1201 SE GATEWAY DRIVE
GRIMES, IA 50111
(515) 986-1882 phone / (515) 986-1883
fax
PLEASE PRINT APPLICATION and Supplement
to Application TO MAIL OR FAX. Only
complete applications will be accepted.
If you need special accommodations completing this
application please contact CIRHA AT (515) 986-1882.
NAME
PHYSICAL
ADDRESS
(Proof Required for Section 8)
CITY STATE ZIP
MAILING
ADDRESS
CITY STATE ZIP
HOME
PHONE
WORK PHONE
YOU ARE RESPONSIBLE FOR
REPORTING ADDRESS CHANGES IN WRITING TO THE CIRHA OFFICE.
REQUIRED FOR SECTION 8
APPLICATIONS!
You must attach a copy of ONE of the following items
so CIRHA may assign proper preference for the Section 8 waiting list:
1) Your current lease or
2) Utility bill or
3) Valid driver’s license or
state issued ID of Head of Household showing current physical address or
4) A piece of mail addressed to
the Head of Household from a state or federal agency.
FAMILY MEMBERS: List all persons including yourself who will
reside in the rental unit while you are being assisted
RELATIONSHIP BIRTH SOCIAL
FULL NAME
TO HEAD DATE
SECURITY # SEX
1.)
__________________________ Head of Household ______________ _________________ M
F
2.)
__________________________
______________
______________ _________________ M
F
3.) __________________________ ______________ ______________ _________________ M
F
4.)
__________________________
______________
______________ _________________ M
F
5.)
__________________________
______________ ______________ _________________ M
F
6.)
__________________________
______________
______________ _________________ M
F
Is any household member listed above
currently pregnant?: Yes
No Due Date:
________________________
PROGRAM INFORMATION:
Have
you previously participated in a rental assistance program? Yes No
If yes, with what Housing Authority?
________________________________________________
Racial group
identification (Used for statistical purposes only).
White __ Hispanic __ Native American __
Other __ African American __ Asian
__ Prefer not to answer __
(You may choose to be on both lists.)
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SECTION 8 VOUCHER YES (circle one)
NO Choose Section 8 if: 1)
You wish to receive rental assistance in a unit you
would find yourself (this might include the unit where you currently live if
it meets Section 8 criteria). 2)
You wish to live in the counties of Boone, Dallas,
Jasper, Madison, Marion or Story in any towns except Knoxville or Pella. REQUIRED! Attach a copy of one of the following
items so CIRHA may determine proper
preference for the Section 8 waiting list: 1) Your current
lease 2) Utility bill 3) Valid driver’s
license or state issued ID of Head of Household. 4) A piece of
mail addressed to the Head of Household
from a state or federal agency. Also indicate if either of the following applies to
you in determining proper preference: 1) Does Head
of Household claim the preference of ELDERLY (age 62 and older), DISABLED or
HANDICAPPED? YES NO 2)
Does Head of Household claim the preference of NEAR
ELDERLY (age 50 to 61): YES NO |
CIRHA OWNED HOUSING YES (circle one)
NO Choose Owned Housing if: 1)
You would prefer to have CIRHA offer you an existing unit
rather than having to find one yourself. 2)
You are willing to move to a unit owned by CIRHA in one
of the towns listed below. (NOTE: Do not choose Public Housing if you do not
wish to live in one of the towns listed below.) REQUIRED! Circle YES or NO for the counties below: Boone County YES NO (The towns of
Boone and Madrid) Dallas County YES NO (The towns of
Perry and Redfield) Jasper County YES NO (The towns of
Colfax and Newton) Marion County YES NO (The town of
Melcher/Dallas) Do not write in additional towns or counties. The towns listed are where CIRHA owns
Public Housing. (For other towns and
counties choose the Section 8 program on left side of page.) |
After CIRHA receives your
application you will receive a confirmation letter listing each of the waiting
lists you have selected.
Once your name reaches the
top of a waiting list you will be contacted by mail to schedule an enrollment
interview.
YOU
MUST INFORM CIRHA IN WRITING IF YOUR ADDRESS CHANGES !!!
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APPLICANT CERTIFICATION:
ALL APPLICATION INFORMATION
IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
APPLICANT SIGNATURE: DATE:
CO-APPLICANT SIGNATURE: DATE:
WARNING: Section 1001 of Title 18 of the U.S. code makes it a
criminal offense to make willful false statements of misrepresentation to any
Department or agency of the U.S. as to any matter within its jurisdiction.
OMB Control # 2502-0581
Exp. (07/31/2012)
Supplemental and Optional Contact Information for HUD-Assisted Housing
Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY
ASSISTED HOUSING
This form is to be provided to each applicant for
federally assisted housing
Instructions:
Optional Contact Person or Organization: You have the right by law to include as part of your
application for housing, the name, address, telephone number, and other
relevant information of a family member, friend, or social, health, advocacy,
or other organization. This contact
information is for the purpose of identifying a person or organization that may
be able to help in resolving any issues that may arise during your tenancy or
to assist in providing any special care or services you may require. You
may update, remove, or change the information you provide on this form at any
time. You are not required to
provide this contact information, but if you choose to do so, please include
the relevant information on this form.
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Applicant Name: |
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Mailing Address: |
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Telephone No:
Cell Phone No: |
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Name of Additional Contact Person or Organization: |
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Address: |
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Telephone No:
Cell Phone No: |
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E-Mail Address (if applicable): |
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Relationship to Applicant: |
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Reason for Contact:
(Check all that apply)
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Commitment of Housing Authority or Owner: If you are
approved for housing, this information will be kept as part of your tenant
file. If issues arise during your
tenancy or if you require any services or special care, we may contact the
person or organization you listed to assist in resolving the issues or in
providing any services or special care to you. |
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Confidentiality Statement: The information provided on this form is
confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law. |
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Legal Notification: Section 644 of the Housing and Community Development Act of 1992
(Public Law 102-550, approved October 28, 1992) requires each applicant for
federally assisted housing to be offered the option of providing information
regarding an additional contact person or organization. By accepting the
applicant’s application, the housing provider agrees to comply with the
non-discrimination and equal opportunity requirements of 24 CFR section
5.105, including the prohibitions on discrimination in admission to or participation
in federally assisted housing programs on the basis of race, color, religion,
national origin, sex, disability, and familial status under the Fair Housing
Act, and the prohibition on age discrimination under the Age Discrimination
Act of 1975. |
Check
this box if you choose not to provide the contact information.
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Signature
of Applicant
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Date |
The information
collection requirements contained in this form were submitted to the Office of
Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44
U.S.C. 3501-3520). The public reporting
burden is estimated at 15 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of
information. Section 644 of the Housing
and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the
obligation to require housing providers participating in HUD’s assisted housing
programs to provide any individual or family applying for occupancy in
HUD-assisted housing with the option to include in the application for occupancy
the name, address, telephone number, and other relevant information of a family
member, friend, or person associated with a social, health, advocacy, or
similar organization. The objective of providing such information is to
facilitate contact by the housing provider with the person or organization
identified by the tenant to assist in providing any delivery of services or
special care to the tenant and assist with resolving any tenancy issues arising
during the tenancy of such tenant. This
supplemental application information is to be maintained by the housing
provider and maintained as confidential information. Providing the information
is basic to the operations of the HUD Assisted-Housing Program and is
voluntary. It supports statutory
requirements and program and management controls that prevent fraud, waste and
mismanagement. In accordance with the
Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information, unless the collection
displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and
Urban Development (HUD) to collect all the information (except the Social
Security Number (SSN)) which will be used by HUD to protect disbursement data
from fraudulent actions.
Form HUD- 92006 (05/09)