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.
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 driverís 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.
††††††††††††††††††††††††††††††††††††††††††††††† †††† †††††† 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:† ________________________
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.)
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.
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 driverís license or state issued ID of Head of
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.)
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 !!!
ALL APPLICATION INFORMATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.†
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.
Telephone No:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Cell Phone No:
Name of Additional Contact Person or Organization:
Telephone No:†††††††† †††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact:† (Check all that apply)
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.
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.
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 applicantís 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.
Signature of Applicant††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††
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)