515-986-1882(VOICE & TDD) 515-986-1883(FAX)
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CIRHA
SECURITY DEPOSIT GRANT |
PROGRAM APPLICATION
Applicant name
Mailing address
Address where you are
currently living
Home phone number
Work phone number
Other phone number where we
may leave a message or contact you
HOW MANY PEOPLE WILL BE RESIDING IN YOUR
HOUSEHOLD
LIST ALL HOUSEHOLD MEMBERS 18 YEARS AND OLDER:
Applicant Social Security Number
Birth Date
Household Member #2
Social Security Number
Relationship to Applicant Birth Date
Age
Household Member #3
Social Security Number
Relationship to Applicant Birth Date
Age
TYPE OF ASSISTANCE APPLYING FOR : RENT DEPOSIT
Rent deposit for the following address:
Amount needed Date of scheduled move in
Paid to what individual or
company:
Address
Applicants applying for rental security deposit
assistance must provide written documentation from the landlord stating that
the applicant has been approved for occupancy provided that the required
security deposit is paid in full, the anticipated date of move in, the units
monthly rental amount, and the required deposit amount.
DEPOSIT ASSISTANCE WILL NOT
BE PROVIDED IF APPLICANT MOVES INTO
THE RENTAL UNIT BEFORE APPROVAL
OF THIS APPLICATION.
TYPE OF ASSISTANCE APPLYING FOR : UTILITY DEPOSIT(S)
Type of utility: Gas
Electricity Water
Utility Deposit #1 Amount needed Date needed
Paid to:
Address
Utility Deposit #1 Amount needed Date needed
Paid to:
Address
Applicants applying for utility deposit assistance
must provide written documentation from the utility company(s) stating that the
applicant is eligible for utility hook up provided that the required deposit
amount is paid in full. This statement
should also include any outstanding balances held by the applicant, a
description of any approved payment arrangements, and the deposit amount
necessary to establish basic utility service.
HAS ANYONE IN YOUR HOUSEHOLD EVER RECEIVED CIRHA
SECURITY DEPOSIT ASSISTANCE?
If yes, who and when
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IMPORTANT If you are completing this
application in cooperation with the Department of Human Services, your
appointed case worker may provide a written statement certifying that all
income sources included on this application are current, complete and
accurate |
INCOME FOR ALL HOUSEHOLD MEMBERS
Income includes employment, self-employment,
student loans, student grants, JTPA or other training allowances, unemployment,
worker compensation, social security, social security disability, railroad or
other retirement income, Veteran’s benefits, TANIF, child support, alimony,
military pay, interest, dividends, commissions, money from other person, income
from rent/room board.
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Who Receives |
Type of Income |
Amount |
How Often Received |
CIRHA USE
ONLY |
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READ THIS !!! YOU MUST provide
current written verification of all income sources. This may
include check stubs, employer documentation, award letters, tax returns,
financial statements.
ASSET INFORMATION
Assets include checking
accounts, savings accounts, IRA’s, Certificates of Deposit, stocks, bonds, real
estate owned and investments.
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Name of Account Holder |
Type of Account |
Balance in Account |
CIRHA USE
ONLY |
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READ THIS !!! YOU MUST provide
current written verification for all asset information. This may include financial statements.
APPLICANT STATEMENT
I certify that the information given to the
Date Signature of Applicant
FOR
PHA USE ONLY
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Date and Time received:
Completion deadline:
County where funds will be used: Boone
Town where funds will be used:
Landlord documentation received: yes no
Utility company(s) documentation: yes no Number of utilities:
APPROVED:
Total amount paid
Security Deposit Utility
Follow-up scheduled for:
DENIED:
CIRHA Housing Specialist: