _______________

Signature of Other Adult______________________________________________

Date _______________

Signature of Other Adult______________________________________________

Warning: 18. U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned for not more than five years or both. Chapter 414.39 of Florida Statues makes it a crime, punishable by fine of $50.00 to $5,000.00, or imprisonment for up to five (5) years, or both, if a housing applicant or tenant deliberately makes false statements about his or her income, or fails to disclose material fact affecting income and rent

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PINELLAS COUNTY HOUSING AUTHORITY PUBLIC HOUSING APPLICATION

OMB Control # 2502-0581 Exp. (11/30/2015) Optional and Supplemental 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 Applicant Name: Mailing Address: Telephone No: Cell Phone No: Name of Additional Contact Person or Organization: Address: Telephone No: Cell Phone No: E-Mail 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 102-550, 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.

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. 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 at 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 102-550, 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)