POUGHKEEPSIE
HOUSING AUTHORITY
21 Charles Street Bldg. 4 · Poughkeepsie, NY 12601
POUGHKEEPSIE
HOUSING AUTHORITY
21 Charles Street Bldg. 4 · Poughkeepsie, NY 12601
TEL: (845) 485-8862
FAX: (845) 485-2630
| ATTENTION ALL APPLICANTS:
The Poughkeepsie Housing Authority requests that all applications are completed with all information within the contents of the application. ALL APPLICATIONS RETURNED INCOMPLETE WILL BE DISCARDED AND WILL NOT BE PROCESSED.
PROPERTIES ARE LOCATED IN THE CITY OF POUGHKEEPSIE
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(FOR SPEECH AND HEARING IMPAIRED) NEW YORK RELAY CENTER
TTY USERS (HEARING AND SPEECH IMPAIRED ONLY)
NON-TTY (VOICE)
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THE FOLLOWING PERSON(S) DO NOT HAVE SOCIAL SECURITY NUMBERS OF CARDS:
| (Name) | (Name) |
| (Name) | (Name) |
| (Name) | (Name) |
| (Name) | (Name) |
| (Your Signature) | (Date) |
| Authorization for the Release of Information/
Privacy Act Notice |
U.S. Department of Housingand Urban
Development
Office of Public and Indian Housing |
| to the U.S. Department of Housing
and Urban Development (HUD)
and the Housing Agency/Authority (HA) |
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| PHA requesting release of information;(Cross out space if none)
(Full address, name of contact person, and date)
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IHA requesting release of information:(Cross out
space if none)
(Full address, name of contact person, and date) |
| Authority: Section 904 of the Stewart B. McKinney
Homeless Assistance Amendments Act of 1988, as amended by Section 903 of
the Housing and Community Development Act of 1992 and Section 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 verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U>S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits. |
Who Must Sign the Consent Form:
Each member of your household who is 18 years of age or older must sing
the consent form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the household become
18 years of age.
Persons who apply for or receive assistance under the following programs are required to sign this consent form: PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19(c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing Section 8 Rental Certificate Section 8 Rental Voucher Section 8 Moderate Rehabilitation |
| Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and HA need this information to verify your household’s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits. | Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA’s grievance procedures and Section 8 informal hearing procedures. |
| Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to Has for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form. | Source of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 year when I have received assisted housing benefits.) U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments of retirement income as referenced at Section 6103 (1) (7)(A) of the Internal Revenue Code.) U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].) Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits |
Consent: |
Signatures:
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Privacy Act Notice.
Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by 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 Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participant s to submit the Social Security Number of each household member who is six years or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-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 regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or 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 members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval. |
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 of information collected based on the consent form. Us 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 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 HA or the owner responsible for the unauthorized disclosure or improper use. |
Authorization to Release Information
I, , ________________________________________hereby authorize any credited representative of the Poughkeepsie Housing Authority to request and receive information from any source which is necessary to determine my and all persons listed on my application, suitability and need for assisted housing at the Poughkeepsie Housing Authority. |
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Do I have the right to request a reasonable accommodation or modification
of my unit while in public or assisted housing?
A modification of your Public Housing unit or its associated premises, then… Will my request automatically be approved? We will try to approve your request if you can show that… 815-777-0782 during regular business hours. If you need help filling out this form, or if you want to give us your request in some other way, we will help you. Signature (Head of Household)_________________________ Date___________ The Poughkeepsie Housing Authority will make every effort to make this information available to persons with disabilities in alternative formats upon request. Please allow a minimum of seven days for preparation of the material. |
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REQUEST FOR A REASONABLE ACCOMODATION Head of Household Address Day phone ________________________Home phone (if different)_______________________
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Name
Relationship
Check the applicable request. An accommodation or adjustment in the following program, rule, policy, practice, or service that I currently must follow to meet the terms of the program. I understand that I may ask for change in how I meet the terms of the program’s rules and regulations. (Please be specific and explain what is needed. Attach a separate sheet if necessary for additional information.) A modification in my unit or to another part of the associated housing
complex. (Please tell what specifically is needed. Attach a separate sheet
if necessary for additional information.
Name Title: Organization: Address: Phone: I,________________________ , give the Poughkeepsie Housing Authority permission to contact the individual(s) identified in No. 4 of this form for purposes of verifying that I or a family member needs the reasonable accommodation requested above. (NOTE: This must be signed by the person designated in No. 1 of this form or by an individual with authority to sign on that person’s behalf). Signature (Head of Household) Date |
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21 CHARLES ST. BLDG. 4 POUGHKEEPSIE, NY 12601 TEL. (845) 485-8862 FAX (845) 485-2630 NAME WORK # HOME# ADDRESS WHERE YOU RESIDE: MAILING ADDRESS IF DIFFERENT: ARE YOU A PREVIOUS TENANT OF PHA? _______________IF YES,
FAMILY COMPOSITION (THOSE EXPECTED TO RESIDE IN APT.)
YEARLY INCOME $ _____________________WELFARE ASSISTANCE $ _____________________ OTHER INCOME $ _____________________ASSETS: TYPE ________________________________ INTEREST ON ASSETS $ ________________ MEDICAL (SENIORS ONLY)$ __________________ EMPLOYER ________________ ___________ PHONE # _____________________________________ NAME AND ADDRES OF EMPLOYMENT LOCATION (NOT MAILING ADDRESS): _____________________________________________________________________________________ _____________________________________________________________________________________
FULL TIME STUDENT? _________________CURRENT RENT & UTILITIES? $ ______________ PRESENT HOUSING-LANDLORD NAME: ______________________________________________ ADDRESS: ________________ ___________PHONE # ______________________________________ WHAT IS YOUR REASON FOR WANTING TO MOVE INTO PUBLIC HOUSING? _____________________________________________________________________________________ ETHNIC GROUP: ___ WHITE, NON-HISPANIC ORIGIN ___ WHITE, HISPANIC ___ BLACK, NON-HISPANIC ORIGIN ___ BLACK, HISPANIC ___ AMERICAN INDIAN OR ALASKAN ___ ASIAN, PACIFIC Signature of Applicant ________________ ___________ Date___
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