The Processing of ALL Applications for Housing Include ... · payingjob, including self-employment. Example: Bob Smith andSara Smith have submittedan applicationfor housing. Bob is

The Processing of ALLApplications for Housing

Include:

-Police Backgrounds-Credit Checks

-Landlord Checks

Bad reports on any of the above itemsWILL result in cancellation of your

application!

Any fraud or untruthful statement onany part of your application for housingwill cause IMMEDIATE cancellation of

your application!

Applying for Public Housing

1sl Step - Complete the application document (see instructions below).

General Information• The online application is a flliable PDF document, which requires the Adobe Acrobat program. Your computer shouldalready have Adobe Acrobat on it. However, ifyour computer does not have this program, it is readily available onlinefor free. All of your information (except signatures) can be typed into the application document while online. Thecompleted application document can then be printed out on 8.5 in. x 11 in. white paper. This function has been providedin an effort to save you time and money by eliminating a trip to our office to pick up the application package andpreventing errors that might cause the application to be considered incomplete.• Ifyou prefer, you may print a blank online application or pick up an application package at our office and complete itby hand (in ink only).• The application should be truthfully and thoroughly completed. Untruthful or misleading statements on the applicationis considered fraud and will result in derogatory action up to and including application cancellation, eviction, and/orcriminal prosecution.• N/A should be written in those portions of the application that are Not Applicable to you or your household.

Page I1. Applicant Information - This portion of the document is where the individual completing the application shouldreflect their name and contact information. This information is vital when we need to contact you regarding the status ofyour application. You should ensure that this information always remains accurate and immediately update it with ouroffice if any changes occur.

II. Household Composition - The member of your household that will be the primary contact point for the familyshould be listed in position number I, which is designated Head of Household. The other members of the householdshould be listed in the remaining positions (2 - 8), as applicable. ALL PERSONS THAT WILL BE LIVING ORSTAYING IN YOUR HOUSEHOLD MUST BE LISTED. PURPOSEFULLY OMlTTING PERSONS THAT WILLLIVE OR STAY IN YOUR HOUSEHOLD IS CONSIDERED FRAUD AND WILL RESULT IN DEROGATORYACTION UP TO AND INCLUDING APPLICATION CANCELLATION, EVICTION, AND/OR CRIMINALPROSECUTION.

Page2II. Household Composition (Continued) - Additional space to list household members if needed.

m. Absent Parent Information - List the parent(s) of any child in your household that will not reside in yourhousehold with you and the child. Refusal to provide this information will result in application cancellation.Example: Jane Doe and John Doe are divorced and have separate households. Jane Doe and John Doe have a juvenileson Jimmy. Jane Doe has custody ofJimmy and has submitted an application for housing listing Jimmy in position 2 onthe Household Composition portion ofthe application. John Doe's information must be listed in the Absent Parentportion ofthe application. The number ofthe position the child is listed in the Family Composition portion oftheapplication should be reflected in the FAMILY MEMBER NUMBER column (see below).

FAMILY ABSENTFATHER'SIMOTHER'S NAME ABSENT PARENT'S ADDRESS COMMENTSMEMBER (Street or P.O. Box, City, State & Zip)NUMBER(See Pg. Ior Above)

2 John Doe 1234 Main Street, Timbuktu, AL. 55667 None

IV. Income Information - This information in this section must be complete and accurate to ensure eligibility. Answerthe questions in this portion of the application by marking the appropriate boxes and filling in the blanks.

List ALL employment income - Complete this portion of the application for any household members that works a wage

payingjob, including self-employment.Example: Bob Smith and Sara Smith have submitted an application for housing. Bob is the Head ofHousehold and islisted in position 1 and Sara is listed in position 2 on the Household Composition portion ofthe application. Bob worksfor XYZ Construction Company and Sara works for S&S Cash and Carry. The number ofthe position the wage earninghousehold member is listed in the Family Composition portion ofthe application should be reflected in the FAMILYMEMBER NUMBER column (see below).

FAMIT..Y NAME, ADDRESS & PHONE NUMBER OF EMPLOYER YEARS HOURLY PAY PERIOD HOURSMEMBER OCCUPATION EMPLOYED PAY (Ex. Weekly, Bi· WORKEDNUMBER RATE weekly, Etc.) PER PAY(See Pg. I PERIODor Above)

I XYZ Construction Co., P.O. Box I. Mobile, AL. 36666 555-5656 Carpenter 3 SIO.OO Bi-weekly 80

2 S&S Cash & Carry, Mobile, AL 555-2323 Cashier I $7.25 Weekly 25

List ALL other sources of income - Complete this portion of the application for any household member that receivesnon-wage income, including any income that you are entitled to but may not be receiving.Example: Bob and Sara Smith have submitted an application for housing. Bob and Sara have a son together namedDavid. David is handicapped and receives Social Security Income (SSI). Sara also has a daughter named Annafrom aprevious marriage, who she receives court ordered child supportfor. David is listed in position 3 and Anna is listed inposition 4 on the Household Composition portion ofthe application. The number ofthe position the household memberis listed in the Family Composition portion ofthe application should be reflected in the FAMILY MEMBER NUMBERcolumn (see below).

FAMILY MEMBER SOURCE OF INCOME AMOUNT OF INCOME FREQUENCY RECEIVEDNUMBER (Ex. Weekly, Bi-weekly, Monthly, Etc.)

(See Pg. I or Above)

3 Social Security Income S595.00 Monthly

4 Child Suppon $100.00 Monthly

Page 3Military Information - Answer the questions in this portion of the application by marking the appropriate box. Completethis portion of the application for any household member that is serving active or reserve duty.

Bank Information - Complete this portion of the application for any household member that has any account(s) with abank or credit union. Answer the questions concerning investments (stocks, bonds, real-estate, insurance, etc,) bymarking the appropriate box.

v. Expenses - The information in this section must be complete and accurate to ensure that you are receiving all eligibledeductions. Answer the questions in the Childcare and Special Needs portions of the application by marking theappropriate boxes and filling in the blanks.

Page 4V. Expenses (continued) - The information in this section must be complete and accurate to ensure that you are receivingall eligible deductions. Answer the questions in the Medical and Utilities portions of the application by marking theappropriate boxes and filling in the blanks.

VI. Rental History - The information in this section will be used to screen housing applicants and must be complete andaccurate to ensure eligibility. If you have never rented/leased an apartment or home in the past, check the box at the topfor Not Applicable (N/A). If you are currently renting/leasing, complete part 1. Ifyou have rented/leased in the past butare not currently renting/leasing, then complete part 2 and part 3 - ifmore than one past Landlord. Ifyou are currentlyrenting/leasing and have rented/leased multiple times in the past, complete parts 1,2 and 3. Complete this portion of theapplication by marking the appropriate boxes and filling in the blanks.

Page 5VD. Marital Status History - Complete tbis portion of the application by marking the appropriate boxes and ftIling inthe blanks.

VIII. Additional Information - Complete this portion of the application by marking the appropriate boxes and filling inthe blanks.

IX. Program Information - Complete this portion of the application by marking the appropriate boxes and filling in theblanks. The information in this section will be used to screen housing applicants and must be complete and accurate toensure eligibility. The questions in this section concem ARRESTS and WARRANTS and other lawful offenses. lfyouor a household member have ever been ARRESTED, had WARRANTS issued for your arrest, or been in trouble withthe law - regardless of conviction - you must answer the guestion(s) in the affirmative. Give explanation(s) regardingarrests, warrants, etc. in the space provided by part 4 of this section. PURPOSEFULLY OMITTING INFORMATIONREGARDING CRIMINAL INFORMATION IS CONSIDERED FRAUD AND WILL RESULT IN DEROGATORYACTION UP TO AND INCLUDING APPLICATIO CANCELLATION, EVICTION, AND/OR CRIMINALPROSECUTION.

Page 6X. Applicantffenant Vehicle Information - Complete this portion of the application by marking the appropriate boxesand ftIling in the blanks. If you intend to park a motorized vehicle on the streets within the Housing Authority, thissection must be completed.

XI. Other Information - Complete this portion of the application by fJJIing in the blanks. This family informationshould be a local and reliable altemate contact point that can be notified if we are having difficulty getting in touch withyou.

Signatures - Leave the signature blanks unsigned. The application must be signed in the presence of a HousingAuthority staff member at the time the application is submitted to our office.

2nd Step - Submit your application at our office and complete the supplementary documents (seeinstructions below).

• Applications are accepted in our office located at 604 Dumont Street, Chickasaw, Alabama on Wednesday's only fromthe hours of 8:00 A.M. -11:00 A.M. and 1:00 P.M. - 4:00 P.M.• Applications are not accepted on any Wednesday that lands on the last working day of the month or the 3rd of the month.• To apply for an apartment you must be a legally married couple, one of whom is at least 18 years of age (marriage licenserequired) or an individual at least 19 years of age.• You need to bring the following documents with you:

-Valid Driver's License or State Issued ill Card (MUST Have for all adults) originals only-Social Security Card (MUST Have for Everyone in household) originals only-Birth Certificate (MUST Have for everyone in household) originals only-Marriage license/Divorce Decree/Death Certificate (if applicable)-If you are on SS or SSI you need to bring your award letter-If you are on TANF we need a copy of your award letter

• You MUST have a VALID Driver's License or State ID Card and Social Security Cards (for EVERYONE that willbe on the application) when the application is returned. Applications WILL NOT be processed without thesedocuments.• The processing of an application includes, but is not limited to: Prior landlord verifications, police backgroundcheck and a credit check, on all adults age 18 and up. Your application can be cancelled if negative reports arereceived on any of these items.• Return all forms included with your application to the Chickasaw Housing Authority Office.• Application CANNOT be faxed, mailed, brought in by someone else, etc. j it must be returned in person.• It will take approximately 30 - 45 minutes to complete the application process in our office so plan accordingly.

THE HOUSING AUTHORITY OF THE CITY OF CHICKASAW

604 DUMONT STREET CHICKASAW, ALABAMA 36611

(251) 457-6841

FAX (251)457-9751 Dear Housing Applicant: Your application for housing will now begin the approval process. It will take approximately 2 - 3 weeks to process your application if we have all of your information. If additional information is requested, it needs to be delivered to Chickasaw Housing Authority immediately. Your housing application will not be considered complete until we have all requested information. When we have obtained all necessary information, one of the following things will happen: I. Your application will be approved and you will be placed on the eligible waiting list. You will be called when an apartment becomes available, or; 2. Your application will be cancelled. You will be sent a letter to the address on your application stating the reason for cancellation. Some of the reasons for cancellation are bad credit, bad landlord report, fraud, police record, etc ... It will state on the letter if there is another step you may take to try and receive housing, or; 3. Additional information will be requested in order to complete your application. Once an application is completed/approved, it moves to the eligible waiting list for the bedroom-size apartment that you qualify for. You will be called when your application comes up for housing. When you are called for an apartment, you will need to have the following: -At least $100 of your $200 - $300 security deposit. -Your first month's pro-rated rent (which will have to be determined by the date you actually move in). -Your first month's garbage which is $18.15. -This has to be paid in a personal check or money order. Cash is NOT accepted. -You will have to go to Mobile Gas (before you rent) to have gas service put in your name for the apartment that is going to be rented to you. There is normally a $50 deposit (although the amount varies) that has to be paid to them at that time. -On the day you rent you will also be expected to establish power in your name with Alabama Power Company for the apartment where you will be residing. Water for your apartment is included in your rent and all apartments are equipped with gas stoves as well as a refrigerator. Most apartments have a washer and dryer connection but there are a few that do not have either. If you require either of these, you should inform the person taking your application of your needs. There are a few apartments within Chickasaw Housing that have central heat/air. These are all located in the area reserved strictly for elderly residents. You will need a window a/c unit if you wish to have air conditioning. We call approved applicants as their name comes up. When we call, you will need to be ready to rent within at least a day or two. We cannot hold apartments for days or weeks while a prospective tenant tries to save up their money to move in. You will need to plan ahead for this.

Chickasaw Housing Authority

Housing Authority Use ONLY

APPLICATION Telephone Number: (251)457-6841Fax Number: (251)457-9751

DApplication #: Application for Admission

Date: Time: A.M. - D P.M. - D

Notes: _

Application for Continued Occupancy

Re-exam Date: Current: Previous: _

DepositsRegular Deposit: Pet Deposit: _

Smoker's Deposit: Other Deposit: _

Total Deposit: _

Family StatusNo. in Family: Sex of Head: F - D M - D

No. of Minors: Head/Spouse 62 or Over: D

No. of Bedrooms: Head/Spouse Disabled: D

Age of Head: Spouse Deceased: D

D

DD Divorced:

Husband/Wife Present: D Separated:

Single:

OtherLocal Preference: Credit Score: _

Eligible: D Ineligible: D

RentAmount: _

....Everything below this Line is to be completed by Applicant (print in ink)....Answer N/A for items that do no apply to you. Do not leave anything blank!

I. Applicant Information -

Racial Group EthnicityName:

White: D Hispanic/Latin: D First Last M.1.

African American: D Non-Hispanic/Latin: D Physical Address:

Asian or Street City State Zip

Pacific Islander: D Mailing Address:

American Indian orStreet City State Zip

Alaskan Native: D Home Phone #: Work Phone #:

Other: D Other Phone #:

II. Household Composition - List all persons that will live in the rental um while you are on the Public Housmg program.

No. PRINT FULL NAME RELAnON SEX DATE OFTO HEAD (M or F) BIRTH

AGE PLACE OF BIRTH U.S. SOCIAL SECURITYCn1ZEN ~BER

(Y orN)

1. HEAD

2.

3.

II. Household Comoosition (Continued\

N,. PRINT FULL NAME RELATION SEX DATE OF AGE PLACE OF BIRTH U.S. SOCIAL SECURITYTO HEAD (M or F) BIRTH CITIZEN NUMBER

ry or N)

4.

s.

6.

7.

8.

Are any changes in your family composition anticipated? No 0 Yes 0 If Yes, explain: _

Ill. Absent Parent Information - List ALL absent oarenHs) for ANY children that will be livin in your household.

FAMILY ABSENT FATHER'SfMOTHER'S NAME ABSENT PARENT'S ADDRESS COMMENTSMEMBER (Street or P.O. Box, City, State & Zip)NUMBER(See Pg. Ior Above)

IV. Income Information -Do you have Zero ($0.00) family income? No 0 Yes 0 (lfYes, you must complete a Zero Income questionnaire)

Are you or any adult member of your household a full-time student? No 0 Yes 0

If Yes, where are you/they enrolled: _

List ALL employment income (including self-employment) for each household member:

FAMILY NAME, ADDRESS & PHONE NUMBER OF EMPLOYER OCCUPATION YEARS HOURLY PAY PERIOD HOURSMEMBER EMPLOYED PAY (Ex. Weekly, Bi- WORKEDNUMBER RATE weekly, Etc.) PER PAY(See Pg. I PERIODor Above)

eollt e to ut rna no e recelVIDP.

FAMILY MEMBER SOURCE OF INCOME AMOUNT OF INCOME FREQUENCY RECEIVEDNUMBER (Ex. Weekly, Bi-weekly, Monthly, Etc.)

(Sec Pg. I or Above)

List ALL other sources of income: examples include (but are not limited to) - WelfareffANF, Social Security, SSI, pensions,survivor benefits, disability compensation, food stamps, unemployment compensation, baby-sitting, daycare subsidy, child support,alimony, annuities, interest, dividends, income from rental property, Armed Forces or Military Reserve, VA Benefits, cash or inkind contributions from individuals, scholarships, or grants. You must include alimony and/or child support that you are

. I d b t b

2

Military Information: is there any member of your household now serving active duty or reserve in the Military Service (Anny,

h T, ")? N 0 Y 0 IfYM'Navy, " orce, annes, etc. 0 es es, give t e 0 owmg m ormation on eac ml Itary person:

FAMILY RANK BRANCH OF ADDRESS OF MILITARY EMPLOYERMEMBER SERVICENUMBER(See Pg. I or 2)

fdd'/ 11 h k'I'B ok I fa n ormatiOn: 1St any/a c ec 109, savmgs, cre II Union, certl Icate 0 eposlt accounts, etc.

FAMILY TYPE OF ACCOUNT BANK ACCOUNT NUMBER CURRENT BALANCEMEMBERNUMBER

(See Pg. 1 or 2)

Do you own:

1. Stocks & Bonds - No 0 Yes 0 If Yes. current value: $, _

2. Savings Bonds - No 0 Yes 0 lfYes, current value: $, _

3. Real Estate (land or houses) - No 0 Yes 0 If Yes, current value: $ _

Have you EVER owned real estate? - No 0 Yes 0 lfYes, when: _

4. Life Insurance or Retirement Account(s) - No 0 Yes 0 If Yes, current value(s): $ _

V. Expenses-Childcare:

OR 0 monthly $ _

I. Do you pay out-of-pocket for childcare expenses to allow a family member to work or go to school? No 0 Yes 0

If Yes, list the childcare provider's - Name: _

Mailing Address: _

Telephone Number(s): _

2. ChildcareiBaby-sitiing Cost: 0 weekly $, _

3. Do you receive assistance for childcare costs (Ex. Childcare South, family contributions, etc.)? No 0 Yes 0

If Yes, who provides your childcare assistance? _

Value of childcare assistance: 0 weekly $ OR 0 monthly $

Special Needs:

l. For determining allowable income deductions, does any member of your household have a disability? No 0 Yes 0

2. Does any member of your household require special accommodations? No 0 Yes 0 If Yes, what special

accommodations are needed: _

3. Do you pay for a care atlendant or for any equipment for any member with a disability in order to permit that person or

someone else in the family to work? No 0 Yes 0 If Yes, describe expenses: _

3

Medical:

I. Are you paying for Medicare benefits? No 0 Yes 0 lfYes, monthly amount paid $ _

2. Are you receiving medical assistance through the welfare department (DHR)? No 0 Yes 0

If Yes, monthly amount of benefits $, _

3. Do you pay out-of-pocket for any medical insurancelhospitalization (such as BlueCross)? No 0 Yes 0

lfYes, indicate amount per payment: 0 weekly $ OR 0 bi-weekly $ OR 0 monthly $ _

4. Are you making payments on outstanding medical bills? No 0 Yes 0 lfYes, amount paid per month $, _

5. Do you pay out-of-pocket for any prescription drugs on a regular basis? No 0 Yes 0

If Yes, amount paid per month $

Utilities:

If you pay for your own utilities, check the box beside the utilities listed below that are paid by you and indicate the amount. If

you do not pay for ANY of the utilities listed, check the box here 0 to indicate Not Applicable (N/A).

I. Electricity: No 0 Yes 0 If Yes, monthly amount $ 2. Gas: No 0 Yes 0 If Yes, monthly amount $ _

3. Water: No 0 Yes 0 lfYes, monthly amount $ 4. Sewage: No 0 Yes 0 lfYes, monthly amount $ _

5. Garbage: No 0 Yes 0 If Yes, monthly amount S 6. Phone: No 0 Yes 0 If Yes, monthly amount $, _

7. Cell Phone: No 0 Yes 0 If Yes, monthly amount S 8. Cable TV: No 0 Yes 0 If Yes, monthly amount $__

9. Other· : No 0 Yes 0 If Yes, monthly amount $

VI. Rental History - Provide the infonnation below for your current and two previous Landlords. Check the box here 0 toindicate Not Applicable (N/A) if you have never rented/leased before.

t. Name of Current Landlord: _

Mailing Address of Landlord: -;;:----,- --,,,-- -;;:----,-_=_Street City State Zip

Monthly Rent $ Number of Bedrooms: Number of Persons in Household: _

How long have you been a tenant of this Land lord? Years: Months: _

Do you owe any money to the Landlord named above? No 0 Yes 0 If Yes, amount owed $ _

2. Previous Residence Address: --------,,=-------------=----------,,=--c;;---,--Street City State Zip

Name of Previous Landlord: _

Mailing Address of Landlord: -;;:- ---,,,-- -;;:-__=_Street City Stale Zip

How long were you a tenant of this Land lord? Years: Months: _

3. Previous Residence Address: _

Street City Stale Zip

Name of Previous Landlord: _

Mailing Address of Landlord: -;;:----,- --,,,-- -;;:-=_=,----Street City State Zip

How long were you a tenant of this Landlord? Years:

4

Months:

VD. Marital StatuslHistory -

I. Have you ever been married? No 0 Yes 0 If Yes, how many times? __ Maiden Name: _

2. Have you ever been separated? No 0 Yes 0

lfYes, from who: __=,----.,;:-:-,- ----;:-----;-,..., ----;;:-:- = ....",_Date Name Slreet Address City Stale Zip

3. Have you ever been divorced? No 0 Yes 0

IfYes,fromwho: __-=-__,.,- ----;:-:-:- --= = ----;:-_Dale Name Slreet Address City Stale Zip

4. Are you widowed? No 0 Yes 0

If Yes, provide Social Security Number(s) of deceased: _

5. Any additional comments:

Vill. Additional Information -

I. Have you ever used a name or Social Security number other than the one you are using now? No 0 Yes 0

If Yes, explain: _

2. Have you ever applied for Public Housing or Section 8 Housing? No 0 Yes 0

3. Have you ever lived in Public Housing or Section 8 Housing? No 0 Yes 0

4. Have you ever lived in housing that is referred to as the "PROJECTS"? No 0 Yes 0

5. If you have lived or currently live in Public Housing (Projects) and/or Section 8 Assisted Housing or housing where the

amount of rent you paid was based on your income, complete the following:

Where (address): When (dates): _

6. Do you owe any money to a Public Housing Authority, Project or Section 8 Housing Program? No 0 Yes 0

IfYes, how much $

IV. Pro ram Information -

I. Have you or any family member listed on this application ever been ARRESTED? No 0 Yes 0

2. Have you or any family member listed on this application ever had ;l WARRANT issued for an arrest? No 0 Yes 0

3. Have you or any family member listed on this application ever been in trouble with the law? For example, traffic citations

or any other situations? No 0 Yes 0

4. If you answered Yes to any of the questions in this section, explain:

!!!NOTICE!!! - Your are reminded that all your answers will be verified through local, state and federal lawenforcement crime information data systems. Giving false information on your application is considered fraud and willresult in the cancellation of your application or eviction if you have been housed.

5

License Plate Number: _

X. Applicantrrenant Vehicle Information· Check the box here 0 to indicate Not Applicable (N/A) if you will not be parking amotorized vehicle (car, truck, van, suv, motorcycle, etc.) on the streets within the Housing Authority.

I. Are you the registered owner of this vehicle? No 0 Yes 0 If No, complete the following information:

Name and address of owner: --:c:=:----------;:::=::---------;:;:::------;:::::-------:;".---Name Street City State Zip

2. Vehicle Information:

Year/Make/Model: _

Color: Vehicle Identification Number (VIN): _

Liability Insurance Provider:

XI. Other Information -

Name of your relative that lives nearest to you: Relationship: _

Address of relative: -------:-----------:c--------:------=:-----Street City State Zip

Telephone number{s):

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements ormisrepresentations to any Department or Agency of the Unites States as to any matter within its jurisdiction.

I!We certify that all information given to the Chickasaw Housing Authority in this application is correct. IIWe understand andacknowledge that if these facts are not lrue, housing assistance or housing will not be provided, and IIWe will be declaredineligible. I!We understand that after the information in this application is verified, it will be submitted to the U.S. Department ofHousing and Urban Development (HUD) on Form HUD-50058 (the Federal Privacy Act Statement contains additional informationconcerning the authorized use of Ihis information). IIWe also understand that staff of the Chickasaw Housing Authority will verifythis information, and I aUlhorize the Chickasaw Housing Authority 10 submit inquiries necessary for the purpose of verifying Ihefacts herein stated.

Signature: -,,--,-=,-- _Head of House

Signature: --:;__-,-,_:-,...- _spouse or Other Adult

Signature: === _Other Adult

Dale: _

Date: _

Date: _

CHA Representative: _

Note: Uyou believe that you have been discriminated against, you may report the incident by calling the Fair Housing andEqual Opportunity toll-free hotline at I(800)669-9777, or by asking the Chickasaw Housing Authority to provide you with aHUD Housing Discrimination Complaint Form (HUD-903).

6

THE HOUSING AUTHORITY OF THE CITY OF CHICKASAW604 Dumont Street

Chickasaw, AL 36611251-457-6841 Fax 251-457-9751

Date: _

Landlord: _

Address:

Tenant: _

S.S. Number:. _

Address: _

The above named individual has applied for low-income housing. He/she has given yourname as a former/present landlordreference. We would appreciate it if you would complete the following questionnaire. Please return this form within(10) ten days from the date above, if possible, in the enclosed self-addressed, stamped envelope.

Thank you,Katherine H.Henson, Occupancy Specialist

I have no objection to your giving the below requestedinformation and request you to do so.

Applicant Signature: _

Balance left owed, if any: $ _

1. How long were they in residence? From: To: _

2. ~hol~ed~iliehousehold?~ _

3. How did iliey pay their rent? On Time Late _

4. ~ould you rent to Him/Her again? Yes No If not, why? _

5. How did He/She keep the premises? _

6. ~ere they considerate of their neighbors? Yes No, _

7. How did they get along with others? _

8. Did the tenant control ilieir children and were they well behaved? Yes No, _

Ifno, explain: _

9. Did they have loud parties? Yes No _

10. ~ere there any kind of disturbances/incidents that police action had to be taken? Yes No _

If yes, explain: _

II. Did the tenant damage your property beyond the due-to-normal wear and tear? Yes No _

If yes, explain: _

12. Did the tenant have housekeeping habits that affected the other tenants' welfare, health and safety? Yes No__

If yes, explain: _

13. ~as the unit left in good condition? Yes No _

Ifno, explain: _

14. Amount of rent paid: $ _

IS. Comments: _

Landlord's Signature: Telephone # Date, _


Chickasaw, AL 36611251-457-6841 Fax 251-457-9751

Date: _

Landlord: _

Address:

Tenant: _

S.S. Number:. _

Address: _














Ifno, explain: _



If yes, explain: _


If yes, explain: _


If yes, explain: _


Ifno, explain: _


IS. Comments: _



Chickasaw, AL 36611251-457-6841 Fax 251-457-9751

Date: _

Landlord: _

Address:

Tenant: _

S.S. Number:. _

Address: _














Ifno, explain: _



If yes, explain: _


If yes, explain: _


If yes, explain: _


Ifno, explain: _


IS. Comments: _


CHICKASAW HOUSING AUTHORITY604 DUMONT STREET

CHICKASAW, AL. 36611(251)457-6841

SOURCES OF INCOME

SOURCETANF

__Food Stamps__Child Support__SSA Disability__SSI Disability

SSA88I

__AlimonyChildcare SouthContributionsOther

AMOUNT FREQUENCY

1.

2.

3.

EMPLOYER'S NAME/ADDRESS

OCCUPATION YEARS PAY RATE HRS. PER WEEK

i\pplicllnlrrennnf is n<lvised thnll1ny person who obinins nr nltemilis fo obtnin, Ill' who csillblishcs or IIftcmpls 10 cstnblish eligibility for nny pcrSlln whoImllwingly or infenlionnlly ni<ls 01' nbefs snch person in ohfnining or nllempling 10 oblnin honsing or n re<luction in pUhlic housing rentnl chnrges, or nllY "ent!tubshly, 10 which such person would noj ofherwise be entitled, by mcnos of n false statement, fnilure to disclose informnfion, impcnonntion or other fnullllcn1scheme or devise shllll be guilty of n mis<lemellnor lind. npnn conviction, shllll be punished by line of nolless Ihnn $300.00 nor more Ihnn $500.00 or bepunishednt hnrd Illbor fill' fhe conoly no110 exceed '60 <Inys, or mny he both lined nnd imprisoned, nlthe discretion of the conrt. (24-1-10, Code of i\lnhnmn,1975).

The above information is correct to the best of my lmowledge and I have no objection toinquiries for the purpose of verifying the facts herein stated.

SIGNATURE OF APPLICANT/TENANT DATE


ELIGIBILITY CONSENT FORM

Each member of the family of an applicant or participant who is at least 18 years of age, and eachfamily head and spouse regardless of age, shall sign this consent form. Applicants will sign theconsent form when applying for assistance and participants will sign the form at the next regularlyscheduled income reexamination.

I authorize the Department ofHousing and Urban Development (HUD) and the Chickasaw HousingAuthority (CHA) to obtain from the State Wage Information Collection Agencies (SWICA's) anyinformation or materials necessary to complete or verify the application for participation or maintaincontinued assistance under the program administered by CHA.

I also authorize HUD and CHA to verify income information necessary for determining eligibilityor continue assistance for previous employers or current employer.

I also authorize HUD to request income return information from the IRS and the Social SecurityAdministration for the sole purpose ofverifying income information pertinent to the applicant's orparticipant's eligibility.

This consent form will expire 15 months after the date the consent form is signed.

Print Full Name (Head of Household)

Print Full Name (Spouse)

Print Full Name (Household member18 years ofage or older)



Signature

Signature

Signature

Signature

Signature

Date

Date

Date

Date

Date

Failure to sign this consent form will result in denial of assistance and/or termination of thisassistance.


PUBLIC HOUSING, SECTION 8 CERTIFICATES AND VOUCHERS PROGRAMS

DECLARATION OF UNITED STATES CITIZENSHIP

I hereby declare, under penalty ofperjury, that I am a citizen of the United States of America.

Print Name: Signature: Date:(Head ofHousehold)

Print Natne: Signature: Date:(Spouse)

Print Natne: Signature: Date:(Household Member)

Print Name: Signature: Date:(Household Member)




Witness: Date: _

Signature

Note: For each adult, the form must be signed by the adult. For each child, the form must be signed by an adult memberofthe family residing in the assisted dwelling unit who is responsible for the child.

This document will be filed in the head-of-household's file folder and serve as verification and evidence ofdeclarationof U.S. Citizenship.


Chickasaw, AL 36611251-457-6841 (Fax) 251-457-9751

AUTHORIZAnON

Name _

Address _

Social Security Number _

Telephone Number _

The following named agencies are authorized to give the Chickasaw Housing Authority information to

determine eligibility for admission to and/or continued occupancy oflow-rent public housing units operated

by the Chickasaw Housing Authority and to determine rent for these units:

- Social Security Administration

- Department of Pensions & Security

- Department of Veterans Affairs

- Food Stamp Office

- Internal Revenue Service

- Mobile County Board of Health

- Mobile Mental Health Center

- Chickasaw Police Department

- Banks and other Financial Institutions

- Courts

- Law Enforcement Agencies

- Credit Bureaus

- Employers, Past and Present

- Landlords

- Providers of:AlimonyChild CareChild SupportCreditHandicapped Assistance.Medical CarePensions/Annuities

- Schools and Colleges

- Utility Companies

- Unemployment Verification

- Welfare AgenciesSignature: HEAD Date _

Signature: SPOUSE Date _

Signature: OTHER Date _

Witness: (If signed by "X" mark) _

Original is retained by the requesting organization. form HUD-9886 (7/94)ref. Handbooks 7420.7, 7420.8, & 7465.1

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD)and the Housing Agency/Authority (HA)

Persons who apply for or receive assistance under the followingprograms are required to sign this consent form:

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and pay-ments of retirement income as referenced at Section 6103(l)(7)(A)of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent islimited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: (1)HUD and the Housing Agency/Authority (HA) to request verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date) (Full address, name of contact person, and date)

U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing

gcgoodwin

Typewritten Text

CHICKASAW HOUSING AUTHORITY 604 DUMONT STREET CHICKASAW, ALABAMA 36611 EQUAL HOUSING OPPORTUNITY

Original is retained by the requesting organization. form HUD-9886 (7/94)ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________Head of Household Date

___________________________________________Social Security Number (if any) of Head of Household

__________________________________________________ _______________Spouse Date

__________________________________________________ _______________Other Family Member over age 18 Date

__________________________________________________ _______________Other Family Member over age 18 Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

__________________________________________________ ________________Other Family Member over age 18 Date




Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses ofinformation collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $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, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.

Page 1

Chickasaw Housing Authority Accommodation Request Verification

Date: To:

Health Care Provider’s Name

Address: Health Care Provider’s Address

Definition of Disabled: Under Federal law, an individual is disabled if he/she has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment. The term "physical or mental impairment" includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech, and hearing impairment, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, Human Immunodeficiency Virus infection, mental retardation, emotional illness, drug addiction, and alcoholism. This definition doesn't include any individual who is a drug addict and who is currently using illegal drugs or an alcoholic who poses a direct threat to property or safety because of alcohol use. Live-In Aide: A person who resides with an elderly person(s), near elderly person(s) or person(s) with disabilities and who: (a) is determined by HA to be essential to the care and well being of the person(s); (b) is not obligated to support the family member; and (c) would not be living in the unit except to provide the necessary supportive services [24 CFR 5.403]. Occasional, intermittent, multiple or rotating care givers do not meet the definition of a live–in aide since live-in-aides must reside with a family permanently for the family unit size to be adjusted in accordance with the subsidy standards established by the PHA.

Health Care Provider’s Certification: My signature below certifies that I have read and fully understand the definitions of “disabled,” “Live-In Aide,” and the penalty for misusing this form.

Health Care Providers Signature Date

Note Both page 1 and 2 MUST be completed and returned to receive consideration

Penalties For Misusing This Verification Form: Title 18, Section 1001 of the U. S. Code states that a person is guilty of a felony for knowingly and willingly making false statements to any department of the United States Government, including the Department of Housing and Urban Development (HUD) or a Public Housing Authority. HUD, the Housing Authority and any employee of HUD or the Housing Authority 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 resident may be subject to a misdemeanor and fined not more than $5,000. Any applicant or resident 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 or the Housing Authority for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 42 U.S.C. 208 (f)(g) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 f, g, and h.

Page 2

Applicant/Resident Information: Applicant/Resident Name:

Address:

Accommodation Requested By Resident/Applicant

The person named above has applied for or is receiving federal rental assistance. The person has requested an accommodation based on a disability or medical need. If a person who is elderly (age 62 or older), near elderly (age 52 to 61), or has a disability requests an accommodation, the Housing Authority must consider the request. The Housing Authority must determine whether the person qualifies as disabled under federal law and/or whether the person requires an accommodation in order to have an equal opportunity to use and enjoy the housing site.

We would appreciate your cooperation in answering the questions on this form and returning it to the Housing Authority. Enclosed is a self-addressed envelope for this purpose. The person listed above has consented to the release of this information, as shown below.

Authorization to Release Information: 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. Where there are circumstances which would require the Housing Authority to verify information that is up to five years old, a separate consent attached to a copy of this consent was provided/authorized by me on:

Applicant/Resident Signature Date

Information Requested:

1. Is the person listed above disabled, as defined on page 1? Yes No

2. In your professional opinion, and by definition, does the person listed above require the accommodation requested? Yes No

3. Please provide (in the space below) any medical information that would be helpful to the Housing Authority in making a decision.

Name of Physician Supplying Information Title

Name of Organization/Practice/Hospital

Signature of Physician Supplying Information Date

Note

Both page 1 and 2 MUST be completed and returned to receive consideration

Form 8821 OMB No. 1545-1165

Tax Information Authorization (Rev. August 2008)

Department of the TreasuryInternal Revenue Service

Employer identification number Social security number(s)

3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS forthe tax matters listed on this line. Do not use Form 8821 to request copies of tax returns. (a)

Type of Tax(Income, Employment, Excise, etc.)

or Civil Penalty

(b)Tax Form Number

(1040, 941, 720, etc.)

(c)Year(s) or Period(s)

(see the instructions for line 3)

Specific use not recorded on Centralized Authorization File (CAF). If the tax information authorization is for a specific use not recorded on CAF, check this box. See the instructions on page 4. If you check this box, skip lines 5 and 6 ©

4

Disclosure of tax information (you must check a box on line 5a or 5b unless the box on line 4 is checked):

5 a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoing

basis, check this box ©

b If you do not want any copies of notices or communications sent to your appointee, check this box ©

Retention/revocation of tax information authorizations. This tax information authorization automatically revokes allprior authorizations for the same tax matters you listed on line 3 above unless you checked the box on line 4. If you do not want to revoke a prior tax information authorization, you must attach a copy of any authorizations you want to remain in effect and check this box ©

6

7

Signature of taxpayer(s). If a tax matter applies to a joint return, either husband or wife must sign. If signed by acorporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certifythat I have the authority to execute this form with respect to the tax matters/periods on line 3 above.

© Do not use this form to request a copy or transcript of your tax return. Instead, use Form 4506 or Form 4506-T.

Title (if applicable)

Date Signature

Print Name

Form 8821 (Rev. 8-2008) Cat. No. 11596P

For IRS Use Only

Telephone

Function

Date

/

/

Name

( )

Received by:

(d)Specific Tax Matters (see instr.)

For Privacy Act and Paperwork Reduction Act Notice, see page 4.

Title (if applicable)

Date Signature

Print Name

To revoke this tax information authorization, see the instructions on page 4.

Taxpayer information. Taxpayer(s) must sign and date this form on line 7.

1 Taxpayer name(s) and address (type or print)

Plan number (if applicable)

Daytime telephone number

Appointee. If you wish to name more than one appointee, attach a list to this form.

2 CAF No.

Name and address Telephone No.

Fax No. Telephone No.

Check if new: Address

( )

PIN number for electronic signature

Fax No.

© IF NOT SIGNED AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED.

© Do not sign this form unless all applicable lines have been completed.

© DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

PIN number for electronic signature

Form 8821 (Rev. 8-2008) Page 2

When To File

IF you live in . . .

THEN use this address . . .

Fax Number*

Alabama, Arkansas, Connecticut, Delaware,District of Columbia, Florida, Georgia,Illinois, Indiana, Kentucky, Louisiana, Maine,Maryland, Massachusetts, Michigan,Mississippi, New Hampshire, New Jersey,New York, North Carolina, Ohio,Pennsylvania, Rhode Island,South Carolina, Tennessee, Vermont,Virginia, or West Virginia Alaska, Arizona, California, Colorado,Hawaii, Idaho, Iowa, Kansas, Minnesota,Missouri, Montana, Nebraska, Nevada,New Mexico, North Dakota, Oklahoma,Oregon, South Dakota, Texas, Utah,Washington, Wisconsin, or Wyoming

Internal Revenue ServiceMemphis Accounts Management CenterPO Box 268, Stop 8423Memphis, TN 38101-0268

Internal Revenue Service1973 N. Rulon White Blvd. MS 6737Ogden, UT 84404

901-546-4115

801-620-4249

General Instructions Section references are to the Internal Revenue Codeunless otherwise noted. Purpose of Form

Form 8821 does not authorize your appointee toadvocate your position with respect to the federal taxlaws; to execute waivers, consents, or closingagreements; or to otherwise represent you before theIRS. If you want to authorize an individual to representyou, use Form 2848, Power of Attorney andDeclaration of Representative.

Use Form 56, Notice Concerning FiduciaryRelationship, to notify the IRS of the existence of afiduciary relationship. A fiduciary (trustee, executor,administrator, receiver, or guardian) stands in theposition of a taxpayer and acts as the taxpayer.Therefore, a fiduciary does not act as an appointeeand should not file Form 8821. If a fiduciary wishes toauthorize an appointee to inspect and/or receiveconfidential tax information on behalf of the fiduciary,Form 8821 must be filed and signed by the fiduciaryacting in the position of the taxpayer.

Form 8821 authorizes any individual, corporation, firm,organization, or partnership you designate to inspectand/or receive your confidential information in anyoffice of the IRS for the type of tax and the years orperiods you list on Form 8821. You may file your owntax information authorization without using Form 8821,but it must include all the information that is requestedon Form 8821.

Form 8821 must be received by the IRS within 60 daysof the date it was signed and dated by the taxpayer.

All APO and FPO addresses, AmericanSamoa, nonpermanent residents of Guamor the Virgin Islands**, Puerto Rico (or ifexcluding income under section 933), aforeign country, U.S. citizens and thosefiling Form 2555, 2555-EZ, or 4563.

Internal Revenue ServiceInternational CAF DP: SW-31111601 Roosevelt Blvd.Philadelphia, PA 19255

215-516-1017

*These numbers may change without notice. **Permanent residents of Guam should use Department of Taxation, Government of Guam, P.O. Box 23607,GMF, GU 96921; permanent residents of the Virgin Islands should use: V.I. Bureau of Internal Revenue,9601 Estate Thomas Charlotte Amalie, St. Thomas, V.I. 00802.

Where To File Chart

Use Form 4506, Request for Copy of Tax Return, toget a copy of your tax return. Use Form 4506-T, Request for Transcript of TaxReturn, to order: (a) transcript of tax accountinformation and (b) Form W-2 and Form 1099 seriesinformation.

Form 8821 (Rev. 8-2008) Page 3

Specific Instructions Line 1. Taxpayer Information

Employee plan or exempt organization. Enter the name,address, and EIN of the plan sponsor or exemptorganization, and the plan name and three-digit plan number. Trust. Enter the name, title, and address of the trustee,and the name and EIN of the trust. Estate. Enter the name, title, and address of thedecedent’s executor/personal representative, and the nameand identification number of the estate. The identificationnumber for an estate includes both the EIN, if the estate hasone, and the decedent’s TIN.

Line 3. Tax Matters

Line 2. Appointee

If you want to name more than one appointee, indicate soon this line and attach a list of appointees to Form 8821.

For example, you may list “Income, 1040” for calendar year“2006” and “Excise, 720” for “2006” (this covers all quartersin 2006). For multiple years or a series of inclusive periods,including quarterly periods, you may list 2004 through (thruor a hyphen) 2006. For example, “2004 thru 2006” or “2nd2005-3rd 2006.” For fiscal years, enter the ending year andmonth, using the YYYYMM format. Do not use a generalreference such as “All years,” “All periods,” or “All taxes.” Any tax information authorization with a general reference willbe returned. You may list the current year or period and any tax yearsor periods that have already ended as of the date you signthe tax information authorization. However, you may includeon a tax information authorization only future tax periods thatend no later than 3 years after the date the tax informationauthorization is received by the IRS. The 3 future periods aredetermined starting after December 31 of the year the taxinformation authorization is received by the IRS. You mustenter the type of tax, the tax form number, and the futureyear(s) or period(s). If the matter relates to estate tax, enterthe date of the decedent’s death instead of the year orperiod.

Enter your appointee’s full name. Use the identical full nameon all submissions and correspondence. Enter the nine-digitCAF number for each appointee. If an appointee has a CAFnumber for any previously filed Form 8821 or power ofattorney (Form 2848), use that number. If a CAF number hasnot been assigned, enter “NONE,” and the IRS will issue onedirectly to your appointee. The IRS does not assign CAFnumbers to requests for employee plans and exemptorganizations.

Enter the type of tax, the tax form number, the years orperiods, and the specific tax matter. Enter “Not applicable,” in any of the columns that do not apply.

Partnership Items

Taxpayer Identification Numbers (TINs) TINs are used to identify taxpayer information withcorresponding tax returns. It is important that you furnishcorrect names, social security numbers (SSNs), individualtaxpayer identification numbers (ITINs), or employeridentification numbers (EINs) so that the IRS can respond toyour request.

Sections 6221-6234 authorize a Tax Matters Partner toperform certain acts on behalf of an affected partnership.Rules governing the use of Form 8821 do not replace anyprovisions of these sections.

Individuals. Enter your name, TIN, and your street addressin the space provided. Do not enter your appointee’s addressor post office box. If a joint return is used, also enter yourspouse’s name and TIN. Also enter your EIN if applicable. Corporations, partnerships, or associations. Enter thename, EIN, and business address.

Where To File Generally, mail or fax Form 8821 directly to the IRS. See theWhere To File Chart on page 2. Exceptions are listed below.

If you want to revoke an existing tax informationauthorization and do not want to name a new appointee,send a copy of the previously executed tax informationauthorization to the IRS, using the Where To File Chart onpage 2. The copy of the tax information authorization musthave a current signature and date of the taxpayer under theoriginal signature on line 7. Write “REVOKE” across the topof Form 8821. If you do not have a copy of the taxinformation authorization you want to revoke, send astatement to the IRS. The statement of revocation orwithdrawal must indicate that the authority of the appointeeis revoked, list the tax matters and periods, and must besigned and dated by the taxpayer or representative. If thetaxpayer is revoking, list the name and address of eachrecognized appointee whose authority is revoked. When thetaxpayer is completely revoking authority, the form shouldstate “remove all years/periods” instead of listing the specifictax matters, years, or periods. If the appointee iswithdrawing, list the name, TIN, and address (if known) of thetaxpayer.

Revocation of an Existing Tax InformationAuthorization

To revoke a specific use tax information authorization,send the tax information authorization or statement ofrevocation to the IRS office handling your case, using theabove instructions.

Check the appropriate box to indicate if either the address,telephone number, or fax number is new since a CAF numberwas assigned.

If Form 8821 is for a specific tax matter, mail or fax it tothe office handling that matter. For more information, see theinstructions for line 4. Your representative may be able to file Form 8821electronically with the IRS from the IRS website. For moreinformation, go to www.irs.gov. Under the Tax Professionalstab, click on e-services–Online Tools for Tax Professionals. Ifyou complete Form 8821 for electronic signatureauthorization, do not file a Form 8821 with the IRS. Instead,give it to your appointee, who will retain the document.

Representative Address Change If the representative’s address has changed, a new Form8821 is not required. The representative can send a writtennotification that includes the new information and theirsignature to the location where the Form 8821 was filed.

Form 8821 (Rev. 8-2008) Page 4

The time needed to complete and file this form will varydepending on individual circumstances. The estimatedaverage time is: Recordkeeping, 6 min.; Learning about thelaw or the form, 12 min.; Preparing the form, 24 min.;Copying and sending the form to the IRS, 20 min.

If you have comments concerning the accuracy of these

time estimates or suggestions for making Form 8821 simpler,we would be happy to hear from you. You can write toInternal Revenue Service, Tax Products CoordinatingCommittee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave.NW, IR-6526, Washington, DC 20224. Do not send Form8821 to this address. Instead, see the Where To File Charton page 2.

You are not required to provide the information requestedon a form that is subject to the Paperwork Reduction Actunless the form displays a valid OMB control number. Booksor records relating to a form or its instructions must beretained as long as their contents may become material inthe administration of any Internal Revenue law.

Privacy Act and Paperwork Reduction ActNotice

The IRS may provide this information to the Department ofJustice for civil and criminal litigation, and to cities, states,the District of Columbia, and U.S. possessions to carry outtheir tax laws. We may also disclose this information to othercountries under a tax treaty, to federal and state agencies toenforce federal nontax criminal laws, or to federal lawenforcement and intelligence agencies to combat terrorism.

Partnerships. Generally, Form 8821 can be signed by anyperson who was a member of the partnership during any partof the tax period covered by Form 8821. See PartnershipItems on page 3.

All others. See section 6103(e) if the taxpayer has died, isinsolvent, is a dissolved corporation, or if a trustee, guardian,executor, receiver, or administrator is acting for the taxpayer.

Corporations. Generally, Form 8821 can be signed by: (a)an officer having legal authority to bind the corporation, (b)any person designated by the board of directors or othergoverning body, (c) any officer or employee on writtenrequest by any principal officer and attested to by thesecretary or other officer, and (d) any other person authorizedto access information under section 6103(e).

Line 4. Specific Use Not Recorded on CAF

Line 6. Retention/Revocation of TaxInformation Authorizations

Line 7. Signature of Taxpayer(s)

Individuals. You must sign and date the authorization.Either husband or wife must sign if Form 8821 applies to ajoint return.

Check the box on line 4 if Form 8821 is filed for any of thefollowing reasons: (a) requests to disclose information to loancompanies or educational institutions, (b) requests todisclose information to federal or state agency investigatorsfor background checks, (c) application for EIN, or (d) claimsfiled on Form 843, Claim for Refund and Request forAbatement. If you check the box on line 4, your appointeeshould mail or fax Form 8821 to the IRS office handling thematter. Otherwise, your appointee should bring a copy ofForm 8821 to each appointment to inspect or receiveinformation. A specific-use tax information authorization willnot revoke any prior tax information authorizations.

Check the box on this line and attach a copy of the taxinformation authorization you do not want to revoke. Thefiling of Form 8821 will not revoke any Form 2848 that is ineffect.

Generally, the IRS records all tax information authorizationson the CAF system. However, authorizations relating to aspecific issue are not recorded.

We ask for the information on this form to carry out theInternal Revenue laws of the United States. Form 8821 isprovided by the IRS for your convenience and its use isvoluntary. If you designate an appointee to inspect and/orreceive confidential tax information, you are required bysection 6103(c) to provide the information requested on Form8821. Under section 6109, you must disclose your socialsecurity number (SSN), employer identification number (EIN),or individual taxpayer identification number (ITIN). If you donot provide all the information requested on this form, wemay not be able to honor the authorization.

In column (d), enter any specific information you want theIRS to provide. Examples of column (d) information are: lieninformation, a balance due amount, a specific tax schedule,or a tax liability.

For requests regarding Form 8802, Application for UnitedStates Residency Certification, enter “Form 8802” in column(d) and check the specific use box on line 4. Also, enter theappointee’s information as instructed on Form 8802. Note. If the taxpayer is subject to penalties related to anindividual retirement account (IRA) account (for example, apenalty for excess contributions) enter, “IRA civil penalty” online 3, column a.


Chickasaw, AL 36611251-457-6841

APPLICANTIRESIDENT CERTIFICATION

Applicant(s)/Resident(s) Statement

I/we certify that the information* given to the Chickasaw Housing Authority on householdcomposition, income, net family assets, and allowances and deductions is accurate andcomplete to the best ofmy/our knowledge and belief. I/we understand that false statementsor infonnation is punishable under Federal Law. I/we also understand that false statementsor information is grounds for termination ofhousing assistance and termination ofresidency.

Signature ot Head ot Household

Signature of Spouse

bate

Date

If you believe you have been discriminated against, you may call the Fair Housing and EqualOpportunity National Toll-Free Hot Line at 800-424-8590. (Within the Washington D.C.Metropolitan Area, call 426-3500.)

*After verification by this Housing Authority, the information will be submitted to theDepartment of Housing and Urban Development on Form HUD - 50058 (Tenant DataSummary), a computer-generated facsimile ofthe form or on magnetic tape. See the FederalPrivacy Act Statement for more information about its use.

NO. LOCAL PREFERENCES POINTS TOTAL POINTS

1 Minimum Income of $8,000 with at least 6 600months Job History

2 Working Family with at least 6 months Job 400History

3 Chickasaw Residency 300

4 Veteran 200

5 Elderly Family Over Single Person (1 BR Only) 0

6 Near Elderly Over Single Person (1 BR In 0Project Designated For The Elderly Only)

TOTAL

Read and sign warning before completing this application!

WARNING

***********************NOTICE********************ONCE YOU HAVE SUBMITTED YOUR APPLICATION TO THE

CHICKASAWHOUSING AUTHORITY IT BECOMES THEPROPERTY OF THE HOUSING AUTHORITY.

****************************************************Misrepresentation is a serious dwelling lease violation that may result in eviction. If it is found that anapplicant or tenant has misrepresented the facts upon which his/her rent is based so that he/she is payingless than he/she should be paying, the dwelling lease and/or housing assistance will be terminated. Inaddition, the applicant/tenant may be subject to civil and criminal penalties.

Tbe applicant/tenant is advised that any person who, by means of a false statement, failure to discloseinformation, impersonation or other fraudulent scheme or device: 1)Obtains or attempts to obtain, or 2)Establishes or attempts to establish eligibility for, and/or 3) Knowingly or intentionally aids or helps suchperson obtain or attempt to obtain housing or a reduction in public housing rental charges or any rentsubsidy to which such person would not otherwise be entitled, shall be euilty of a misdemeanor. Uponconviction, the person shall be punished by a fine of not less than $300 nor more than $500, be punishedat discretion of the conrt. (24-1-10, Code of Alabama, 1975).

Signatu re: _ Date:~-------

Documents that you MUST have with you to submit anappJication:1. Social Security Cards for ALL household members.2. Drivers License or Picture I.D. for ALL adult household members.

Other Documents to bring with you:1. Birth Certificates for Al,L household members.2. All FINAL Divorce Decrees/Legal Separation Papers.3. Marriage Certificate/Death Certificate.4. Landlord's name and complete mailing address for the past 5 years.5. Employer's name and complete mailing address.6. Most recent Social Security/SSI Award Letter.7. Child Support Court Order or Address of person giving the support.8. Unemployment Letter9. Veterans Benefit Award Letter.10. TANF Award Letter.11. Food Stamp Award Letter.12. Childcare South Award Letter.13. Childcare providers mailing address.