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Our Lady of Angels Apartments, Inc.
& Franciscan Village II
(a.k.a. Our Lady of Angels II)
Tenant Selection Plan
(collectively known as Franciscan Village)
Franciscan Village
Tenant Selection Plan
Index
Project Eligibility Requirements Project Specific Requirements Citizenship/Immigration Requirements Social Security Number (SSN) Requirements Eligibility of Students for Section 8 Assistance
Income Limits
Procedures for Taking Applications and Selecting from the Waiting List Taking Applications Preferences Income-Targeting Applicant Screening Criteria Existing Tenant Search Report Procedures for Rejecting Ineligible Applicants
Occupancy Standards
Unit Transfer Policies
Policies to Comply with Section 504 of the Rehabilitation Act of 1973, The Fair Housing Amendments of 1988, and Title VI of the Civil Rights Act of 1964
Policies to Comply with Violence Against Women Act (VAWA) and Department of Justice Reauthorization Act of 2005 and and Violence Against Women Reauthorization Act (VAWA) of 2013
Policy for Opening and Closing the Waiting List
No Smoking Policy
List of Attachments
A Acceptable DHS Documents
B Acceptable Forms of Verification – Social Security Number
C Preliminary Application
D Verification of Disability Packet
E Letter for First Refusal of an Apartment
F Letter for Second Refusal of an Apartment
G Letter for No Longer Interested in an Apartment
H Letter Contacting Applicant if he/she wishes to Remain on Waiting List
I Letter of Rejection – Upon Review of Application Request & Upon Review of Preliminary Application
J Letter of Rejection after Application Interview
K HUD-5380 – Notice of Occupancy Rights under the Violence Against Women Act
L HUD-5382 – Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and Alternate Documentation
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Tenant Selection Plan
Project Eligibility Requirements Project Specific Requirements
Our Lady of Angels Apartments, Inc. and Franciscan Village, II, Inc., dba as Franciscan Village, sponsored by the Province of the Sacred Heart Franciscans, was approved by the U.S. Department of Housing and Urban Development for construction and subsidy of 174 apartments for adults over sixty-two years of age, or, in the case of OLA Apartments, Inc., mobility impaired, under the Section 202/8 and PRAC programs. The purpose of Franciscan Village, as approved by the Department of Housing and Urban Development, is to provide housing and appropriate support service to persons over sixty-two years of age or mobility impaired as defined by the Department of Housing and Urban Development. Franciscan Village was not selected nor does it possess the resources required to meet the special needs of other eligible 202 constituencies such as the developmentally disabled or the chronically mentally ill, per the Department of Housing and Urban Development’s Regulatory Agreement. Citizenship/Immigration Requirements By law, only U.S. citizens and eligible noncitizens may benefit from federal rental assistance. Assistance in subsidized housing is restricted to the following: a) U.S. citizens or nationals; and b) noncitizens who have eligible immigration status as determined by HUD regulations. Noncitizens (except those age 62 and older) must sign a Verification Consent Form and submit documentation of their status or sign a declaration that they do not claim to have eligible status. Noncitizens age 62 and older must sign a declaration of eligible immigration status and provide a proof of age document. Attachment A is an exhibit of the acceptable forms of documentation regarding the immigration status of a noncitizen. U.S. citizens must sign a declaration of citizenship. Also, our owner policy requires at least one additional proof of citizenship (birth certificate, military discharge papers, valid passport, or naturalization certificate) for those declaring to be U.S. citizens or nationals. Applicants must submit required documentation of citizenship/immigration status no later than the date the owner initiates verification of other eligibility factors. Social Security Number (SSN) Requirements Each member of an applicant’s household except for those who do not claim to have eligible immigration status and persons 62 and older who were already receiving federal housing assistance somewhere else on January 31, 2010, must disclose such SSN before the household may be housed. However, they do not need to have or disclose their SSN in order to be placed on the waiting list. Furthermore, they may retain their place on the
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Social Security Number (SSN) Requirements (continued) waiting list if all household members required to disclose a SSN cannot do so at the time a unit becomes available for them. The applicant who has not disclosed and/or provided verification of SSNs for all non-exempt household members has 90 days from the date they are first offered an available unit to disclose and/or verify the SSNs. During this 90-day period, the applicant may, at its discretion, retain its place on the waiting list. After 90 days, if the applicant is unable to disclose and/or verify the SSNs of all non-exempt household members, the applicant should be determined ineligible and removed from the waiting list. Adequate documentation means a social security card issued by the Social Security Administration (SSA) or other acceptable evidence of the SSN. Refer to Attachment B.
Eligibility of Students for Section 8 Assistance
A student’s eligibility for Section 8 assistance will be determined at move-in, annual recertification, initial certification (when an in-place tenant begins receiving Section 8), and at the time of an interim recertification if one of the family composition changes reported is that a household member is enrolled as a student.
Section 8 assistance shall not be provided to any individual who:
a. Is enrolled as either a part-time or full-time student at an institution of higher education for the purpose of obtaining a degree, certificate, or other program leading to a recognized educational credential;
b. Is under the age of 24;
c. Is not married;
d. Is not a veteran of the United States Military;
e. Does not have a dependent child;
f. Is not a person with disabilities, as such term is defined in 3(b)(3)(E) of the United States Housing Act of 1937 (42 U.S.C. 1437a(b)(3)(E)) and was not receiving section 8 assistance as of November 30, 2006).
g. Is not living with his or her parents who are receiving Section 8 assistance; and
h. Is not individually eligible to receive Section 8 assistance and has parents (the parents individually or jointly) who are not income eligible to receive Section 8 assistance.
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Eligibility of Students for Section 8 Assistance (continued)
For a student to be eligible independent of his or her parents (where the income of the parents is not relevant), the student must demonstrate the absence of, or his or her independence from, parents. The student must meet, at a minimum all of the following criteria to be eligible for Section 8 assistance. The student must:
a. Be of legal contract age under state law;
b. Have established a household separate from parents or legal guardians for at least one year prior to application for occupancy, or
Meet the U.S. Department of Education’s definition of an independent student. (See HUD handbook 4350.3 Rev 1 Glossary for definition of Independent Student);
c. Not be claimed as a dependent by parents or legal guardians pursuant to IRS regulations; and
d. Obtain a certification of the amount of financial assistance that will be provided by parents, signed by the individual providing the support. This certification is required even if no assistance will be provided.
Any financial assistance a student receives (1) under the Higher Education Act of 1965, (2) from private sources, or (3) from an institution of higher education that is in excess of amounts received for tuition is included in annual income, except if the student is over the age of 23 with dependent children or if the student is living with his or her parents who are receiving Section 8 assistance.
If an ineligible student is a member of an applicant household or an existing household receiving Section 8 assistance, the assistance for the household will not be prorated but will be terminated in accordance with the guidance in the HUD handbook 4350.3 Rev 1 paragraph 8-6 A.
An ineligible student cannot be evicted or required to move from a unit as long as the student is in compliance with the terms of the lease.
Income Limits
HUD establishes income limits and revises them annually to ensure that federal rental assistance is provided only to low-income individuals and families. The income limit schedule used for Franciscan Village is very low and extremely low-income limit due to our Section 8 (post-1981) subsidy.
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Procedures for Taking Applications and Selecting from the Waiting List Taking Applications Prospective applicant calls or comes in and we inform applicant to be eligible they must be 62 years of age or older, if younger, mobility impaired and must not exceed current income limits for single and double occupancy. Next, we advise the applicant of our no smoking policy and that no pet dogs are allowed per our pet policy. At the time of application request we take the following information from the applicant – their full name (including middle name, if applicable), date of birth, address, and phone number. Lastly, we advise the applicant that we will mail or hand them a preliminary application (Attachment C) to complete and return in our self-addressed envelope. Upon receipt of the completed preliminary application, we find the applicant to be eligible; we place them on the waiting list according to the date of their application and time received in the mail. However, if the applicant states they are under 62 and mobility impaired, we mail them a verification of disability packet (Attachment D) to complete. Upon receipt of the packet from the applicant, we mail the verification of disability form to the doctor. Upon receipt of the verification of disability form from the doctor, we find the applicant to be eligible we place them on the waiting list according to the date of their application and time received in the mail. Applicants will be notified of feasibility of an available apartment in chronological order. At no time will this chronological order be deviated from, unless we have met 10% (13 apartments) of under age 62 and mobility impaired tenants, our current occupancy goes below the 40% extremely low income limit, or a requested two bedroom unit is not available. These specified applicants would remain in place on the waiting list and would be notified once an appropriate apartment becomes available. When an apartment is available the applicant is contacted by phone for an interview. As vacancies arise, applicants will be given two opportunities to decline. When an applicant first rejects an apartment, they will be placed at the bottom of the waiting list as of the date they refused versus the original date of application and a letter will be sent (Attachment E). If they decline twice, they will be removed from the waiting list and a letter will be sent (Attachment F). If applicant is no longer interested in an apartment here, they will be taken off the waiting list and a letter will be sent (Attachment G). Applicants will be contacted periodically by mail to determine if he/she wishes to remain on the waiting list (Attachment H). Applicants who fail to respond within thirty days are removed from the waiting list.
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Taking Applications (continued) When setting up an appointment we ask the applicant to bring in the following information: 1. Social Security card, Birth Certificate, & Driver’s License/
State Identification card 2. Social Security award letter 3. Sources of monthly income (ex. pensions, employment, annuities, etc.) 4. Sources of assets and copies of statements (1 month savings, 6 months
checking, IRA’s, stocks, etc.) 5. Current tax bill or written statement from realtor showing current market
value of house, if owned 6. Name & address of landlord, if renting 7. Documentation of “out of pocket” medical expenses 8. Documentation of pharmacy expenses 9. Receipts for “over the counter” health/medical items prescribed for a
specific medical condition and the medical doctor’s contact information Preferences Per the Violence Against Women Act (VAWA) regulations, an emergency transfer for a tenant from another LSC property would take preference over the next applicant on the waiting list. Income-Targeting Our current method for choosing families with extremely low-income is Method 1 in the HUD Handbook 4350.3 which states: “Method 1 – Admit only extremely low-income families until the 40% target is met. In chronological order, owners select eligible applicants from the waiting list whose incomes are at or below the extremely low-income limit to fill the first 40% of expected vacancies in the property. Once this target has been reached, admit applicants in waiting list order.” Currently our occupancy is in compliance with 40% at the extremely low-income limit.
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Applicant Screening Criteria Applicants who meet all eligibility standards for residency must move into Franciscan Village within thirty days of the date of determination that they are eligible for residence. The applicant must meet the eligibility requirements listed below. At the time of the interview, documentation must either be provided or sent in order to verify eligibility in various areas.
1. Head of household must be sixty-two years or older and/or mobility
impaired as defined by the Dept. of HUD.
2. Eligibility income must not exceed HUD established income limit in effect at the time of interview.
3. Rental history verified by prior landlords must demonstrate that the
applicant has paid rent on time, has had no housekeeping problems, has not violated security or noise regulations, and has had no social problems with other residents.
4. Applicants with pets and assistance animals must meet all requirements
within the animal ownership rules, which have been established according to guidelines of the Dept. of HUD.
5. Franciscan Village will prohibit admission for the following
regardless of when it occurred:
a. Any person who was evicted from any type housing for drug-related criminal activity or criminal activity including the manufacture and/or sale of illegal or dangerous drugs.
b. Any person who is currently engaged in illegal use of drugs or for which Landlord has reasonable cause to believe that a person’s illegal use or pattern of illegal use of a drug may interfere with the health, safety, and right to peaceful enjoyment of the property by other residents;
c. Any person who is subject to a national, state or local sex offender lifetime registration requirement;
d. Any person who, at the time of application, is subject, for a specified length of time, to a national, state or local sex offender registration requirement.
e. Any person, if there is a reasonable cause to believe that such person’s behavior, from abuse or pattern of abuse of alcohol, may interfere with the health, safety, and right to peaceful enjoyment of the property by other residents. The screening standards are based on behavior, not the condition of alcoholism.
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Applicant Screening Criteria (continued) Our Lady of Angels Apartments, Inc. will prohibit admission for the following if it has occurred in the past seven (7) years:
a. Any person who engages in other criminal activity that threatens the health, safety, and right to peaceful enjoyment of the property by other residents or the health and safety of Franciscan Village, its employees, contractors, subcontractors, or agents. Other criminal activity includes the following criminal history within the past seven (7) years (seven year look-back period begins from date of conviction or release from detention or incarceration whichever is more recent to the date of screening):
(1) Violent felonies involving injury to or death of another and destruction
of property; (2) Arson (3) Sexual offenses (4) More than one (1) drug or alcohol offenses including OVI offenses (5) Any theft offense (6) More than three (3) minor offenses (other than minor traffic offenses)
When applying screening criteria to a specific case, Franciscan Village may consider all of the circumstances relevant to a particular applicant or occupant’s case before making a final decision. Franciscan Village may take into consideration the seriousness of the offense, the degree of participation in the offending activity, and the effect denying housing would have on non-offending occupants.
If Franciscan Village discovers that a household member was erroneously admitted (the household member was subject to a lifetime registration requirement at admission and was admitted after June 25, 2001), Franciscan Village will immediately pursue eviction or termination of assistance for the household member. If Franciscan Village erroneously admitted a lifetime sex offender, the family will be offered an opportunity to remove the ineligible family member from the household. If the family is unwilling to remove that individual from the household, Franciscan Village will terminate assistance for the household.
6. An applicant who withholds or falsifies information on the application will
not qualify to be a resident.
7. If the tenant or a member of the tenant’s household, regardless of the date of admission, engages in criminal activity (including sex offenses) while living in HUD-assisted housing, Franciscan Village will pursue eviction or termination of assistance to the extent allowed by HUD requirements, the lease, and state or local law.
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Existing Tenant Search Report Authorized Franciscan Village staff will use an Existing Tenant Search report at the time they are processing an application to determine if the applicant or any applicant household members are currently residing at another Multifamily Housing or Public and Indian Housing (PIH) location. This report is accessed through EIV, a web-based computer system containing verification information on individuals participating in HUD’s rental assistance programs. If the applicant or a member of the applicant’s household is residing at another location, authorized Franciscan Village staff will discuss this with the applicant, giving the applicant the opportunity to explain any circumstances relative to his/her being assisted at another location. Depending on the outcome of the discussion with the applicant, authorized Franciscan Village staff may need to follow-up with the respective PHA or O/A to confirm the individual’s program participation status before admission. The report gives the authorized Franciscan Village staff the ability to coordinate move-out and move-in dates with the PHA or O/A of the property at the other location. The search results will be retained with the application along with any documentation obtained as a result of contacts with the applicant and the PHA and/or O/A at the other location. Procedures for Rejecting Ineligible Applicants Those applicants who do not meet the eligibility requirements for residency will be notified of such ineligibility. The applicant(s) shall receive a prompt, written notice advising them of the rejection, the reason(s) for the rejection of their application request, preliminary application, or application interview, and shall advise them of their right to dispute/appeal the rejection. Also, attached to the written rejection notice will be the Violence Against Women Act (VAWA) HUD forms HUD-5380 and HUD-5382. This notice shall also advise the applicant that they have fourteen (14) days to either respond in writing or to request an in-person meeting regarding their intent to dispute/appeal the rejection. Refer to Attachment I and Attachment J for rejection notifications and Attachment K, and Attachment L for the VAWA HUD forms.
Occupancy Standards
By HUD regulation, the owner must develop and follow occupancy standards that take into account the size and number of bedrooms needed based on the number of people in the family. Occupancy standards serve to prevent the over- or under-utilization of units that can result in an inefficient use of housing assistance. Occupancy standards also ensure that tenants are treated fairly and consistently and receive adequate housing space. Our occupancy standards comply with Federal, State, and local fair housing and civil rights laws; tenant-landlord laws; and HUD’s Equal Opportunity and non-discrimination requirements under HUD’s administrative procedures. Franciscan Village does not exclude otherwise eligible elderly families with children from our elderly/disabled property covered by HUD Handbook 4350.3. Franciscan Village’s policy to determine appropriate unit size is generally two-persons-per-bedroom. The property has 131 “one bedroom” units and 2 “two bedroom units”.
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Occupancy Standards (continued) The procedure used to place applicants on a list for more than one unit size is determined by the number of household members, a live-in aide, or for medical reasons.
Unit Transfer Policies
Franciscan Village does not permit unit transfers unless a tenant requires a live-in aide, has a change in family composition, requires a documented special accommodation, needs a handicap accessible unit, or needs an emergency transfer under VAWA regulations. The following outlines the unit transfer procedure:
1. Franciscan Village will act as quickly as possible to move a tenant who is a victim
of domestic violence, dating violence, sexual assault, or stalking to another unit, subject to availability and safety of a unit.
2. Change in family composition would allow a tenant living in a one bedroom unit
to transfer to a two bedroom unit when available.
3. Tenants requesting transfers would have priority over applicants on waiting list. An in-house tenant waiting list for unit transfers would be established.
4. A written request by the tenant for a unit transfer is required.
5. Third party verification would be required for special accommodation unit
transfer. 6. Change in family composition in a two bedroom unit would require the sole
tenant remaining to transfer to a one bedroom unit once one becomes available. (This does not apply to live-in aides.)
Policies to Comply with Section 504 of the Rehabilitation Act of 1973, The Fair Housing Act Amendments of 1988, and Title VI of the Civil Rights Act of 1964
Franciscan Village has a policy of non-discrimination. All services and accommodations of the facility are available to persons without regard to race, color, religion, sex, national origin, disability and familial status. Franciscan Village specifically follows policies and regulations set forth by the U.S. Department of Housing and Urban Development and does not deviate from the purpose for which it was approved by HUD.
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Policies to Comply with Violence Against Women Act (VAWA) and Department of Justice Reauthorization Act of 2005
and Violence Against Women Reauthorization Act (VAWA) of 2013
The VAWA provides legal protections to victims of domestic violence, dating violence, sexual assault, or stalking. These protections prohibit Franciscan Village from evicting or terminating assistance from individuals being assisted under a project-based Section 8 program if the asserted grounds for such action is an instance of domestic violence, dating violence, sexual assault, or stalking. The law offers the following protections against eviction or denial of housing based on domestic violence, dating violence, sexual assault, or stalking. VAWA protections. An applicant will not be denied admission on the basis that the applicant is or has been a victim of domestic violence, dating violence, sexual assault, or stalking, if the applicant otherwise qualifies for assistance or admission. An incident or incidents of actual or threatened domestic violence, dating violence, sexual assault, or stalking will not be construed as a serious or repeated lease violation by the victim or threatened victim of the domestic violence, dating violence, sexual assault, or stalking, or as good cause to terminate the tenancy of, occupancy rights of, or assistance to the victim. Criminal activity directly related to domestic violence, dating violence, sexual assault, or stalking, engaged in by a member of a tenant’s household or any guest or other person under the tenant’s control, shall not be cause for termination of tenancy of, occupancy rights of, or assistance to the victim, if the tenant or immediate family member of the tenant is the victim. Limitations of VAWA protections. Management has the authority to evict a tenant or terminate assistance for a lease violation unrelated to domestic violence, dating violence, sexual assault, or stalking, and management will not subject such a tenant to a more demanding standard than other tenants in making the determination whether to evict, or to terminate assistance or occupancy rights. Management has the authority to evict or terminate assistance to any tenant or lawful occupant if management demonstrates an actual and imminent threat to other tenants or those employed at or providing service to Franciscan Village if that tenant or lawful occupant is not terminated from assistance.
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Policies to Comply with Violence Against Women Act (VAWA) and Department of Justice Reauthorization Act of 2005
and Violence Against Women Reauthorization Act (VAWA) of 2013 (continued)
Management has the authority to evict or terminate assistance only when there are no other actions that could be taken to reduce or eliminate the threat, including, but not limited to, transferring the victim to a different unit, barring the perpetrator from the property, contacting law enforcement to increase police presence or develop other plans to keep the property safe, or seeking other legal remedies to prevent the perpetrator from acting on a threat. Documenting the occurrence of domestic violence, dating violence, sexual assault, or stalking. Management presented with a claim for continued or initial tenancy or assistance based on status as a victim of domestic violence, dating violence, sexual assault, stalking, or criminal activity related to domestic violence, dating violence, sexual assault, or stalking will request that the individual making the claim document the abuse. The request for documentation must be in writing. Management will require submission of documentation within 14 business days after the date that the individual received the request for documentation. However, management may extend this time period at its discretion. The documentation will remain confidential, unless required by law. Remedies available to victims of domestic violence, dating violence, sexual assault, or stalking. Notwithstanding any Federal, State, or local law to the contrary management may bifurcate a lease, or remove a household member from a lease without regard to whether the household member is a signatory to the lease, in order to evict, remove, terminate occupancy rights, or terminate assistance to any tenant or lawful occupant who engages in criminal acts of physical violence against family members or others, without evicting, removing, terminating assistance to, or otherwise penalizing the victim of such violence who is a tenant or lawful occupant. Such eviction, removal, termination of occupancy rights, or termination of assistance will be in accordance with the procedures prescribed by Federal, State, or local law for termination of assistance or leases under the relevant Section 8 project-based programs. Management has authority, when notified, to honor court orders addressing rights of access to or control of the property, including civil protection orders issued to protect the victim and to address the distribution of property among household members in a case where a family breaks up. The VAWA protections will not supersede any provision of any Federal, State, or local law that provides greater protection for victims of domestic violence, dating violence, sexual assault, or stalking.
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Policy for Opening and Closing the Waiting List
Franciscan Village has never closed the waiting list. However, if we would close the waiting list we would advise potential applicants that the waiting list is closed and refuse to take additional applicants. When we agree to open the waiting list and agree to accept applications again, the notice of this action will be announced in a publication likely to be read by potential applicants in the same manner (if possible, in the same publications) as the notification that the waiting list was closed. Advertisements will include where and when to apply and will conform to the advertising and outreach activities described in our Affirmative Fair Housing Marketing Plan.
No Smoking Policy Franciscan Village is a non-smoking facility effective April 1, 2010. Smoking is prohibited by Tenants, their guests, family members, invitees and all other persons on, in or about the apartment buildings. A violation of the No Smoking Policy shall be a “material non-compliance” with the Lease Agreement and Lease Addendum and shall subject the Tenant to, among other things, but not limited to, termination of the Lease, eviction, injunctive relief and such other damages in law or equity that may be available to the Landlord. There will be no prohibition on smoking outside of Franciscan Village’s apartment buildings so long as such smoking does not interfere with the quiet enjoyment of any Tenant’s occupancy of his or her apartment.
Attachment A
Attachment B
Attachment C
August 3, 2017
Dear Sir or Madam:
Franciscan Village is a Section 8 subsidized senior apartment building. Seniors must be 62 years of age or older (if younger must be mobility impaired), income cannot, at this time, exceed $23,800.00 per year for single occupancy, $27,200.00 per year for double occupancy. There are no medical services provided.
Please Note: Franciscan Village has a NO-SMOKING POLICY. This policy prohibits smoking in the apartments and all public areas of the buildings.
To be considered for occupancy and added to our waiting list, please complete the Preliminary Application form (all fields), sign and date the form. In compliance with HUD regulations, please complete the Supplement to Application for Federally Assisted Housing form (#90026). Return the completed forms to Franciscan Village in the enclosed stamped self-addressed envelope or drop them off at our offices. If we do not have your response by September 3, 2017 then we will assume you are no longer interested in an apartment here.
The waiting list at this time is approximately one year to one and half years long. If you have any questions, please call me at (216) 941-3330.
Very truly yours,
Catherine Sabolik Property Manager
CS/cb
Encl.
Attachment C
PRELIMINARY APPLICATION
The undersigned applied for an apartment in the Franciscan Village of Our Lady of Angels. It is understood that this application is preliminary only and involves no obligation of the Franciscan Village of Our Lady of Angels to deliver occupancy of the proposed premises. Name: Telephone _____________________ Address ________________________________________________ City State Zip __________ Date of Birth Social Security # ____ Marital Status ______ Race: African-American Caucasian Hispanic _____ Other_____ American Indian/Alaskan Native Asian/Pacific Islander _____ Spouse Date of Birth ___________ Social Security # _____________________________
Car: Yes No License Plate # ________________________ Color of car: Year: Make: _________________ References: (We suggest your banker, clergyman, former employer or landlord) Name Telephone (_____) ______________ Address ________________________________________________________________ City ____________________________________ State __________ Zip__________ Name Telephone (_____) ______________ Address ________________________________________________________________ City ____________________________________ State ___________ Zip __________ Please provide a complete list of states in which applicants have resided: ___________________________________________________________________________
Are you, or anyone in your household, subject to a lifetime sex offender registration requirement in any state? _____________
Attachment C
Are you under 62 years old and mobility impaired? Yes___ No ___ If you marked yes to the above question, we will mail another form to you to fill out. That form is a HUD requirement. Are you under 62 years old and need a handicap suite? Yes ___ No ___ If you are over 62 years old do you need a handicap suite? Yes ____ No ____ Were you referred by a resident? If so, who? _______________________________________________________
GROSS INCOME PER YEAR: (Pension, Social Security, Wages) $ _____________ Total Savings, C.D.’s, stocks & bonds, other assets, approximate value $___________ Do you own a home? Yes No If yes, approximate value $ ___________ If you do not own a home:
Amount of monthly rent $ ________________
Utilities included? Yes No _____
Are you presently receiving a rental subsidy? Yes No ____ No representations, promises or agreements as to occupancy or date of possession have been made, and this application shall not be construed as an agreement. Applicants shall have the right to withdraw this application. The undersigned declares that the facts contained in this preliminary inquiry are true and complete to the best of his/her knowledge and understands that false statements on the preliminary inquiry relative to verifying income, assets and other factors relating to eligibility determinations and our resident selection standards may result in the rejection of this application.
________________ Signature of Applicant #1 Date ________________ Signature of Applicant #2 Date
Limited English Proficiency: The federal government put in place a program to help applicants who have limited English language skills. The program was established to build awareness of the applicants needs and to develop methods that will assure that their needs will be met. If you have a limited understanding of the English language you are entitled to have someone speak on your behalf.
OMB Control # 2502-0581 Exp. (02/28/2019)
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: 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.
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)
Attachment C
DDoo yyoouu hhaavvee aa SSoocciiaall SSeeccuurriittyy NNuummbbeerr ((SSSSNN))??
If you do not disclose a SSN, you may not be able to receive housing assistance.
The federal government requires each applicant for HUD-assisted housing to provide documentation of their SSN to the property owner/manager by the time a unit becomes available. This requirement affects household members who are U.S. citizens, U.S. nationals and eligible noncitizens.
The SSNs of all members of my household have been provided. What do I do?
Nothing further is required. The owner/property manager will contact you if there is a problem with the SSN of any of your household members.
I have not provided SSNs for all of my household members to the property owner/manager. What do I do?
U.S. Department of Housing and Urban Development
Office of Housing
Does everyone in your household have a SSN?
Yes No 1. Ensure the correct SSN for
each household member who is a U.S. citizen, U.S. national or eligible noncitizen is reported to the owner/property manager by the time a unit becomes available.
2. You will need to provide the owner/property manager with documentation to verify the SSNs.
1. For any household member who is a U.S. citizen, U.S. national or eligible noncitizen and does not have a SSN, apply for a SSN by submitting a completed SS-5 form to the Social Security Administration. For the SS-5 form and/or assistance, contact the owner/property manager.
2. Provide documentation of a SSN for each household member who is a U.S. citizen, U.S. national or eligible noncitizen to the owner/property manager by the time a unit becomes available.
Note: If you turned 62 before January 31, 2010, ask the property manager for further details on what you need to do.
Attachment C
Attachment D Date Name Address City, State Zip Dear Name: Per your application, you stated you are under 62 years of age and mobility impaired. HUD requires us to verify with your doctor that you are on disability due to your mobility impairment. Upon receipt of the verification from your doctor that you are mobility impaired, we will put your name on the waiting list. Please give us your doctor’s name and address, sign the explanation to applicant form and sign the last page of the verification form, where it is highlighted in yellow, (do not fill it out) and return all forms in the self-addressed stamped envelope. We must mail the verification form to the doctor. Please do not take the form to the doctor. If you do not respond to us by date your application will be denied. If you have any questions, please call me at (216) 941-3330. Thank you. Sincerely, Catherine Sabolik Property Manager CS/cb Encl.
Attachment D
VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR
QUALIFICATION FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY
EXPLANATION TO THE APPLICANT HUD permits owners to verify that you have a disability only if: 1) Your eligibility for admission is dependent on your being a person with a disability; or 2) You claim eligibility for deductions that are given to a person with a disability. The definitions of disability vary depending on the project you are applying for or living in. The owner determines the definition(s) to use by consulting with HUD Handbook 4350.3. The third party from whom this verification is being requested has knowledge of whether your disability meets the applicable definition(s) of disability (or person with a disability). An owner may request from a third party only the minimum information necessary to determine whether you meet the applicable definition of disability (or person with a disability). Any other request for information about you is not relevant and may not be asked (e.g., diagnosis, treatment plan). __________________________________________ ______________ Signature of Applicant Date
Attachment D
PLEASE PRINT YOUR NAME: ________________________________________________________ PLEASE PRINT YOUR DOCTOR’S NAME, ADDRESS, & PHONE #: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ We need your doctor’s address and phone number in order to verify you are on disability for a mobility impairment. Please complete and return this form in the enclosed self-addressed stamped envelope. Thank you.
Attachment D
Page 1 of 3
VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR
QUALIFICATION FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY
Date: _____________ To: _______________________________
_______________________________ _______________________________ _______________________________
From: Franciscan Village Heather M. Carey, Occupancy Manager 3648 Rocky River Dr. Cleveland, Ohio 44111 (216) 941-3330 – Fax (216) 941-7758 – TTY (800) 750-0750
RETURN THIS VERIFICATION TO THE PERSON LISTED HERE. Subject: Verification of Disability
Name: SSN: XXX-XX-0000 Address: This person has applied for housing assistance under a program of the U.S. Department of Housing and Urban Development (HUD). HUD requires the housing owner to verify all information that is used in determining this person’s eligibility or level of benefits. We ask your cooperation in providing the following information and returning it to the person listed at the top of the page. Your prompt return of this information will help to assure timely processing of the application for assistance. Enclosed is a self-addressed, stamped envelope for this purpose. The applicant/tenant has consented to this release of information as shown below. INFORMATION BEING REQUESTED For each numbered item below, mark an “X” in the applicable box that accurately describes the person listed above. 1. ___ YES ___ NO Has a physical, mental, or emotional impairment that is expected to be of long-continued and indefinite duration, substantially impedes his or her ability to live independently, and is of a nature that such ability could be improved by more suitable housing conditions. 2. ___ YES ___ NO Has a mobility impairment that is expected to be of long-continued and indefinite duration.
Attachment D
Page 2 of 3
3. ___ YES ___ NO Is a person with a developmental disability, as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 6001(8)), i.e., a person with a severe chronic disability that: a. Is attributable to a mental or physical impairment or combination of mental and physical impairments; b. Is manifested before the person attains age 22; c. Is likely to continue indefinitely; d. Results in substantial functional limitation in three or more of the following areas of major life activity: (1) Self-care, (2) Receptive and expressive language, (3) Learning, (4) Mobility, (5) Self-direction, (6) Capacity for independent living, and (7) Economic self-sufficiency; and e. Reflects the person’s needs for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated. 4. ___ YES ___ NO Is a person with a chronic mental illness, i.e., he or she has a severe and persistent mental or emotional impairment that seriously limits his or her ability to live independently, and whose impairment could be improved by more suitable housing conditions. 5. ___ YES ___ NO Is a person whose sole impairment is alcoholism or drug addiction. The undersigned declares, under oath, that the facts contained in this verification form are true and complete to the best of his/her knowledge. ___________________________________________ ______________________________ NAME AND TITLE OF PERSON FIRM/ORGANIZATION SUPPLYING THE INFORMATION (PRINT) ___________________________________________ ______________ ____________ SIGNATURE PHONE DATE NOTE TO APPLICANT/TENANT: YOU DO NOT HAVE TO SIGN THIS FORM IF EITHER THE REQUESTING ORGANIZATION OR THE ORGANIZATION SUPPLYING THE INFORMATION IS LEFT BLANK.
Attachment D
Page 3 of 3
RELEASE: I hereby authorize the release of the requested information. Information obtained
under this consent is limited to information that is no older than 12 months. There are circumstances which would require the owner to verify information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of this consent.
______________________________________________ ______________________________ SIGNATURE DATE PENALTIES FOR MISUSING THIS CONSENT: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or any employee of HUD, the PHA or owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. Section 408 (a) (6), (7) and (8). Franciscan Village does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.
Attachment E
Date Name Address City, State Zip Dear Name, Per our phone conversation on date, we were advised that you were not able to take an apartment at this time. This is your first refusal. Therefore, your name has been placed at the bottom of the waiting list as of date. However, per our waiting list procedure, if you refuse an apartment a second time your name will be removed from the waiting list. Please update us if your contact information changes (i.e. telephone, address). If you have any questions, please call us at (216) 941-3330. Sincerely, Catherine Sabolik Property Manager CS/cb
Attachment F Date
Name Address City, State Zip
Dear Name,
Per our phone conversation on date, you informed us that you were not able to take an apartment at this time. During our conversation you were informed about our Waiting List procedure. The procedure states if an apartment is refused a second time your name will be removed from the waiting list. This is your second refusal. As of date, your name has been removed from our waiting list.
At any time you can call and request a new application if you wish to reapply for an apartment here.
If have any questions, please call me at (216) 941-3330.
Sincerely,
Catherine Sabolik Property Manager
CS/cb
Attachment G Date Name Address City, State Zip Dear Name, Per our phone conversation on DATE, you stated that you were no longer interested in housing at Franciscan Village and have requested that we remove your name from our waiting list. As of DATE, your name has been removed from our list. However, if your situation changes, you may request to have a new application sent to you to reapply to the waiting list at any time in the future. If have any questions, please call me at (216) 941-3330. Sincerely, Catherine Sabolik Property Manager CS/cb
Attachment H
Date
Name Address City, State Zip
Dear Applicant We are currently updating our waiting list. If you wish to remain on the list, please fill out the form below and return it in the enclosed stamped envelope. If there is no response by Date, your name will be removed from the waiting list.
If you have any questions please call me at 941-3330
PLEASE KEEP MY NAME ON THE WAITING LIST.
PLEASE REMOVE MY NAME FROM THE WAITING LIST
I HAVE AN ADDRESS OR PHONE NUMBER CHANGE:
Name: ____________________________________________________________
Address: __________________________________________________________
City/State/Zip: ______________________________________________________
Telephone Number: (______) ____________________________________
Sincerely, Catherine Sabolik Property Manager
Attachment I
3648 Rocky River Drive, Cleveland, OH 44111 PH: 216-941-3330 FAX: 216-941-7758 TTY: 800-750-0750 Date
Name Address City, State Zip Dear Name:
Thank you for submitting your preliminary application for residency at our community. Your preliminary application for admission has been denied due to: ________ Your family composition does not meet HUD requirements.
________ You are under 62 years of age and your health care provider has
determined that you are not mobility impaired.
________ Your income is above the HUD income limits.
________ Your previous rental history does not meet our screening criteria.
________ Your previous criminal history does not meet our screening criteria.
________ Your household is in need of a _____ bedroom and we do not have this size
in our development.
________ Your application is incomplete.
________ Other: _______________________________________________________
Our community adheres to the Federal Fair Housing Law. We do not discriminate against any person because of Race, Color, Age, Religion, Sex, Handicap, Familial Status, or National Origin. If you feel that you have been discriminated against, please contact this office, or the HUD field office to report such action.
You have a right to appeal our decision regarding your preliminary application. If you disagree with this determination, you may request a meeting to discuss/appeal the rejection:
If you believe this decision has been made in error If you believe there are extenuating circumstances that should be considered If you are a victim of abuse covered by the Violence Against Women Act and you feel
your status as a victim contributes to the decision to deny
Attachment I
If you are a person with a disability, and believe a reasonable accommodation would allow us to continue processing your application
You may either call Catherine Sabolik at (216) 941-3330 to request an in-person meeting to discuss your application and the reason(s) for our decision, or you may write to the above person at Franciscan Village, 3648 Rocky River Drive, Cleveland, Ohio 44111.
Please note that persons with disabilities have the right to request reasonable accommodations to participate in the informal hearing process. We must receive either your request for an in-person meeting or your letter of appeal by no later than 14 days from the date of this letter. Sincerely,
Catherine Sabolik Property Manager
CS/cb
Encl.: HUD forms 5380 & 5382
Page 15
Attachment J
3648 Rocky River Drive, Cleveland, OH 44111 PH: 216-941-3330 FAX: 216-941-7758 TTY: 800-750-0750 Date Name Address City, State Zip Subject: Your application interview for admission to Franciscan Village Apartments Dear Name: After your application interview, we regret to inform you that you are not eligible for residency. The decision was reached for the following reason(s): ______________________________________________________________________. You have a right to appeal our decision regarding your application interview. If you feel we have erred in our decision, or you have additional information that you want to provide to us, you may either call Catherine Sabolik at (216) 941-3330 to request an in-person meeting to discuss your interview and the reason(s) for our decision, or you may write to the above person at Franciscan Village, 3648 Rocky River Drive, Cleveland, Ohio 44111. Please note that we must receive either your request for an in-person meeting or your letter of appeal by no later than 14 days from the date of this letter. Sincerely, Catherine Sabolik Property Manager CS/cb
NOTICE OF OCCUPANCY RIGHTS UNDER THE VIOLENCE AGAINST WOMEN ACT
U.S. Department of Housing and Urban Development OMB Approval No. 2577-0286
Expires 06/30/2017 Attachment K
Form HUD-5380 (12/2016)
Our Lady of Angels Apartments, Inc. DBA Franciscan Village
Notice of Occupancy Rights under the Violence Against Women Act1
To all Tenants and Applicants
The Violence Against Women Act (VAWA) provides protections for victims of domestic
violence, dating violence, sexual assault, or stalking. VAWA protections are not only available
to women, but are available equally to all individuals regardless of sex, gender identity, or sexual
orientation.2 The U.S. Department of Housing and Urban Development (HUD) is the Federal
agency that oversees that Section 202/8 is in compliance with VAWA. This notice explains your
rights under VAWA. A HUD-approved certification form is attached to this notice. You can fill
out this form to show that you are or have been a victim of domestic violence, dating violence,
sexual assault, or stalking, and that you wish to use your rights under VAWA.”
Protections for Applicants
If you otherwise qualify for assistance under Section 202/8, you cannot be denied admission or
denied assistance because you are or have been a victim of domestic violence, dating violence,
sexual assault, or stalking.
Protections for Tenants
If you are receiving assistance under Section 202/8, you may not be denied assistance,
terminated from participation, or be evicted from your rental housing because you are or have
been a victim of domestic violence, dating violence, sexual assault, or stalking.
1 Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual orientation. 2 Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or marital status.
2
Form HUD-5380 (12/2016)
Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,
dating violence, sexual assault, or stalking by a member of your household or any guest, you
may not be denied rental assistance or occupancy rights under Section 202/8 solely on the basis
of criminal activity directly relating to that domestic violence, dating violence, sexual assault, or
stalking.
Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom
you stand in the place of a parent or guardian (for example, the affiliated individual is in your
care, custody, or control); or any individual, tenant, or lawful occupant living in your household.
Removing the Abuser or Perpetrator from the Household
Franciscan Village may divide (bifurcate) your lease in order to evict the individual or terminate
the assistance of the individual who has engaged in criminal activity (the abuser or perpetrator)
directly relating to domestic violence, dating violence, sexual assault, or stalking.
If Franciscan Village chooses to remove the abuser or perpetrator, Franciscan Village may not
take away the rights of eligible tenants to the unit or otherwise punish the remaining tenants. If
the evicted abuser or perpetrator was the sole tenant to have established eligibility for assistance
under the program, Franciscan Village must allow the tenant who is or has been a victim and
other household members to remain in the unit for a period of time, in order to establish
eligibility under the program or under another HUD housing program covered by VAWA, or,
find alternative housing.
In removing the abuser or perpetrator from the household, Franciscan Village must follow
Federal, State, and local eviction procedures. In order to divide a lease, Franciscan Village
may, but is not required to, ask you for documentation or certification of the incidences of
domestic violence, dating violence, sexual assault, or stalking.
3
Form HUD-5380 (12/2016)
Moving to Another Unit
Upon your request, Franciscan Village may permit you to move to another unit, subject to the
availability of other units, and still keep your assistance. In order to approve a request,
Franciscan Village may ask you to provide documentation that you are requesting to move
because of an incidence of domestic violence, dating violence, sexual assault, or stalking. If the
request is a request for emergency transfer, the housing provider may ask you to submit a written
request or fill out a form where you certify that you meet the criteria for an emergency transfer
under VAWA. The criteria are:
(1) You are a victim of domestic violence, dating violence, sexual assault, or
stalking. If your housing provider does not already have documentation that you
are a victim of domestic violence, dating violence, sexual assault, or stalking, your
housing provider may ask you for such documentation, as described in the
documentation section below.
(2) You expressly request the emergency transfer. Your housing provider may
choose to require that you submit a form, or may accept another written or oral
request.
(3) You reasonably believe you are threatened with imminent harm from
further violence if you remain in your current unit. This means you have a
reason to fear that if you do not receive a transfer you would suffer violence in the
very near future.
OR
You are a victim of sexual assault and the assault occurred on the premises
during the 90-calendar-day period before you request a transfer. If you are a
victim of sexual assault, then in addition to qualifying for an emergency transfer
4
Form HUD-5380 (12/2016)
because you reasonably believe you are threatened with imminent harm from
further violence if you remain in your unit, you may qualify for an emergency
transfer if the sexual assault occurred on the premises of the property from which
you are seeking your transfer, and that assault happened within the 90-calendar-day
period before you expressly request the transfer.
Franciscan Village will keep confidential requests for emergency transfers by victims of
domestic violence, dating violence, sexual assault, or stalking, and the location of any move by
such victims and their families.
Franciscan Village’s emergency transfer plan provides further information on emergency
transfers, and Franciscan Village must make a copy of its emergency transfer plan available to
you if you ask to see it.
Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,
Sexual Assault or Stalking
Franciscan Village can, but is not required to, ask you to provide documentation to “certify”
that you are or have been a victim of domestic violence, dating violence, sexual assault, or
stalking. Such request from Franciscan Village must be in writing, and Franciscan Village
must give you at least 14 business days (Saturdays, Sundays, and Federal holidays do not count)
from the day you receive the request to provide the documentation. Franciscan Village may,
but does not have to, extend the deadline for the submission of documentation upon your request.
You can provide one of the following to Franciscan Village as documentation. It is your choice
which of the following to submit if Franciscan Village asks you to provide documentation that
you are or have been a victim of domestic violence, dating violence, sexual assault, or stalking.
Attachment L
Form HUD-5382 (12/2016)
CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286 DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017 DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING, AND ALTERNATE DOCUMENTATION Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and program participants in certain HUD programs from being evicted, denied housing assistance, or terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual orientation.
Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your housing provider may give you a written request that asks you to submit documentation about the incident or incidents of domestic violence, dating violence, sexual assault, or stalking. In response to this request, you or someone on your behalf may complete this optional form and submit it to your housing provider, or you may submit one of the following types of third-party documentation:
(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an attorney, or medical professional, or a mental health professional (collectively, “professional”) from whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or “stalking” in HUD’s regulations at 24 CFR 5.2003. (2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or administrative agency; or (3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or tenant.
Submission of Documentation: The time period to submit documentation is 14 business days from the date that you receive a written request from your housing provider asking that you provide documentation of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing provider may, but is not required to, extend the time period to submit the documentation, if you request an extension of the time period. If the requested information is not received within 14 business days of when you received the request for the documentation, or any extension of the date provided by your housing provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or issuance of this form does not serve as a written request for certification. Confidentiality: All information provided to your housing provider concerning the incident(s) of domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details shall not be entered into any shared database. Employees of your housing provider are not to have access to these details unless to grant or deny VAWA protections to you, and such employees may not disclose this information to any other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of assistance; or (iii) otherwise required by applicable law.
2
Form HUD-5382 (12/2016)
TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE, DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING 1. Date the written request is received by victim: _________________________________________ 2. Name of victim: ___________________________________________________________________ 3. Your name (if different from victim’s):________________________________________________ 4. Name(s) of other family member(s) listed on the lease:___________________________________ ___________________________________________________________________________________ 5. Residence of victim: ________________________________________________________________ 6. Name of the accused perpetrator (if known and can be safely disclosed):____________________ __________________________________________________________________________________ 7. Relationship of the accused perpetrator to the victim:___________________________________ 8. Date(s) and times(s) of incident(s) (if known):___________________________________________ _________________________________________________________________ 10. Location of incident(s):_____________________________________________________________ This is to certify that the information provided on this form is true and correct to the best of my knowledge and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or eviction. Signature __________________________________Signed on (Date) ___________________________ Public Reporting Burden: The public reporting burden for this collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The information provided is to be used by the housing provider to request certification that the applicant or tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is subject to the confidentiality requirements of VAWA. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget control number.
In your own words, briefly describe the incident(s): ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
5
Form HUD-5380 (12/2016)
A complete HUD-approved certification form given to you by Franciscan Village with
this notice, that documents an incident of domestic violence, dating violence, sexual
assault, or stalking. The form will ask for your name, the date, time, and location of the
incident of domestic violence, dating violence, sexual assault, or stalking, and a
description of the incident. The certification form provides for including the name of the
abuser or perpetrator if the name of the abuser or perpetrator is known and is safe to
provide.
A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or
administrative agency that documents the incident of domestic violence, dating violence,
sexual assault, or stalking. Examples of such records include police reports, protective
orders, and restraining orders, among others.
A statement, which you must sign, along with the signature of an employee, agent, or
volunteer of a victim service provider, an attorney, a medical professional or a mental
health professional (collectively, “professional”) from whom you sought assistance in
addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of
abuse, and with the professional selected by you attesting under penalty of perjury that he
or she believes that the incident or incidents of domestic violence, dating violence, sexual
assault, or stalking are grounds for protection.
Any other statement or evidence that Franciscan Village has agreed to accept.
If you fail or refuse to provide one of these documents within the 14 business days, Franciscan
Village does not have to provide you with the protections contained in this notice.
If Franciscan Village receives conflicting evidence that an incident of domestic violence, dating
violence, sexual assault, or stalking has been committed (such as certification forms from two or
6
Form HUD-5380 (12/2016)
more members of a household each claiming to be a victim and naming one or more of the other
petitioning household members as the abuser or perpetrator), Franciscan Village has the right to
request that you provide third-party documentation within thirty 30 calendar days in order to
resolve the conflict. If you fail or refuse to provide third-party documentation where there is
conflicting evidence, Franciscan Village does not have to provide you with the protections
contained in this notice.
Confidentiality
Franciscan Village must keep confidential any information you provide related to the exercise
of your rights under VAWA, including the fact that you are exercising your rights under VAWA.
Franciscan Village must not allow any individual administering assistance or other services on
behalf of Franciscan Village (for example, employees and contractors) to have access to
confidential information unless for reasons that specifically call for these individuals to have
access to this information under applicable Federal, State, or local law.
Franciscan Village must not enter your information into any shared database or disclose your
information to any other entity or individual. Franciscan Village, however, may disclose the
information provided if:
You give written permission to Franciscan Village to release the information on a time
limited basis.
Franciscan Village needs to use the information in an eviction or termination
proceeding, such as to evict your abuser or perpetrator or terminate your abuser or
perpetrator from assistance under this program.
A law requires Franciscan Village or your landlord to release the information.
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Form HUD-5380 (12/2016)
VAWA does not limit Franciscan Village’s duty to honor court orders about access to or control
of the property. This includes orders issued to protect a victim and orders dividing property
among household members in cases where a family breaks up.
Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or
Assistance May Be Terminated
You can be evicted and your assistance can be terminated for serious or repeated lease violations
that are not related to domestic violence, dating violence, sexual assault, or stalking committed
against you. However, Franciscan Village cannot hold tenants who have been victims of
domestic violence, dating violence, sexual assault, or stalking to a more demanding set of rules
than it applies to tenants who have not been victims of domestic violence, dating violence, sexual
assault, or stalking.
The protections described in this notice might not apply, and you could be evicted and your
assistance terminated, if Franciscan Village can demonstrate that not evicting you or
terminating your assistance would present a real physical danger that:
1) Would occur within an immediate time frame, and
2) Could result in death or serious bodily harm to other tenants or those who work on the
property.
If Franciscan Village can demonstrate the above, Franciscan Village should only terminate
your assistance or evict you if there are no other actions that could be taken to reduce or
eliminate the threat.
Other Laws
VAWA does not replace any Federal, State, or local law that provides greater protection for
victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to
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Form HUD-5380 (12/2016)
additional housing protections for victims of domestic violence, dating violence, sexual assault,
or stalking under other Federal laws, as well as under State and local laws.
Non-Compliance with The Requirements of This Notice
You may report a covered housing provider’s violations of these rights and seek additional
assistance, if needed, by contacting or filing a complaint with the U.S. Department of HUD,
1350 Euclid Avenue, Suite 500, Cleveland, Ohio 44115-1815, phone 216-357-7900,
fax 216-357-7920, TTY Federal Relay 1-800-877-8339.
For Additional Information
You may view a copy of HUD’s final VAWA rule at https://www.gpo.gov/fdsys/pkg/FR-2016-
11-16/pdf/2016-25888.pdf. Additionally, Franciscan Village must make a copy of HUD’s
VAWA regulations available to you if you ask to see them.
For questions regarding VAWA, please contact the Cuyahoga County Department of Public
Safety & Justice Services, 310 W. Lakeside Ave., Suite 300, Cleveland, Ohio 44113,
phone 216-443-5906.
For help regarding an abusive relationship, you may call the National Domestic Violence Hotline
at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may
also contact Domestic Violence & Child Advocacy Center, 216-391-HELP (4357).
For tenants who are or have been victims of stalking seeking help may visit the National Center
for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-
programs/stalking-resource-center.
For help regarding sexual assault, you may contact the Cleveland Rape Crisis Center,
216-619-6192.
9
Form HUD-5380 (12/2016)
Victims of stalking seeking help may contact Legal Aid Society, 1-888-817-3777.
Attachment: Certification form HUD-5382
Attachment J Date
Name Address City, State Zip Subject: Your application interview for admission to Franciscan Village Apartments.
Dear Name:
After your application interview, we regret to inform you that you are not eligible for residency. The decision was reached for the following reason(s): ______________________________________________________________________. You have a right to appeal our decision regarding your application interview. If you feel we have erred in our decision, or you have additional information that you want to provide to us, you may either call Catherine Sabolik at (216) 941-3330 to request an in-person meeting to discuss your interview and the reason(s) for our decision, or you may write to the CEO of our management company, Mr. Curt Brosky, LSC Service Corp., 14300 Detroit Avenue #110, Lakewood, OH, 44107.
Please note that we must receive either your request for an in-person meeting or your letter of appeal by no later than 14 days from the date of this letter.
Sincerely,
Catherine Sabolik Property Manager
CS/cb
Encl.: HUD forms 5380 & 5382
