In This Application Packet You Will Find the Following

PRAC APPLICATION PACKET

NOTICE TO ALL APPLICANTS

In this Application Packet you will find the following:

Nondiscrimination and Reasonable Accommodation Statement

Rental Application

Special Unit Requirement Questionnaire

Applicant Verification for Case Worker User Services

Family Summary Sheet

Owner’s Summary of Family

Background Authorization Form

Resident Selection Criteria

HUD Form 9887 and 9887A

Race and Ethnicity Form

Notice of Occupancy Rights Under VAWA

List of information needed to process your application:

Please initial on each line

______Completed Application. If not applicable please put “n/a”.

______Verification of all household income and assets (last 6 consecutive payroll stubs, SSI/SS award letter, Child Support Award letter, Alimony/Divorce Decree, last 6 checking account statements, last savings account statement, Whole life insurance policies, etc.).

______Copy of SS Card and birth certificate for each member of the household, and picture ID for anyone 18 and older. Any licensed driver will also need a copy of driver’s license.

______Immigration documents if not US Citizen.

Incomplete applications will be not be processed or added to wait list. Please call or come by within 48 hours to check the status of your application.

We will pull credit report and criminal background history, you do not need to provide this to us.

To be completed by employee of NHE, Inc., that receives this application:

Completed Application Received ______Time Application Received ______

Name of Applicant ______Application Received By: ______

NHE, INC.

NONDISCRIMINATION AND

REASONABLE ACCOMMODATION STATEMENT

IT IS THE POLICY OF THIS COMPANY TO PROVIDE HOUSING ON AN EQUAL OPPORTUNITY BASIS. WE DO NOT DISCRIMINATE ON THE BASIS OF RACE, RELIGION, COLOR, CREED, SEX, FAMILIAL STATUS, NATIONAL ORIGIN OR HANDICAP. IF YOU FEEL YOU HAVE BEEN DISCRIMINATED AGAINST BY THIS COMPANY, PLEASE CALL THE MAIN OFFICE OF NHE, INC. AT (803) 937-3545 OR CONTACT US THROUGH THE SOUTH CAROLINA RELAY CENTER AT 1-800-735-2905. THE NAME OF THE PERSON TO CONTACT AT NHE, INC. IS PATRICIA SHERMAN, VICE PRESIDENT OF AFFORDABLE PROPERTY MANAGEMENT.

PRAC RENTAL APPLICATION

Date ______BR Size ______Phone ______

Name ______

Family Composition
Name (Full Legal Name) / Social Security # / Relationship / Date of Birth / Age / Marital Status
Head of Household / M S D
W Separated
M S D
W Separated
M S D
W Separated
M S D
W Separated

• Do you expect the above household members to change during the coming year?  Yes No

If yes, explain: ______.

• Are any members in your household full or part time students?  Yes No

If yes list members: ______.

• Will all of the above household members live in the apartment full time?  Yes No

If No, explain: ______.

• Do you or any household member (s) need a reasonable accommodation/modification including accessible features or accessible unit? Yes  No

If so, what? ______.

• Are you or any of the above household members a convicted SEX OFFENDER in the State of South Carolina or the United States of America? Yes  No

If so, please list the states? ______.

• Are any of the above household members US Military Veterans? Yes No

If so, who? ______.

• If you are 62 years of age or older as of 1/31/2010 and do not have a Social Security Number, were you receiving HUD assistance at another location on 1/31/2010?  Yes  No

If so, where? ______.

RENTAL APPLICATION RESIDENT HISTORY

• Present address: ______Zip Code ______

Present telephone or number where you can be reached: ______

Present landlord: ______

Landlord’s address: ______Landlord’s phone: ______

Livedat this address: (From) ______to ______Amount of Rent: $______

Reason for Moving: ______

DISPLACEMENT STATUS CODES

• Are any of the above household members seeking to be housed temporarily as a result of displacement from subsidized housing as a result of a declared disaster?

1 = Government Action 2 = Natural Disaster 3 = Private Action 4 = Not Displaced Reason Code: ______

PREVIOUS HOUSING CODES

• 1 = Substandard5 = Lacking a fixed nighttime residence Reason Code:______

3 = Standard6 = Fleeing/attempting to flee violence

4 = Conventional Public Housing

• Is your household’s primary nighttime residence a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building, bus or train station, airport, or camping ground.  Yes  No

If yes, please describe: ______.

• Is your household currently living in a supervised publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by a charitable organizations or by federal, State, or local government programs for low-income individuals)? Yes  No

If yes, please describe: ______.

• Is your household currently exiting an institution after residing for 90 days or less, while also previously residing in an emergency shelter or place not meant for human habitation immediately before entering that institution?  Yes  No

If yes, please describe: ______.

• Is your household fleeing, or attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against and you individually or another member of your household, including a child, that has either taken place within the individual’s or family’s primary nighttime residence or has made the individual or family afraid to return to their primary nighttime residence? (2) Does your household have no other residence? (3) Does your household lack the resources or support networks, e.g., family, friends, and faith-based or other social networks, to obtain other permanent housing? ______YES ______NO If yes to all, please describe: ______.

• Does your household contain any homeless veterans?  Yes No
• Are you a homeless family with children?  Yes No

• Does your household meet any other type of homelessness?  Yes No

If yes, please describe: ______.

• Have you or any member of your household ever been evicted?  Yes No

If yes, from where? ______.

Please give details: ______.

• Do you or any member of your household owe money to any Public Housing Authority, HUD, apartment community or previous landlord? Yes  No

If yes, to whom? ______. How much? ______.

• Have you or any family member ever lived in public or assisted housing?  Yes No

If yes, at what property and address? ______

Dates of occupancy:______

• Have you ever committed any fraud in a federally assisted housing program or been asked to repay money for knowingly misrepresenting information for such housing programs, apartment community or previous landlord?  Yes  NoIf yes, how much? ______

• Does anyone in your household have a criminal or juvenile record or has anyone ever been convicted of any crime other than a traffic violation?  Yes  No

If yes, describe and list all convictions: ______.

• Are you or any member of your household a current illegal user of or addicted to a controlled substance?

 Yes No

• Are you or any member of your household currently engaged in illegal use of a drug or shows a pattern of illegal use that may interfere with the health, safety, or right to peaceful enjoyment by other residents?

 Yes  No

• Is your or any member of your household’s abuse, or pattern of abuse, of alcohol a potential interference with the health, safety, or right to peaceful enjoyment of the premises by other residents?

 Yes No

• Have you or any member of your household ever been convicted of illegal manufacture or distribution of a controlled substance?  Yes  No

• Does anyone in your household have any criminal charges pending against them?  Yes No

If yes, whom and explain: ______.

• Have you or any other adult member of your household ever used any name (s) or social security number (s) other than the one you are currently using?  Yes  No

If yes, explain: ______.

• Do you have insurance for your personal belongings?  Yes No

IF NOT, PLEASE BE ADVISED THAT YOUR PERSONAL BELONGINGS ARE NOT COVERED BY OURINSURANCE.

Pets are only allowed in 202 Elderly communities. Then only when the pet meets the criteria in the Pet Lease Addendum (Form F-27) and the Pet Acknowledgement and Information Form (F-26) and when a $300.00 pet deposit is paid.

DO YOU OWN A PET?  Yes No

IF YES: WHAT KIND ______WEIGHT______LBS.

HAS YOUR PET BEEN NEUTURED/SPAYED?  Yes No

CAN YOU PROVIDE PROOF THAT YOUR PET’S SHOTS ARE CURRENT?  Yes No

Please indicate with your dated signature below that you have received a copy of our Pet Lease Addendumand completed the Pet Acknowledgement and Information Form (F-26).

______

SignatureDate

INCOME, ASSET, AND EXPENSE INFORMATION

Income
Do you or any adult member of your household have ANY income from the following list below or any OTHER sources? Please include ALL income you are receiving for yourself and/or on behalf of a minor. Yes No
Yes / No / Yes / No
1. / Employment / 7. / Alimony/Child Support
2. / WorkCenter Income / 8. / Veteran’s Benefits
3. / Social Security / 9. / Retirement Benefits
4. / SSI Disability / 10. / Pension Benefits
5. / Disability / 11. / Recurring Gift
6. / Unemployment Benefits / 12. / Other
If you answered YES to any of the above; Complete the area provided on the next page
Household Member / Source of Benefit/ Income / Employer or Agency’s Mailing Address, City, State, Zip / #Hrs Per Week / Full/Part time / Amount Per Month
F
P
F
P
F
P
F
P
Assets
Do you or any member of your household own any of the following types of assets?
Yes / No / Yes / No
1. / Checking Account / 5. / Stocks and Bonds
2. / Saving Account / 6. / Personal Needs Account
3. / Certificate of Deposit (CD) / 7 / Life Insurance Policy (not term)
4. / Real Estate / 8. / Other Financial Assets
Have you or any other member of your household disposed of any of the above types of assets at less than fair market value during the past two years? YES NO If YES explain:
If you answered Yes to any of the above, please complete the following information:
# / Asset Description / List Name of Bank and/or Financial Institution of Current Asset(s) and/or Asset(s) Disposed Of
Expenses
The following Medical Expense section applies ONLY to elderly / disabled / handicap households:
Yes / No / Yes / No
1. / Doctor Bills / 5. / Health Insurance /Medicare
2. / Dental Bills / 6. / Prescribed Equipment
3. / Hospital Bills / 7. / Eyeglasses
4. / Pharmacy Expense / 8. / ______
If you answered YES to any of the above, please complete the following information:
# / Name of Doctor, Medical Practice, Hospital, Insurance, or Pharmacy / Address / Telephone # / Fax # (optional)
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
( ) / ( )
CERTIFICATION
By signing this application, I/we certify the accuracy of the following information: the information submitted is true and correct and I/we authorize management to verify any references I/we have listed. I/we authorize management to access any records pertaining to me/us which may be on file with law enforcement and credit bureau authorities. I/we authorize my/our present and prior landlords to release information regarding my/our tenancy. I/we understand that it is a crime to knowingly provide false information for the purpose of obtaining or maintaining occupancy in: and/or, for the purpose of securing a lower rent in a subsidized housing development. I/we understand that the penalty for knowingly providing false information is up to five years in prison and/or $10,000 fine upon conviction.
I/we hereby do swear and attest that all of the information above about me is true and correct. I/we also understand that all changes in the income of any member of the household as well as any changes in the household members must be reported to the landlord in writing immediately.
Head of Household: / Date Signed
Spouse or Co-Head / Date Signed

APPLICANT CONSENT FOR INFORMATION SHARING BETWEEN CASE WORKER

AND MANAGEMENT

The applicant, ______, is currently using the services of ______, a case worker, at the______MentalHealthCenter.

I understand that there is a working relationship between ______Mental Health Center and NHE, the management agent for my apartment complex. I further understand that it is beneficial for me for these entities to share information concerning my residency. I hereby provided my consent for employees of NHE to share information with the caseworker listed above, or any subsequent or supervisory caseworkers assigned to me by ______Mental Health Center. Likewise, I provide my consent for the caseworker, or any subsequent or supervisory caseworker to share with NHE, through its appropriate employee(s) information concerning me now or in the future that relates to

1)my payment of rent and other charges;

2)the cleanliness of my apartment; and

3)my disturbance of the other residents or staff persons

4)my credit and criminal reports obtained by NHE, Inc.

______

Signature of ApplicantDate

OMB Control #2502-0581

Exp.(02/28/2019)

SupplementalandOptionalContactInformationforHUD-AssistedHousingApplicants

SUPPLEMENTTOAPPLICATIONFORFEDERALLYASSISTEDHOUSING

Thisformistobeprovidedtoeachapplicantforfederallyassistedhousing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application forhousing,thename,address,telephonenumber,andotherrelevantinformationofafamilymember,friend,orsocial,health,advocacy,orotherorganization.Thiscontactinformationisforthepurposeofidentifyingapersonororganizationthatmaybeabletohelpinresolvinganyissues that may arise during your tenancy or to assist in providing any special care or services you may require. You mayupdate,remove, or change the information you provide on this form at any time. You are not required to provide this contactinformation,butifyouchoosetodoso,pleaseincludetherelevantinformationonthisform.

ApplicantName:
MailingAddress:
TelephoneNo: / Cell PhoneNo:
Name of Additional Contact Person orOrganization:
Address:
TelephoneNo: / Cell PhoneNo:
E-Mail Address (ifapplicable):
Relationship toApplicant:
Reason for Contact: (Check all thatapply)
Emergency / Assist with RecertificationProcess
Unable to contactyou / Change in leaseterms
Termination of rentalassistance / Change in houserules
Eviction fromunit / Other:
Late payment ofrent
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. Ifissues ariseduringyourtenancyorifyourequireanyservicesorspecialcare,wemaycontactthepersonororganizationyoulistedtoassistinresolvingthe issues or in providing any services or special care toyou.
ConfidentialityStatement:Theinformationprovidedonthisformisconfidentialandwillnotbedisclosedtoanyoneexceptaspermittedbytheapplicant or applicablelaw.
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 personororganization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equalopportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assistedhousing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibitiononage discrimination under the Age Discrimination Act of1975.

Checkthisboxifyouchoosenottoprovidethecontactinformation.

Signature ofApplicant / Date

TheinformationcollectionrequirementscontainedinthisformweresubmittedtotheOfficeofManagementandBudget(OMB)underthePaperworkReductionActof1995(44U.S.C.3501-3520).Thepublicreportingburdenisestimatedat15minutesperresponse,includingthetimeforreviewinginstructions,searchingexistingdatasources,gatheringandmaintainingthedataneeded,andcompletingandreviewingthecollectionofinformation. Section644oftheHousingand CommunityDevelopmentActof1992(42U.S.C.13604)imposedonHUDtheobligationtorequirehousingproviders participatinginHUD’sassistedhousingprogramstoprovideanyindividualorfamilyapplyingforoccupancyinHUD-assistedhousingwiththeoptiontoincludeintheapplicationforoccupancythename,address,telephonenumber,andotherrelevantinformationofa familymember,friend,orpersonassociatedwithasocial,health,advocacy,orsimilarorganization.Theobjectiveofprovidingsuchinformationistofacilitatecontactbythehousingproviderwiththepersonororganizationidentifiedbythetenanttoassistinprovidinganydeliveryofservicesorspecialcaretothetenantandassistwithresolvinganytenancyissuesarisingduringthetenancyofsuchtenant.Thissupplementalapplicationinformationistobemaintainedbythehousingproviderandmaintainedasconfidentialinformation.

ProvidingtheinformationisbasictotheoperationsoftheHUDAssisted-HousingProgramandisvoluntary.Itsupportsstatutoryrequirementsandprogramandmanagementcontrolsthatpreventfraud,wasteand mismanagement.InaccordancewiththePaperworkReductionAct,anagencymaynotconductorsponsor,andapersonisnotrequiredtorespondto,acollectionofinformation,unlessthecollectiondisplaysacurrentlyvalidOMBcontrolnumber.

PrivacyStatement:PublicLaw102-550,authorizestheDepartmentofHousingandUrbanDevelopment(HUD)tocollectalltheinformation(excepttheSocialSecurityNumber(SSN))whichwillbeusedbyHUDtoprotectdisbursementdatafromfraudulentactions.

Form HUD- 92006(05/09)

FAMILY SUMMARY SHEET

Applicant: Please complete all information for each individual who will be residing in your household.

Member No. / Last Name of
Family Member / First Name / Relationship
to Head of Household / Date of
Birth
Head / Head of Household
2
3
4
5
6
7
8

OWNER’S SUMMARY OF FAMILY

Apt: # ______

To be completed by Owner/Management Agent.

Member No. /

Last Name of Family Member

/

First Name

/ Relationship to Head of Household / DateofBirth /

Declaration

/ DateVerified
Head / Head of Household
2
3
4
5
6
7
8

Declaration Legend: 1-Citizen/National

2-Non-citizen tenant 62 or older

3-All other non-citizens

4-Not contending eligibility

C-2 PRAC Rental Application 1 of 9 June 2017 Rev