Subsidized Housing Application

“If you, or anyone in your family, are a person with disabilities and you require a specific accommodation in order to fully utilize our programs and services, please contact the Housing Authority Office at 970-565-3831.”

Applicant Name

Date:

PLEASE CHECK THE PROPERTIES AND PROGRAMS YOU ARE APPLYING FOR

Cortez

West 5th Apts (2 Br only)

Dolores

Hillside Apts (2, 3 & 4 Br) Park Central Family Apts (2 Br Only) Park Central Elderly Apts (1 Br Only) Dolores Elderly Apts – (1 Br Only)

Mancos

Verde View Apartments (1 Br Only)

Serving Montezuma, LaPlata and Dolores Counties

Housing Choice Voucher-Section 8 Program

The following Documents (COPIES ONLY-NOT ORIGINALS) are Required to Be Submitted with the Application for Applicant and Household Members:

Social Security Cards
Certified Birth Certificates (Certified copies, not complimentary copies from the hospital) or CIBs for Native Americans
Valid State-Issued IDs (for 18 years of age or older) Must provide Colorado IDs at time of Lease signing
NO APPLICATION FEE REQUIRED

Things You Should Know

Don’t risk your chances for federally assisted housing by providing false, incomplete or inaccurate information on your Application forms

Purpose

This is to inform you that there is certain information you must provide when applying for Housing Assistance. There are penalties that apply if you knowingly omit information or give false information.

Penalties for Committing Fraud

The United States Department of Housing and Urban Development (HUD) places high Committing priority on preventing fraud. If your application or recertification forms contain false or Fraud incomplete information, you may be:
• Evicted from your apartment or house.
• Required to repay all overdue rental assistance you received.
• Fined up to $10,000.
• Imprisoned for up to 5 years; and/or • Prohibited from receiving future assistance.

Your State and local government may have other laws and penalties as well.

Asking Questions

When you sit down with the person who fills out your application, you should know what is expected of you. If you do not understand something, say so. That person can answer your questions or find out what the answer is.

Completing the Application Income Assets

When you give your answers to Application questions, you must include the following. information:
• All sources of money you and any member of your family receive
(wages, welfare payments, alimony, social security, pension, etc.)
• Any money you receive on behalf of your children
(child support, social security for children, etc.)
• Income from assets (interest from a savings account, credit union, or certificate of deposit, dividends from stocks, etc.)
• Earnings from a second job or part-time job
• Any anticipated income (such as a bonus or pay raise you expect to receive)
• All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc., that are owned by you and any adult member of your family household who will be living with you.
• Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children.

Family/Household Members

• The names of all the people (adults and children) who will actually be living with you, whether or not they are related to you.

Signing the Application

• Do not sign any form unless you have read it, understand it and are sure everything is complete and accurate.
• When you sign the Application and certification forms, you are claiming they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information.
• Information that you give on your Application will be verified by your Housing Agency. In addition, HUD may do computer matches of the income you report with various Federal, State or a private agency to verify that it is correct.

Recertifications

You must updated information once a year. Some programs require that you report any changes in income or family/household composition immediately. Be sure to ask when you must recertify. You must report the following on recertification forms:
• All income changes, such as pay increases or benefits, change of job, loss of job, loss of benefits, ect., for all adult family/household members.
• Any family/household members that move in or out.
• All assets that you or your family/household members own and any asset that was sold in the last 2 years for less than full value.

Beware of Fraud

You should be aware of the following fraud schemes:
• Do not pay any money to file an Application
• Do not pay any money to move up on the waiting list
• Do not pay for anything not covered by your lease
• Get a receipt for any money that you pay
• Get a written explanation if you are required to pay any money other than rent (such as maintenance charges).

Reporting Abuse

If you are aware of anyone who has falsified an Application, or if anyone tries to persuade you to make false statements, report them to the manager of your project or Public Housing Authority. If you cannot report to the manager, call the local HUD office or the HUD Hotline on (202) 472-4200. This is a toll-free number. You can also write to the HUD Hotline, Room 8254, 451 Seventh Street, S.W., Washington, D.C. 20410.

By Signing below, I acknowledge that I have read and understand the “Federal Privacy Act Notice” and the “Things You Should Know” information.

Printed Name

Signature

Date

PART I:

Name:

Physical Address

City

State

Zip

Mailing Address

City

State

Zip

Phone: Home

Work

Message

Email address

List all household members who will be living with you if you receive housing assistance (include yourself and your spouse):

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Name

Relationship

Sex

Date of Birth

Have you or any member of your household ever been convicted of or pled guilty or “no contest” to any Drug- related criminal offenses?

Yes No

Are you or anyone in your household currently using marijuana for recreational or medicinal purposes?

Yes No

By signing below, I/We acknowledge and understand that the use of controlled substances for recreational use or medicinal use is prohibited on all Housing Authority of the County of Montezuma property and the use, possession and distribution of a controlled substance will be a deciding factor in the decision to provide housing assistance to you or anyone in your household.

Head of Household/Applicant Signature

Date

Handicap/Disability

Are you, your spouse, or any household members disabled or handicap?

Yes No

Name(s)

What reasonable accommodations need to be provided?

Are you, your spouse or any household member over the age of 18 full time students?

Yes No

If yes: Name(s)

School(s)

Do you have pets?

Yes No

How many?

Type:

Do you have a Service Animal or ESA (Emotional Support Animal)?

Yes No

Type & Breed

PART II:

Do you, your spouse or any household member over the age of 18 work?

Yes No

Name

Employer

Pay per hour

Hours worked per week

Do you, your spouse or any household member over the age of 18 receive any type of welfare assistance (This Includes General Assistance)? Do not include SNAP

Yes No

Name

Monthly Amount

Type

Caseworker

Do you, your spouse or any household member of over 18 receive Child Support?

Yes No

Name

Monthly Amount

Do you, your spouse or any household member receive Social Security, SSI, SSDI, OAP, Pension, etc.?

Yes No

Applicant Name

Monthly Amount

Do you, your spouse or any household members over the age of 18, receive any type of Student Grants/ Loans?

Yes No

Name

Type of Grant/Loan:

Are you, your spouse or any household member over the age of 18 self-employed?

Yes No

Name

Name of Business

Type of Business

Monthly Income after Expenses

List any other income not listed above:

PART III: Assets

Do you, your spouse or any household members have any of the following: Checking or Savings Accounts, Direct Express Bonds, Certificates of Deposit (CDs), IRAs?

Yes No

Checking Account

Name(s) on Account

Amount in Account

Name of Bank / Credit Union

Savings Account

Name(s) on Account

Amount in Account

Name of Bank / Credit Union

Other Accounts

Name(s) on Account

Amount in Account

Name of Bank / Credit Union

Do you, your spouse or any household members own any property of any kind?

Yes No

Explain:

Within the past two (2) years, have you/household members listed on this Application sold or given away assets(including cash, real estate etc.) for more than $1,000 below their fair market value (FMR)?

Yes No

Explain:

PART IV: General Information

Have you, your spouse or any household member over the age of 18 ever received any type of rental assistance from us or any other agency?

Yes No

Name

Address

How long ago?

Name of Agency

Name

Address

How long ago?

Name of Agency

PART V: Background Information

Are you currently a victim of domestic violence, dating violence or stalking?

Yes No

Is there an open Protection Order or Court Case regarding any household member?

Yes No

Name(s)

Are you claiming preference? Check all that apply.

Homeless Veteran Widow of Veteran Domestic Violence

Are you Limited English Proficient?

Yes No

Do you need language assistance for Housing Authority Business?

Yes No

Are you or any member of your household subject to a lifetime state sex offender registration program in any state?

Yes No

In accordance with the regulations at 24 CFR 5.856 and 5.905, O/As and PHAs must perform. Initial necessary criminal history background checks to determine if any applicant, or member of an applicant’s household, is subject to a lifetime registration requirement under a State or Federal sex offender registration program. This check must be carried out with respect to the State in which the housing is located and with respect to States where applicant and members of the applicant’s household are known to have resided.

The information regarding race, ethnicity, and sex designation solicited on this Application is requested in order to assure the Federal Government, acting through the Rural Housing Service, that Federal Laws prohibiting discrimination against tenant Applications on the basis of race, color, national origin, religion, sex, familial status, age and disability are complied with. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your Application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of the individual applicants on the basis of visual observation or surname.”

Ethnicity:

Hispanic Non-Hispanic or Latino

Race: (Mark one or more)

Gender

Female Male

CERTIFIED STATEMENT

Knowing the penalty for making a false statement under the United States Criminal code, I hereby certify that the above information is a true and full statement. Revised 2/2024 Section 35 (a) of the U.S. Criminal Code makes it a criminal offense, punishable by a maximum of ten (10) years imprisonment, $10,000 fine or both, to make a false statement of representation to any department of the U.S. as to a matter within their jurisdiction. The information given above was requested by the Housing Authority of this City in its capacity as a government-funded agency. I/We certify that the unit applied for will be the household’s permanent residence and I/We will not maintain a separate subsidized rental unit in a different location. I understand that submitting this Application does not guarantee that I will be offered housing assistance. All adults over 18 years of age must sign.

SIGNED: X

DATE

SIGNED: X

DATE

Be advised that it is your responsibility to NOTIFY the Housing Authority, in writing, of any CHANGE OF MAILING ADDRESS. When assistance becomes available, we MUST be able to contact you by your current mailing address, at which time a NATIONWIDE CRIMINAL BACKGROUND CHECK AND CREDIT REPORT will be obtained. Applicants will be withdrawn from the waiting list if correspondence sent to them is returned

After Hours Emergency

Hours

Office Location

Mailing Address