Application and Certification Update Form

Application and Certification Update Form

Head of Household must provide income and asset information for all household members and complete Applicant Resident Student Eligibility Certification form. All members 18 & older must sign and date the update form and all other relevant verification and certification forms.

Please list all current information and note any changes which may have occurred since your last certification. You must answer every question.

Home Phone #: ______Apt. #: ______

1. Household Composition: List Head of the Household and all other members who are living or will be living in the unit. Give the relationship of each family member to the Head of Household. If adding a new member 18 or older, member must be approved before he or she can live in unit

# / First Name, Middle Initial and Last Name as shown on Social Security Card / Relationship
To head of
household /

Birth

Date

Age

Social Security # for each member

/ Is household member a Veteran of US Military? Yes or No / Is member a Full or Part Time Student (Y/N) (If Yes, Please note whether Full or Part Time)
1 / (head)
2
3
4
5
6
7
8
9
General Information / YES / NO
2 / Do you plan to have anyone living with you who is not listed on page one?
If yes, who? Name: ______Age: ______
Relationship:______
3 / Have you or any member of your household ever been convicted of illegal use, manufacturing or distribution of a controlled substance or any other felony? If yes, describe: ______When______
4 / Have you or any member of your household ever been convicted of a misdemeanor? If yes, describe: ______When______
5 / Are you or any member of your household currently using an illegal substance? If yes, who: When
6 / Have you or any member of your household ever been convicted of criminal activity involving alcohol abuse, including three or more DUI offenses?
If yes, who: When
7 / Are you or any member of your household currently abusing alcohol?
Household Income / YES / NO
8 / Have you or any member of your household ever been awarded alimony in a court of law or by verbal agreement? If yes provide detail
Monthly amount awarded: $ Amount you receive: $ ______
Name of individual paying alimony: ______
Address & Telephone #: ______
9 / Have you or any member of your household ever been awarded child support in a court of law or by verbal agreement? If yes provide detail
Monthly amount awarded: $ Monthly Received: $ ______
Name of individual paying child support:______
Address & Telephone #: ______
______
Child Support Case ID # ______
Household Income Continued / YES / NO
10 / Do you understand that you must count the full amount of all alimony and or child support even if you do not receive, unless you can provide documentation that shows your efforts to collect?
11 / Are you or any member of your household employed full time, part time or seasonally? If yes, who: ______Hire Date: ______Average hours per week: ______
Monthly Income $ Employer:
Phone # Address: ____
City: State: Zip:
12 / Are you or any member of your household self-employed?
If yes, who? Monthly Income: $
13 / Are you or any member of your household registered with a temporary employment agency? If yes, who? ____
Date of last assignment: Est. Monthly Income $ ____ Agency Name: Phone # Address:
City: State: Zip:
14 / Are you or any member of your household residing in or not residing in your household now receiving military pay and or allowances? If yes, provide detail: ______
15 / Are you or any member of your household entitled to receive or expect to receive Unemployment Benefits? If yes, provide detail:
If yes, who: Weekly award amount $
16 / Are you or any member of your household entitled to receive or expect to receive Net Income from a Business?
If yes, who: Monthly Benefit Income $
17 / Are you or any member of your household entitled to receive or expect to receive Worker’s Compensation?
If yes, who: Monthly Benefit Income $
18 / Are you or any member of your household entitled to receive or expect to receive to Social Security or Social Security Disability Benefits?
If yes, who: Monthly Benefit Income $
Household Income Continued / YES / NO
19 / Are you or any member of your household entitled to receive or expect to receive Supplemental Security Income (SSI)?
If yes, who: Monthly Benefit Income $
20 / Are you or any member of your household entitled to receive or expect to receive a Pension, Annuity, Retirement Fund, Death Benefit or Insurance Payments?
If yes, who: Monthly Benefit Income $
21 / Are you or any member of your household entitled to receive or expect to receive Veteran’s Benefits Or Veteran’s Disability Pay?
If yes, who: Monthly Benefit Income $
22 / Are you or any member of your household entitled to receive Public Assistance (AFDC/TANF/K-TAP cash benefits not food stamps)?
If yes, who: Monthly Benefit Income $
23 / Do you or any other household member receive scholarships, grants or other financial assistance to attend school? If yes, who: ______
24 / Does anyone outside your household pay your bills for you or provide cash contributions to your household? If yes,
Provider name: ______Monthly Income $
25 / Does any member of the household receive any other income not listed above? Examples include but are not limited to lottery winnings, housing or utility benefits?
If yes, who: Monthly Benefit Income $
26 / Will any members 18 and older expect to have Zero income over the next twelve months? If yes, list members: ______
Household Assets / YES / NO
27 / Do you or any other household member have a Checking Account or Money Market Account?
If Yes, who: ______Bank: ______
Account #: ______
28 / Do you or any other household members have a Savings Account or Certificate of Deposit?
If Yes, who: ______Bank: ______
Account #: ______
29 / Do you or any other household members have a Pre-Paid Debit Card or Pay card? If yes, who: ______
30 / Do you or any other household members have a Stocks, Bonds, Treasury Bills, Trust or Securities? If Yes, who: ______
Financial Institute: ______Account #: ______
31 / Do you or anyone in your household own Real Estate, Rental Property, Land Contracts for deed or other real estate holdings?
If yes, who? Location: ______
32 / Do you or any other household member have a Pension, IRA’s, 401 K, Keogh or other Retirement Funds? If Yes, who: ______
Financial Institute: ______Account #: ______
33 / Do you or any other household member have a Whole or Universal Life Insurance? If yes, Insurance carrier Name: ______
Address: ______Policy #: ______
34 / Do you or any other household member have any other current assets not listed above? If yes, describe: ______
Financial Institute: Acct #
35 / Disposed Asset: Within the past two (2) years, have you or any member of your household sold or given away any assets (Including cash, real estate, etc.) for less than Fair Market Value? If yes provide detail
Asset Description: ______
Fair Market Value: ______
Amount you received: ______
Date Disposed: ______
Medical Allowance / YES / NO
36 / Are you and /or the co-head 62 or older?
37 / Are you and/or the co-head disabled?
38 / Are you and/or the co-head enrolled in a Medicare prescription plan?
If yes, provider name: ______
Address; ______
Telephone #______Monthly Premium $______
39 / Do you pay medical expenses that are not covered by insurance?
If yes, please provide contact information for doctors, pharmacies, medical insurance premiums or other individuals/groups that you pay out of pocket below
Name of service provider:
Address: Telephone #
Type of expense: Contact Person:
Name of service provider:
Address: Telephone #
Type of expense: Contact Person:
Name of service provider:
Address: Telephone #
Type of expense: Contact Person:
Name of service provider:
Address: Telephone #
Type of expense: Contact Person:
Name of service provider:
Address: Telephone #
Type of expense: Contact Person:
Childcare Allowance / YES / NO
40 / Do you pay for childcare expenses that are not reimbursed by an outside source to work?
41 / Do you pay for childcare expenses that are not reimbursed by an outside source to look for work?
42 / Do you pay for childcare expenses that are not reimbursed by an outside source to go to school?
If yes to question 40, 41 or 42 please complete the section below.
Name of service provider:
Address:
Telephone # Contact Person:
Name and age of child:
Name and age of child:
Name and age of child:
Name and age of child:

Certification by resident(s): I/We understand and have answered all questions on this recertification update. I/We certify that all answers are true to the best of my/our knowledge and understand that any misrepresentation of information or false statement is punishable under Federal Law.

Resident Signature: Date:

The Owner of this Apartment Community does not discriminate on the basis of disability status in the admission of or access to, or treatment or employment in, its federally assisted programs and activities.

The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing Section 504.

Susan Howell

Section 504 Coordinator

LHP Management, LLC

Suite 2000, 900 S. Gay Street

Knoxville, TN 37902

Phone: (865) 244-4311

Telecommunication: Dial 711(Nationwide Number)

2020ap Certification Update Form S8 & LIHTC 111716