HOUSING AUTHORITY OF THE CITY OF NEW HAVEN (HANH)LOW INCOME PUBLIC HOUSINGMTW RE-EXAMINATION FORM

1. Name of head of household:

2. Name of adult co-head of household:.

3. Address, Street, Apt. # and Zip

4. Contact Numbers: Home:

Work:

Cell:

Other:

5. Drivers License or State ID # of head of household:

Automobile: Year: Make: Model: License:

6. Drivers License or State ID # of co- head of household:.Automobile: Year: Make: Model: License:

For Statistical Purposes Only

Race of Head: C3 Caucasian/White G African American/Black O Asian or Pacific Islandern Native American/ Alaskan Native n Other: _____

Ethnicity of Head: G Hispanic/Latino d Non-Hispanic/Non-Latino

FAMILY INFORMATION

7. List all persons who will live in the unit, including foster children, & live-in aides (for the care of a familymember). Each box must be completed for each member. No one except those listed on this form may live inthe unit.

H

2

3

4

5

6

7

First Name & LastName if different fromHead's

Date ofBirth

Sex SocialSecurityNumber

Relationto

Head

Head

DisabledPerson?

Birthplace:Country

Full-timeStudent?

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN (HANH)LOW INCOME PUBLIC HOUSINGMTW RE-EXAMINATION FORM

1. Nombre del jefe de hogar:.

2. Nombre del co-jefe de hogar.

3. Direccion ciudad, estado y codigo postal,

4. Numeros de telefonos: Hogar:

Trabajo:.

Celular.

Otro:

5, Numero de licencia de conducir del jefe de hogar:

Automovil: Ano: Marca: ______ Modelo: Placas:

6. Numero de licencia de conducir del co-jefe de hogar:Automovil: Ano: Marca: Modelo: Placas:

Raza del:AsiaticoJefe de Hogar

Solamente Para Propositos EstadisticosD Blanco/Caucasico O Americano Africano/Negro O

C3 Americano Native / Natural de Alaska DOtro:

Islefio Pacifico o

£tnica del jefe de Hogar: O Hispano/Latino CJ No-Hispano/No-Latino

INFORMACION FAMILIAR

7, Enumere a todas las personas que vivan en la unidad, incluyendo ninos foster, Ayudantes (para el cuidadode un miembro de la familia). Cada espacio debe ser contestado para cada miembro de la familia. Nadiemas excepto los enumerados en esta forma pueden vivir en la unidad.

H

2

3

4

5

6

Primer Y ultimo Nombre,(De Ser Diferente Del Jefe DeHogar)

Fecha deNacimiento

Sexo Numero deSeguro Social

Relacional jefe de

hogar

Jefe

PersonaIncapacitada?

Lugar denacimiento:(Pafs,Estado)

iEstudiantede tiempocomplete?

FAMILY INCOME INFORMATION8. List the source and amount of all income expected for the coming 12 months for all family

members age 18 years of age or older, including yourself.

See income source examples below:Wages from employment - Self-Employment Income - Social Security/Supplemental SecurityIncome/Social Security Disability Income- Welfare - Temporary Assistance to AidFamilies (TANF) or General Assistance (SAGA)

Unemployment - Pension - Child Support - Other Non-Wage Source

Family Member Name

Head Of Household

IncomeSource

Amount $ Frequency -Per1

d Hourly d Weekly d bi-weekly dSemi-monthly dMonthly

d Hourly d Weekly d bi-weekly dSemi-monthly dMonthly

d Hourly d Weekly d -H-weekly dSetni-monthly dMonthly

d Hourly d Weekly d -H-weekly dSemi-monthly dMonthly

d Hourly d Weekly d bi-weekly dSemi-monthly dMonthly

9. Do you have a checking or savings account or own any Certificates of Deposit, stocks, bonds,etc? n Yes d No If yes, describe the type of asset(s) please: _

What is the market value of all assets?10. Do you own any real estate? O Yes No If yes, what is the address?

11. Have you sold any real estate in the past two years?address? _

Yes d No If yes, what was the

1 Once all income are known and verified, convert income to an annual figure by multiplying:Hourly wages by the number of hours worked per year ( 2,080 for fulltime employment with 40 hours a week and noovertime:Weekly wages by 52:Semi-monthly wages ( paid twice each month) by 24; andBi-weekly wages ( paid every other week by) by 26)

INFORMACION DE INGRESOS DE LA FAMILIA

8. Enumere la fuente de ingresos y la cantidad que espera recibir en los proximos 12meses de todos los miembros del hogar que vienen en la unidad y que seanmayores de 18 anos.

Vease los ejemplos abajo de fuentes diferentes de ingresos:Ingresos por empleo - Ingresos por empleo de negocio propio - Todo Tipo de Seguro Social -Ingresos por ayuda estatal - Ayuda Temporal Para Las Familias (TANF) - Asistencia General (SAGA)- Desempleo - Pension - Pension Alimenticia - Otras fuente del Ingreso

Nombre de losMiembros de Famiiia

Jete de Hogar

Fuente deIngresos

Cantidad $ Frecuencia -

1 " :Por hora i I I iSemanalMensual ~ Bi-Mensual

_ _. Por hora _ L _ Semanali " i Mensual , i Bi-Mensual

Por hora Semanal""Mensual .Bi-Mensual

i l l i P o r hora , , SemanalI 1 Mensual '._ Bi-Mensual

Por hora Semanal""Mensual ~ Bi-Mensual

Per*

! Bi-Semanal

, , Bi-Semanal

1 Bi-Semanal

i Bi-Semanal

Bi-Semanal

9. ^Tiene usted cuentas corrientes, o cuentas de ahorros o pose algun Certificado deDeposito, acciones, escrituras, etc.? Si ~De ser Si, describa el tipo de cuenta(s):^Cual es el valor total de las cuenta (s)?

Si No10. ^Posee Usted cualquier propiedad inmobiliaria (bienes raices)?De ser Si, favor de indicar la direccion?

11. ^Ha vendido usted o algun miembro de la familia bienes raices en losultimos dos ahos por menos del precio del mercado? I Si NoDe ser Si, favor de indicar la direccion:

2 Once all income are known and verified, convert income to an annual figure by multiplying:Hourly wages by the number of hours worked per year ( 2,080 for fuiltime employment with 40 hours a week and noovertime:Weekly wages by 52:Semi-monthly wages ( paid twice each month) by 24; andBi-weekly wages (paid every other week by} by 26)

FOR FAMILIES WITH EXCEPTIONAL EXPENSES OF $2,000 OR MORE ANNUALLY

(PLEASE PROVIDE RECEIPTS AT TIME OF INTERVIEW}

12. Is the head of household or spouse age 62 or older or a person with a disability? GYes GNoIf yes, please answer the following questions. If no, please skip down to question # 16.13. Does your household have any medical expenses (include insurance, Medicare deduction, doctor visits,

hospital, clinic costs, medicine, therapy, supplies, medical transportation, etc.)? G Yes G NoIf yes, please describe the type of expense (not your medical condition) and the non-reimbursedamount you spend per month on all medical expenses:

Type of expense:

Monthly medical expense:$Name, address & phone # of someone who can verify the expense:

14. Do you have any expenses on behalf of a household member with disabilities so an adult in the familycan work? G Yes G NoIf yes, describe the expense and monthly amount:Name, address & phone # of someone who can verify the expense:

15. Do you have childcare expenses for children under age 13 so an adult in the family can work, go toschool or attend job training? G Yes G NoIf yes, name, address and phone # of childcare provider:

Monthly unreimbursed child care cost: $16. Is any member of the household 18 or older other than head and spouse a full time student G Yes G No

If yes, name of the family member and the name, address and telephone number of someone who canverify this information:

17. Is the head of household or spouse a person with a disability? GYes GNoIf yes, name of the family member and the name, address and telephone number of someone who can

verify this information: _____^ _____^

I/We certify that the statements on this application are true to the best of my/our knowledge and belief and understand that theywill be verified. I/We authorize the release of information to the HANH by my/our employer(s), the Department of Publicassistance, the Social Security Administration, and/or other business or government agencies. I/We understand that any falsestatement made on this application will cause me/us to be disqualified for admission.

Head Signature Date

Co-applicant Signature Date

Sect, 1001 of Tide 18 of the United States Code mates it a crimlnat offense to knowingly-matea false statements or misrepresent to any Department or Agency ofthe United States to any matte* within its jurisdtcttort antfhas established penalty of fines up to $100,000 and/or imprisonment not to exceed 5 years.

PARA FAMILIAS QUE TENGAN CASTOS EXCEPCIONALES DE $2,000 0 MAS ANUALMENTE

(Favor De Proveer Recibos Al Tiempo De Entrevista}

12. ^Eseljefedel hogaroelesposo(a)deedadde62ahoso habra algun familiar incapacitado? GSi GNo

De ser Si, favor de contestar las siguientes preguntas. De ser No, favor de contestar las preguntas

deeds el #16.13. ^Tiene la familia algunos gastos medicos (que incluyen, seguros medicos, deducciones del programa

de Medicare, visitas a doctores, hospitales, clinicas, medicinas, terapias, articulos, transportationmedica? G Si G No

De Ser Si, favor de describirnos el tipo de gasto (no su condition medica) y la cantidad que queda sinser reemboisado que usted gasta mensualmente en todos sus gastos medicos:

Tipo de Gasto:

Gastos Medicos mensuales:$

Nombre, direction, y numero telefonico de alguna persona que pueda verificar estos gastos:

14. ^Tiene algun gasto para cuidado de algun miembro incapacitado de la familia para que un adultopueda trabajar? G Si G No

De ser Si, favor de describir el gasto mensual y la cantidad:Nombre, direction, y numero telefonico de alguna persona que pueda verificar estos gastos:

15. ^Tiene la familia gastos para el cuidado de ninos menores de 13 anos para que un adulto de la familiapueda trabajar, ir a la escuela o atender a algun entrenamiento? G Si G No

De ser Si, Nombre, direction, y numero telefonico del proveedor del cuidado del nino:

Cantidad de gasto mensual que no es reemboisado: $

16. i,Hay algun miembro de la familia mayor de 18 anos; aparte del jefe de hogar o esposo que es un estudiantede tiempo completo?G Si G No

De ser Si, favor de proveernos el Nombre, direction, y numero telefonico de alguna persona quepueda verificar esta information:

17. ^Tiene el jefe de hogar o esposo(a) una condition de incapacidad? GSi GNo

De ser Si, favor de proveernos el Nombre, direction, y numero telefonico de alguna persona quepueda verificar esta information:

Yo/nosotros certificamos que las declaraciones hechas en esta solicitud son veridicas, al mejor demi/nuestro conocimiento y de mis/nuestras creencias y se entiende que seran comprobados.Yo/nosotros autorizamos el lanzamiento de la informacion a HANH a traves de mi/nuestro patrono(s), elDepartamento de Asistencia Publica, la administracion de Seguro Social, y/o otras agendas de negocioso agenda gubernamentales. Yo/nosotros entendemos que cualquier declaracion falsa hecha en estasoJicitud me/nos descalificara para la admision.

Jefe De Hogar Fecha

Co- Jefe De Hogar Fecha

Sect. 1001 of Title 18 of the United States Code makes it a criminal offense to knowingly make false statements or misrepresent to any Department or Agency ofthe United States to any matter within its jurisdiction and has established penalty of fines up tq $100,000 and/or imprisonment not to exceed 5 years.

TW Bl ANNUAL OR TRI INCOME CHECKLIS

NSTRUCT10NS: At the initial certification and recertification interviews, head of household shouldinswer the questions below about Annual Income and sign the certification statement

Wilt any household members be receiving any type of income from employment? Q Yes O Noif yes, list names of such family members, who will receive employment incomend the amount expected to be received.

Amount

5

Frequency

3)

Will any household members be receiving income from a family-operated business orbe otherwise self-employed? Q Yes Q Noif yes, list names of such family members who will receive income from self employmentand the amount expected to be received.

Amount Frequency

5SS

i/HI anyone in the household receive Social Security or SSI Benefits? Q Yes Q Noyes, list first names of such recipients and the amount expected to be received.

Amount

-5'5

Frequency

4} Will anyone in the household receive periodic payments from Annuities, Insurance policies,retirement funds, pensions, disability or death benefits, or other similar amounts? Q Yes Q NoIf yes, list first names of recipients and the amount expected to be received.

Amount

35"i

•requency

anyone in the household receive unemployment compensation, disability?

Compensation, workers' compensation or severance pay?U Yes G NoIf yes, list family members who are recipients and the amount expected to be received.

Amount Frequency

Will anyone in the household be receiving public assistance benefits? Q Yes Q No;f yes, list recipients and the amount expected to be received

Amount Frequency

H Will anyone in the household be receiving alimony or child support payments? G Yes G Noif yes, list first names of such family members who are recipients and the amount expectedto be received.

Amount Frequency

S35

3) Will anyone in the household be receiving income from assets? G Yes G NoHas anyone in the household disposed of assets for less than market value in thepast two years? G Yes Q Noif yes, list first names of such family members who own assets and the amount expected tohe received.

Amount Frequency

3.5S

-}) Is any household member, 18 or older, receiving pay as a member of the Armed Services?"3 Yes d NoIf yes, list family members who are recipients and the amount expected to be received.

Amount Frequency

']) !s any household member receiving lottery winnings, paid periodically? U Yes G No

yes, iist family members who are recipients and the amount expected to be received.Amount Frequency

Is any nousehold member receiving recurring monetary contributions or other gifts or:ayments from a non-household member? Q Yes G Noif yes, list family members who are recipients and the amount expected to be received.

Amount Frequency

Resident's Certification

hereby certify that I have answered the questions on this checklist truthfully and that the incomeisted on this form represents all the income available to my household.

Head of Household's name

Head of Household's signature

HANH Staff Member

•:Ct. 1C01 of Pie 1 % of :he Un.ted States Code makes it a criminal offense 'o knowingly make raise statements or misrepresent-; -tfiv Ceoarrrpnt cr ^cency of >he L'n^ed 3'ates to 3ny Bitter wuhin its lunsdiction and nas established cenalry of ^nes MD to

;ICO. 000 and/or imprisonment not to sxceea 5 years.

T\ INCOME CHECKLIST (Part I)OR IIAINU USE ONLY

Use this form in connection with the information provided by family on the Annual income Checklist. In•he left-hand column list the family member who receives income and in the columns to the right enter;he amount of income anticipated for the next 12 months, by category.

SourcesMember Name i Annual of

1 Income Income3

i ContactEmployeror Other

! Amount Entity: ! Providing1 Income

Address ofEntity Providing

NumberInformation

xample; Jane Doe S10,500 ! Wages Walmart 55MLKB!vd, : .203.123.4567New Haven !

06511 Ineau ui nuuactuu

2.

3.

4.

TOTAL INCOME S

^From Asset Income Worksheet (Enter the higher of Actual Asset Income or Imputed Asset Income)

3UM OF INCOME: $

ASSET INCOME: *$

ANNUAL INCOME: =

Enter Figure On income Tiered Worksheet Line 1(8}

Wages from emoloyment: Self-Employment Income; Social 3 ecu city/ Supplementalincome/Social Security Disability Income; .Velfare- Temporary Assistance !o Aid Families (TANF) ?t General

-Distance (SAGA); Unemployment; Pension:

-Nd Suoport; Other Non-Wjqe Source

BASSET INCOME CHECKLISTNLY FOR FAMILIES WITH TOTAL ASSETS VALUED AT MORE THAN $50,000)

.NSTRUCTIONS: At the certification and recemfication interviews, the head of household should answer•"9 questions below about Assets and sign the certification statement.

r amily Member Nama!) Doyouhavecasn

• 'n a savings account? QYes QNo• °n a cnecking account? QYes QNo• '(i a safety deposit box? QYes QNo• 3thome? QYes QNo• Anywhere else? QYes QNo

2) Do you have trust funds available to yourhcusehold? QYes QNo

3) Co you have any equity in rental property orcapital investments? QYes QNo

4) Do you have any stocks, bonds, treasury bills,certificates of deposit or money market funds?

QYes QNo

5) Do you have any retirement or pension funds?QYes QNo

:) Will you receive any lump sum receipts?QYes QNo

H Are you holding any personal items as:nvestments (antique cars, coin or stampcollections, etc.)? QYes QNo

3) Do you have a "Whole Life" Life InsurancePolicy? QYes QNo

3) Have you disposed of any assets for less than.narKet value in the last 2 years? QYes QNo

Value ofAsset

TENANT'S CERTIFICATIONS1 hereby certify that! have answered the questions on this checklist truthfully and have no assets other than"hose claimed on (his form.

Head of Household's name

Head of Household's signature

HANH Staff Member

":01 Gt r.'Je 13 ol :ha United elates Ccaa manea it a criminal ctferseio krcwirqiy r">3ne'aise statements or misrepresent to-iny Ufjgartment ar >*'jency of

.-.a un'ted S'ates to any matter witnm its iursdici:on :md hag esaoiiahed cenaity or lines up to 5100. 000 and/or imprisonment not to exceed 5 yeans.

SSET DIVESTITURE DATA-GATHERING SHEETORHANHUSEONLY

PARTI. UNOi| Oate divested _

v:) Amount received >_•:} Location of landd) Size of parcele) Purchaser/recipient _0 3est source of Market Value _j) iReasonable costs absorbed during divestiture S_PART !!. HOUSES OR OTHER REAL ESTATEj) Date divestedb) Amount received ..:] Address of divested property _d) Purchaser/recipient __e} Best source of Market Value _0 Reasonable S absorbed by tenant during divestiture _PART 111. STOCKS OR BONDS:a) Oate divested _b) Amount received 5_c) issuer of StockyBond _a) Purchaser/recipient _ej 3est source of Market Value _f) Reasonable costs absorbed by tenant during divestiture 5PART IV, CASH, CERTIFICATES OF DEPOSIT3) Date divested _0} Recipient __.<•;) Amount of Cash, CD S.•1} Reasonable costs of divestiture (penalty) 5,PART V. PERSONAL PROPERTY HELD AS AN INVESTMENTj) Date divested _b) Amount received 3.c) Issuer of StockyBond __j) Purchaser/recipient _3) 5est source of Market Value _f) Reasonable costs absorbed by tenant during divestiture 3.PART VI. BUSINESS EQUIPMENT.-3) Oate divested _':) Amount received 5:; f<:suerof Stock/Bond:] Purchaser/recipient _e ) jest source or Market Vslue

r) Reasonable costs absorbed by tenant during divestiture S

FOR HANH USE ONLY

MTW ASSET INCOME WORKSHEET

'Jse [his form in connection with the verified information collected from the Asset Checklist,in the column 1 list the type of asset (e.g. bank account, CD, real estate). Check column 2or 3 depending on whether the asset is current or has been divested. In column 4 indicate:he date any divested assets were sold or given away. In column 5 list the actual cashvalue of each asset and in column 6 indicate the actual income (if any) from the assetslisted.

1 . Type of Asset

a)

b)

c)

d)

ie)

2.Current

5

5

S

S

$

3.Divested

^

3•**

3

S

S

4. DateDivested

5. Market Valueof Asset

$$3

$

$

.

6. Cashincome

from assets

S,.

S

S

S

$

7. DateVerified

When two years have elapsed since any assets were divested, you need not enter them on this form,since they are no longer used to compute income from assets.

Enter the amount in 6f to the Annual Income Worksheet

' EXCEPTIONAL EXPENSES CHECKLISTFAMILIES WHOSE TOTAL EXCEPTIONAL EXPENSES EQUALOR EXCEED S2.QOO ANNUALLY

IR HANH USEONLY PLEASE OBTAIN RECEIPT

INSTRUCTIONS: At the certification and recertification interviews, the head of householdjnculd answer the queslions below about Allowances and sign the certification statement.

1 . Dependent Deduction (for families with more than two dependents)

3. Do you have more than two (2) household members, other thanhead, spouse, foster children, and live-in attendantswho are under age 18? U Yes G No

if you answer no to Question 1(a) skip the rest of Question 1

10 to Question 2.

b. 18 or older and either a full-time student or disabled? Q Yes Q No

c. if ta.or 1b. Is yes, a list name of such family members:

1 Provide contact information of Education or Training verification source:

Childcare Allowance

: Is the family paying for care of children underage 13 so:an adult can work? Q Yes CJ No

a family member can go to school? G Yes Q No

b List the names of children for whom care is provided. Amount

:. Name, address & telephone number of childcare verification source:

j. Usability bxpense Aiiowance

3 Is the family paying for care or apparatus for a disabled family member so that anjdult family member can work? Q Yes Q No

if yes, list family member for whom care/apparatus is being provided.

b. Describe apparatus purchased:

c. Verification source for need & cost of apparatus

d. Describe care provided:

e.Verification source for need and cost of care:

Medical Expenses Allowance

a. Is the head, spouse or sole member of the household at least 62 or disabled? YesQ Nod

b. Does the family expect unreimbursed medical expenses for any 12 months to becovered by this reexamination? G Yes Q Noif Yes, list family member(s) with unreimbursed medical expenses:

Dees qualifying family expect any of the following types of unreimbursed expenses? Amount

Hospital costs?Doctor visits?Dentist visits?Dentures, bridgework, crowns?Eye doctor visits?Eye glasses or contact tenses?Clinic visits?Therapy of any type (include physical, emotional and psychiatric)?Laboratory fees, X-rays, Diagnostic tests?3!cod or oxygen?Prescription or non-prescription medicines?Hearing aid, batteries?In-home health care?Medical transportation?Medical apparatus (rented or purchased)?Medical costs of permanently institutionalized family member4

Hospice care of a family member?Assistive animal expenses?

d. Verification sources for medical expenses:

Q Yes Q Noa Yes a Noa Yes a NoGYesG Noa Yes a NoGYesd Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a Noa Yes a No

333333333353333333

TENANTS CERTIFICATIONS

I hereby certify that I have answered the questions on this checklist truthfully and have noassets other than those claimed on this form.

Head of Household's name

Head of Household's signature

__ _____ HANH Staff Member

: ;ct 1001 of Tills 18 of tne United Spates Cede makes it a cnmmal offensa to knowingly ^ate false statements ormisrepresent to any Cepartment or Agency ot

-»i Jnitfld States to inv matter within its itinsdiction and has established ceralty ol fires UD to ilCO. GOO anxWor ;monsonrnent no! to exceed 5 yeara.

NANT CERTIFICATION

OR HANH USE ONLY

Giving True and Complete Information

[/We certify that all the information provided to the Housing Authority of the City of New Haven onhousehold composition, income, net family assets and items for allowance and deduction is accurateand complete to the best of my/our knowledge and belief.

Income/Family Composition Information

I/We understand that 1 am to notify my caseworker at the Housing Authority within 14 day of the change in\vnting, if the current status of my household income changes by two hundred dollars ($200) or more per monthand/or if there has been any changes in my family composition household size when a person moves in or out ofthe unit.

Decertification/Inspection Notice

I/We understand that I will be terminated from the Housing Choice Voucher Program, if I fail to attend two (2)recertification appointments or one (2) inspection appointment.

No Duplicate Residence or Assistance

I/We certify that the house or apartment will be my principal residence and that I will not obtain duplicate FederalHousing Assistance while I am in this program. I will not sublease my assisted residence. I understand that Imust provide proper notification to the Housing Authority of the City of New Haven of my intent to vacate mysubsidized.

Cooperation

i/We know I am required to cooperate in supplying all information needed to determine my eligibility, level ofbenefits or verify my true circumstances. Cooperation includes attending pre-scheduled meetings/inspections andcompleting and signing needed forms. I understand failure to do so may result in delays, termination of tenancyand termination of assistance.

Criminal and Administrative Actions for False Information

[/We understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federaland/or State law. I also understand that knowingly supplying false, incomplete or inaccurate information isgrounds for termination of housing assistance or termination of tenancy.

'/We understand that failure to comply with all of the above mentioned on this application will cause me/us to beterminated from the Housing Choice Voucher Program.

Head of Household Printed Name Signature Date

-iANH Start Printed Name Signature Gate

EWJOB

LEARN ABOUT THE EARNED INCOME DISREGARD

federal public housing tenants and only disabled Section 8 participants who have their income increase becauseof a new job or better wages may qualify for an Earned Income Disregard. This means that, in calculating monthly rent;he Housing Authority would not count increased family income due to wages. Residents/Participants qualify for theEarned Income Disregard if, when they got the new job or their wages went up, they had been:

• Unemployed for a year or more, or earned less than $3,200 in the past year; or» in job training or some other economic self - sufficiency program; or• Getting TANF welfare benefits within the past six months.

;f you qualify for the Earned Income Disregard, the Housing Authority will not raise your rent because of increased familyincome due to wages. Non - wage income, such as child support or public benefits, is not eligible for the disregard.

The Earned Income Disregard is good for 24 months, ft goes in steps:

1. For the first 12 months, all increased income due to wages will be disregarded(not counted toward your rent).

2. For the next 12 months, the Housing Authority will disregard 50% of the increased income due to wages, if you stopworking, you can stop the clock on the 24 - month period and restart it when you go back to work. However, you haveonly 4 years from the time you first qualify for an Earned Income Disregard to use up your 24 months of benefits.

Child Care Costs May Also Lower Your Rent. The money you pay for childcare may be deducted from your incomewhen HANH calculates your rent. You do not have to be eligible for the Earned Income Disregard to get a child carededuction. This deduction is available to all working families and those enrolled in education and training programs.

How Do I Get The Earned Income Disregard Or Child Care Deduction?

The Housing Authority should determine your eligibility for an Earned Income Disregard and the amount of any childcarededuction whenever you report income from employment. You should bring in proof of your employment and wages ana'for the child care deduction) proof of your child care costs. If you still disagree, ask for a grievance heanng (in writing).

have received and read the flier titled "NEW JOB" regarding Earned Income Disregard and

I do not feel that I am entitled to the Earned Income Disregard

feel that I am entitled to the Earned Income Disregard

Resident/Participant Signature Tenant Social Security # Date

set. 1001 of Titta 18 ot the United States Code mfcea it a criminal offense to (ricwinqly make false statements or msreprssent to any Department or Agency of

a ijp«ed Stares to rjny matter *itt*n :ts lunsaierion and nas established penalty at fines up to J100. 000 and/or imDnsonment not !o exceed 5 yean.

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD)and the Housing Agency/Authority (HA)

U.S. Department of Housingjnd Urban DevelopmentOffice of Public and Indian Housing

'HA r^quesunq release of .nformaiiarr. (Cross out space if non«)rnil dddress. name of contact person,

:.HA <equesting release oi informanan: iCrost out spac* if none)..rull address, name of contact person, ana cate)

Author i t y : Section l)04 at" the Stewart B. McKinney HomelessAss i s tanceAmendmentsActof 19 38. as amended by Section 903of the Housing and Community Development Act of 1992 andSection 3003 ot" the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

This lavv requires that you sign a consent form authorizing: (UHUD and the Housing Agency/Authority I.HA) to request verifi-cation of salary and wages from current or previous employers; 1 2)HUD and the HA to request wa^e and unemployment compensa-tion claim information from me state agency responsible torkeeping that informat ion; (J) HUD to request certain tax returnin formation from the U.S. Social Security Administration and theU.S. Internal Revenue Service, The law also requires independentverif ication uf income information. Therefore. HUD or the HA

request information from financial institutions to ver i fy yourand level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verity your household's income, in order to ensure that you areeligible tor assisted ho using benefits and that these benefits are set.it the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verity your

and level of benefits,

t'ses ol'lnformation to be Obtained: HUD is required to protectthe income information tt obtains in accordance with the PrivacyAct of 1974. 5 U.S.C. 552a. HUD may disclose informationi other than tax return in format ion) for certain routine uses, such as• o oiher government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordance•.vith any applicable State privacy law. HUD and HA employeesmay be sub|ect to penalties for unauthorized disclosures or im-proper uses oi the income information that is obtained based on theconsent form. Private owners may noC request or receivein fo rma t ion authorized by this form.

Who Must Si^n the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentro r rn . volitional signatures must be ootamed from new adult. i i c i n o e r s l u i m n w ; ir-.e household or 'vhenever member1; of '.he' \ o u s c h o l d become i i yours of age.

Persons who apply for or receive assistance under the fol lowingprograms are required to sign this consent form:

PHA-owned rental public housing

Turnkey 111 Homeownership Opportunities

Mutual Help Homeownership Opportunity

Section 23 and l l)(c) teased housing

Section 23 Housing Assistance PaymentsHA-owned rental Indian housing

Section 3 Rental CertificateSection 8 Rental Voucher

Section 3 Moderate Rehabilitation

Failure to Si^n Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA's grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies, l This consent islimited to wages and unemployment compensation 1 have re-ceived during period(s) within trie last 5 years when 1 havereceived assisted housing benefits.)

U.S. Social Security Administration ( H U D only HThis consent isl i m i t e d to the wage and self employment information and pay-ments of retirement income as referenced at Section 61031 U(7)( A)of the Internal Revenue Code.t

U.S. Internal Revenue Service ( H U D only) (This consent isl imi ted to unearned income [i.e., interest and dividends).)

Informat ion may also be obtained directly from: ( a ) current andformer employers concerning salary and wages and Ib ) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verity information thai 1 provide inietermining eligibility for assisted housing programs and the level

of benefits. Therefore, this consent form only authorizes releaseilirectly from employers and financial institutions of informationregarding any periodls) within the last 5 years when 1 havereceived assisted hous ing benefits.

by :he i "questing jrqanization. if. Handbooks M<.0.7, 7420.3, 3, 74R5.1 •irm HUO-9888

Consent- I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forihepurposeofver i fv in? my eiigibmtv jnd l*v«J ufbe..«m-. under HLD's assisted housing pro-ams, i umlerstanu tnat HAs thaireceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Iniddiiion, f must be ^iven nn opportunity to contest those determinations.

i'his consent torm expires 15 months after signed.

.--ad of housenclfl

SecuriiyNumcaf nf Jny) of Mead erf Housencld : [for Family UemCaf ovar ag« 13

Family Member over ago ia

;th*r Family Member over ags I a -^19 ,iher Family Member over aga 18

,;her Family Membw over aqs '3 Cd» Cider Family Member over aq« 18

I'rivacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937(42 U.S.C, 1437 et. seq.), Title VI of the Civil Rights Act ot" I 964 (42 U.S.C. :000d), and by the FairMousing Act(42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and• finer information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHU D-assisted housing programs, to protect the Government's financial interest, and to veri ly (he accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD. except as permitted,ir required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,,ind all other household members age six years and older, have and use. Giving the Social Security Numbers of all household membersiix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide.my of the requested information may result in a delay or rejection of your eligibility approval.

?»naltlet for Misusing this Consent:

MUD. Iha HA *n<J any owner lor any employee of HUD, the HA or the owner) may be subject to penalties lor unauthorized disclosures or irnnrrjper uses of.n format ran ccllected based on 'n« consent form.

Lha of 'he information collected Cased en the 'orm HUD 9S86 is restricted to (he ourposes cited on the form HUD 9336. Any person who knowingly or wilfully-^quests, i; b tains or Discloses any information under false pretenses concerning an applicant or oarticipant may be suoieci to a misdemeanor and fined not mor•h.in 55.000.

iny jDplicant or oarticicant arfected by negligent disclosure of information mgy nrmq civil action for damages, and seek nther relief, ^s may be aporoprtate. Jijare officer or dmployee of HUD. :ha HA or Fhe owner r^soonsidle for tne 'jnaumonzed disclosure or improper use.

;.:qmal is re'ained Dy the r°questing nrqani^aiion. :f. HjnUtiooKS f-420.7, 7J20.3, 1 7-165.1 ;;m HUD-9886 I ?/'M)

Autorizacidn para divulqar informacion/Aviso sobra la Ley de Confidenciaiidadsnviado al Departamento d9 Vivienda y Qesarroiio Urbano (HUD) da tos EE.UU.y a la Gfiana/Autondad de Vivtenda (HA)

Oepartamento da ViviendaV Oesarrollo Urbano da las EE.UU.^ficina ca Vivienda Pu&lica y paraCamumcjades Jnaigenas

13*icina da Vivienda Publica iPHA) que solicita la divuiqacion da informacion.l T jcho la casilla si no correspond*.), Escnoa ia Jireccion comoleta. el nomore del represemanta y la fecHa.)

da Vivienda para Comumdades Indigenas (IHA) quaiQUCita la divuiqacion da informacion. it!ch« la casilla si nocorrespond*.) (Escriba la direccion compieta. di nombra:el reprsaentanta y la fecna.)

\n i-Li.i Li Siccson ^04 de la Lay Stewart B. McKinnev Jc Enmiendas a la

\Miidnoa para las Pursonas sin Hogar de 1488. en su ibrma enmendada por la

•^ccion "'*3 de la Lev de Vivienda y Desarrollo L'omunuario de 1^2 v la

-'occion 3003 Je la Lov General Je Conciliation del Presupuesto de W3. Esta

'ry i« encuentra tfti la Section j;44 del Fitulo 42 del Codigo de los EE.UU

Dicha lev itige que unted r'irme un rbrmulano de consennmiemo en vimid del

:ual auiortza 1 1 1 jl Dooartamento de Vivienda y Desarrollo Uibano (Department

^t' Housing jnu Urban Development, en adelante HUD) y a ijGficina/Autondad

,:e Vivienda (Housing Agency* A uihoriW. on adelantc HA) para solicitar

•- cnticaciones de Un sueldoa v ijlarios devengados de emplcadorcs females o

.-nieriores; I -) al HUD v a la HA para soliciiar mlbrmacion sobre rcclamaciones

de salaries o indvmniZKion por desempleo a la fntidad esuial

de manicncr dicha iniormacion: y |J) al HUD para soltcitar ciena

niorrnacion sobre la jeciaracion de renta a la Aiimmistracion de Se^uiidad

SiKiat I Social Sicunwly al Servitio de Kentas intemaa de lo» EE.UU I IRS). La

i'jv fxiije -idema* una verification mdependiente de la intbrmacton sobre

:ni;resos, Por lo tanto. tfl fHUD o la HA puede soliciiar intbrmacibn a

'nsiuuciones linancierai para venl'icar su itloneidad y ei monto Oe los benehCKis.

Ki mi lid ad: Al tirmar este formulano de tnnsentimiento, u^ted autonzaal HUD y

i la HA menuonada para solicitar iniormacion satire sm mgresos a las I writes

• - :J,is ::n cl lortnuiano. Ambos organismos necesitan fsa iniormacion para

•rn'iLMf iii in^reso lamiliar con el tin de cerciorarce de que usted teune las

ondiciones pma recibir beneilcios de asisiencia para conseguir vivienda y que

•us bcneliciQs 5C li|en en el monlo correcio. Tamo el HUD camo la HA pucden

,-irticipar en programas electronicos de i.-oncordancia gon estas r'uenies para

orit'icar su idoneidati v el monto de los beneticios.

i- iirintii Ue «mpl«o Ue l» informacidn ota(enid«: Se exige que el HUD proiqa

j .niormacion obtenida >sobre m^resoj. de i;oniormidad con la Ley de

C. in fidencial tilad de 1^74. Seccion 552a del Fitulo 5 del Ciidigo de los EE UU.

K! HUD puedc Jivul ai intbrmacion idistinta dc la L-oircspondieme a

ijtlnraciones de renial para tiertas Biases de uso ordmano. por eiemplo. a oiroi

• r^jnismos ^uDernamenialcs can lines Ue aplicacion de la lev. a oraamsmos del

;obierno federal cun fines de deierminacion de la idoneidad para el «mpleo. y a

!.is HA con el ob|«to de iJeterrmnar cl monto de la asistencia para conseguir

-wienda. r.imbien ie e\i?e que la HA proteja la iniormacion soore ;ngresos que

• ihien^a, de tonlormidod con cual uier lev esiatal de conndencialidad aplicable

•.I caso. Los empteados del HUD y de la HA pueden esur suieios a sanciones por

livuli acion no auionzada o oor uso impropio de la informacion sobre mgresos

con el lormulario de conseniimrcnio Los prop let ario-i pjrticularM no

ni rctiblr inrormaciAn ,IUKII i/ajn pur c^tc Turmuliirio.

'uii-rt debc firmar el romiulano dc conscntlmienlo: C.ida lamitiar residents

;i 'J ptopiuuad mavot de 1 8 .irtos debe lirmar jl formulano de consentimienio

is prsciso obiener la llrma de nuevos adulios que in^resen a la residencia o de

,'iieiirt cumplan 1 S .irtos.

^e -jxige que los solicitantes o receptores de .isistencia L-on arre lo a los

M JUicmes pro^ramas lUmcn estc tbrmulario de unseniimiento:

Vivienda publics dcalquilerdc propicUadde una 1*HA.

i.'pomjnidades de Lidquisicion de vivienda propia para entrc^a Have en

nano de upo III (alquiler con option de compra).

Oponunidad de acquisition dc vivienda propia ton un sistema de ayuda

nucua.

Vivienda alquilada segun lasdisposiciones de las Secciones 23 y I9(c).

P.i oj de .isistencia para vivienda se^un las disposiciones de la Seccibn

:3.Vivienda de propiedad de una HA para alquiier 3 comunidades indigenas.

ifentllcado de jlqmler segun las disposiciones de la Section i de la Ley

dc Vivienda de los EE.UU. de 1937.

Cupon de alqmler segun las dtspnsiciones de la Seccion 8.

Rehabihtacion moderada segun las disposiciones de la Seccion i.

Omition Je la rirmi il«l formulario de cansenlimicnio: Si usied no tirma el

iiirmuiano de conseniimiento se Ie puede rev near su idoneidad o se Ie puedcn

suspender los beneticios lie vivienda. o ambas cosas. La rcvocacion de ia idoneidad

o la suspension dc los bcneficios esta su|eta al procedimienio de prescniacion de

. ,'ji-us de la HA y de audiencia iniormai indicados en la Seccion 8

Tiienies dc acopio de mforiiai ion:

Tntidades esiaiales de acopio de mibrmacion sobre salaries. I Este

-.onsemtmienio se hmita a la indemnizaciOn por concepio de salano v desempleo

•4UC se me ha pagado periodicamente en los ultimos 5 arlos cuando he recibido

i-^neiicios de asistcncia para conseguir vivienda.) Adminisiracion de Seaundad

-ocial de los EE.UU (solameme el HUD). lEsieconsentimiento se limita a la

informacion soore salano v empleo mdependiente v soore el pago de mgreso de

nnilacion. citadosen la Seccion o!U3(l)(7i(A) del Codigodel Servicio de Kenias

Intemasde losbE.UU t^•^rvtciode Rentas Iniemas de los EE.UU (IRSI {solameme el HUD). I Ebte

onsentimiento se limita al ingreso no bboral |por ejemplo. mtereses y

Jiviclendos))

r.imbien se puede obiener mr'ormacion directamente de: la) los impieadores

iciualesy anienores, sobre sueldosy salaries y ib) las insmuciones tinancieras,

iibre mgresos no laborales I por eiemplo. interest j v dividendos). Tengo

;r(endido gue la informacion sobre mgresos obtenida de estas luenies se

.•mpleara para venficar la information proporcionada por mi. con el tin de

Jeterrnmar mi idoneidad para pamcipar en los prti^ramaa de asisiencia para

otiseguir vivienday el monlo de lus benetlcios l't>r lo lario. este (ormulano de

onsentimienio ^olamenie auionza la divul gacion de information directamente

Ji: los empleadores y las mstituciones imancieras por cuaiquier periodo de los

nltimos 3 ailos cuando he recibido benelicios de asisiencia para conseguir

.ivienda.

craanizacion sonatania quarda al original. 'jrmulano HUD-988«-Spanish (7/04)f. Manuales 7420.7. 7-120 3 y 7465.1

ronaeniimienio: Ooy mi co risen limien to para permitir que H HUD a lit HA siHicilen v iintengan informacibrj sobre mis ineresos Ue la* fuenres cicada* en «r

To mi ui;i ri<t con <?J llrt de venflcar rni idoneidad y el monio ile los buneilcios de CDnf'ormidad con los programiM tie :r*isrenci« para *i*i*ndi»del HI D. TVngo

,'nltfnijido 'Iue las H.-X ijue reciban information softre mis ingreso* por media del presente Ibrmulano de i-onwntimienro no pueden emplearla para denegar,

u IK-IT n Mi.tpender la imslenria sin efectuitr primero una veriflcjcidn indeptndiente del jnortlo forresportdienf*. si realmente tuve jcceid n lo* rondos v i-ua

.if rrt:ibien>n. iddmdn. •.e me debe dar la Dporlunitlad de refuiar fsas delerminuciones.

r.:i[tf rbrmulano Je comemtmienio se vence li .iieses despues ds nrmarfo

Utf m

Jel .s^'guro social lai exisrei Jel j^te de tamilia Idmiliar mavor de IS

i_\:nv uije

i >rro tamiiiarma^or dtf 13 jrtos t-'etha

'(ro ramiltar mavor de t iartos

Oiro lamiliar moverd* F«na

-iro (amilior mavor d« M jflos ()iro lainihar mavor de I i ados

Wiso sohrefa Lev de CunfldencialWad. Autondad: E! Depart am en to de Vivrenda v Desarrollo Urbarto iHUD) esta iiutonzado para .icopiar e.sta mlormacion en vtrtud

!e la L(iy de Vivienda de los £E UU. Je 1937 (Seccibn MJ7 at -•seij. del Titulo 42 del CYxligo de los EE.UU.). d Titulo VI Je la Lev de DerechosOvilesde 1^64

; SecuorOHJOd del Titulo 42 del C.xJjgo de los EE UU ) v la Levde Viviertda Justa iSeccion J60l-I9del Titulo 42 del Codigo de los EE.UU t. La Ley de Vivienda y

iX-sarrollo L'ninijnitariu de I^MT^Seccion J543 del Titulo 42 del CoJigo de los EE.UU ) exu>eque los solicifantes v participanies presentenel Rumero de seijuro social de

.:jja [ami! lar mavor de sen arios de edad. Final idad: El HUD usa la mlormacion mbre stis ingresosy otra mfbrmacion acopiada paradeterminar'iu idoneidad. el tamarto

.ipropiado de las hahiuciones y d monlo quepagarasu tamiltaporalquiler v servictos punlicos. Olroj usos: el HUD usa la mtbrmacion sobre su rngreso ramiliary otra

•mormacion acopiada para avudar a .idmmistrar y supervisar lo* programas de vivienda realizadoscon asistencia deeseorsajiismo. proti;gerel interes tlnancierodel

ijubiemo o vemlcar la exactitud Je la mtormacion oroporcionada, Esta information puede divulgarsea entrdades federales. estatales v locales idoneas. cuando proceda.

v a inveMieadorcj y tiscales uncareados de iramitarcasos civ lies v penales y asuntos normalivos. De locontrano. la irtfbrmacion noserevelarani diviilaara luera del

HUD. evceoto en los cnsos permitidos o exigido* por la ley. Sancion; Usted debe proporcionar mda la mtbrrnacion solicitada por la HA. rncluso el numero de seguro

ocul MUC feneano usen listed v rodos los demas Tamil lares maycires de seis jflos de cdad. Es Dblieatorio dare! numero de seguro social Je lodos los ramrliares mavores

,'e -.eis unondeedad: ^uomision alectarasu idoneidad. Laumision de cualquief pane ae la rntonnacion solicitada puede hacer.(uese ijemore » demegue la jprooation

ie sii .solicitud oor razortei ile idoneidad.

- i IH-IO(n-s (lor t) mo indebtdo del presen» ibrmulario deconieniimiento:

El HUD. la HA v cualquitfrpropietario 10 trmplcado del HUD. la HA o el propieunoi pueden e'tar sii|etos a ianciunej pordivuliiaeion no autonzada o oof uio indebido

.e la mfbrmaeion acopiada con el nresenle tormulano de consentimiento.

'"I uso de la inrbrmacion .icnpiada con el (brmutano HUD-9HS6 9e limita a los lines cirados en el mismo Cualqmer persona que. a ^arnendas o intencionalmente. solicite.

.btenga o reveie intormac'on de manera (raudulenta soore un solicitanleo panicipantc niiede estar sujeta a aeusacion pordeliro menor v a imposition de una multa

,i3xtma de S3 (;'JO

'.'ujlquitfr !olici!anie o narticipante afectado por la JivulaactOn negligeme du intbrmacinn puede iniciar una accion civil Dor danoa v pcriurttos contra d nt'iunl a

:;mcionariO del HIj'D, la HA o el propretano re^ponsable: de la divulaacion no autonzada o del uso indebidn. o buscar otra mdemnizacidrt oor partedeellos. se§un

proceda.

€st» ctocumanto as iraOucci6n d* un documonto /uriaico expodida por el Oepartamemo d* Vlvionda y Daaarro/to Urbano IHUD), el cual,iroporciona ssti traOucci6n solamonty a modo d* convtintoficis para rju* la ayude a usted a compnnder sus dgrechoa / obligacionos. La. ersi6n en tflqlGs <as ef documvnto oficial, tuqai y qu« nejg. Esta traduccion no constituy* un documento oflcial.

, j ocjantzacion •soJicitanla quarda el orrrujlano HUD-9aae-3panlsr» 17/94)f. Manuales 742Q.7. 7420.3 y

UTHORIZATION FOR RELEASE OF INFORMATION

Purpose: The Housing Authority of the City of New Haven and the U.S. Department ofHousinq and Urban Development may use this authorization and the information obtained,vith it. :0 3dminister and enforce rules and regulations governing its housing programs.

Authorization: I authorize the release of any information (including documentation and othermaterials) pertinent to eligibility for or participation under any of the following programs: Lowincome Rental Public Housing: and Section 8 Housing Assistance Payment Program.

I authorize the above named agencies to obtain information about my family, or me which ispertinent to eligibility or participation in assisted housing programs.

Information Covered; Inquiries may be made about: Child Care Expenses, Credit History,Criminal Record, Family Composition, Employment, Income, Pensions, and Assets,Federal, State or Local Benefits, Handicapped Assistance Expenses, Identity and MartialStatus, Medical Expenses, Social Security Numbers, Residences and Housing History.

Individuals, Organizations or Agencies that may re/ease information; Any individual,organization or agency including any governmental agency may be asked to releaseinformation. For example, information may be requested from: Bank and Other Financialinstitution; Employers - Past and Present; Landlords; Providers of: Alimony, Child Care,Child Support, Credit, Handicapped Assistance, Medical Care and Pensions/ Annuities;Schools and Colleges, Shelters, U.S. Social Security Administration, U.S. Department ofVeterans Affairs, Unemployment Agencies, Utility Companies and Welfare Agencies.

Computer Matching Notice and Consent; I agree that the above named agencies mayconduct computer-matching programs with other governmental agencies including: Federal,State or local agencies. The governmental agencies include: U.S. Office of PersonnelManagement, U.S. Social Security Administration, U.S. Department of Defense, U.S. PostalService, State Employment Security Agencies, State Welfare and Food Stamp Agencies.

match will be used to verify information supplied by the family.

Conditions; I aqree that photocopies of this authorization may be used for the purposestated above. If 1 do not sign this Authorization, I also understand that my housingassistance may be denied or terminated.

Head of Household Name ignature Date

Other Adult Name Signature Date

)tner Aduit Name Signature Date

?ct. '001 <it nne riot tr.e Umiea States Code n-.aKes it a onminai ortense ro *no*mqiy maxe laise-itaiemena of misrepresent to any Cecartrrient or Aaency ot

-i'jni'.ed b'aies 10 any irar.er *nn,n ,3 lucsuittion inaraa es'acusneo penalty Ottawa up to ii'JO, V,;Q ar.a'or imonaomrenl nauo^ccea 5 yean.

•-=1 proposito- La Autondad de Vivienda de la Ciudad de New Haven (HANH) y E.. —r

de Envoltura y Desarrollo Urbano (HUD) puede utilizar esta autorizacion y la informacion obtenida.para admmistrar e imponer las reglas y las reguiaciones que gobiernan sus programas deenvoltura.

lutonzacion: Yo autorizo la liberacion de cualquier informacion (incluyendo la documentacion yotros materials) pertinente a la elegibilidad para o para la participacicn bajo cualquiera de losprogramas siguientes: Vivienda Publica y la Asistencia de Renta de Seccion 8.

Yo Autorizo HANH y HUD obtener informacion acerca de mi o mi familia que es pertinente a laelegibilidad o la participacion en los programas de asistencia de vivienda.

La informacion Cubrira: Informacion obtenida puede ser acerca de: los Gastos del Cuidado deNino, la Historia del Credito, el Registro Criminal, la Composicion de la Familia, el Empleo, losIngresos, las Pensiones, y las Ventajas, Beneficios local, Federal, o del Estado, los Gastos deAyuda por Incapacitado, la Identidad y la Posicion Marcial, los Gastos Medicos, los Numeros delseguro social, la Historia de vivienda y residencias.

Los individuos. las Organizaciones o las Agencias que pueden liberar informacion: Cualquierindividual, organizacibn o agencia incluyendo gubernamental puede liberar informacion. Porejemplo, la informacion se puede solicitarde: el Banco y Otra Institucibn financiera; Empleadores- Pasado y Presente; Propietarios; Proveedores de: Pension, el Cuidado de Nino, Apoyo de Niflo,el Credito, Ayuda par Incapacidad, el Cuidado y las Pensiones Medicos/ las Anualidades; lasEscuelas y los Colegios, los Refugios, los EE.UU. La Administracion de la Seguridad Social, losEE.UU. El Departamento de Asuntos de Veteranos, las Agencias del Desempleo, las Companfasde la Utilidad y Agencias de Bienestar.

La computadora que Empareja y /Vote: Estoy de acuerdo que la agencia denominada puedeoonducir la computadora emparejar los programas con otras agencias gubernamentalesincluyendo: Federal, el Estado o las agencias locales. Las agencias gubernamentales incluyen: losEE.UU. La Oficina de la Direccion Personal, los EE.UU. La Administracion de la Seguridad Social,los EE.UU. El Departamento de la Defensa, los EE.UU. El Servicio Postal, las Agencias de laSeguridad del Empleo del Estado, el Bienestar del Estado y Agencias de Sello de Alimento. Eligual se utilizara para venficar informacibn suministrada por la familia.

Las condictones: Estoy de acuerdo que las fotocopias de esta autorizacion se pueden utilizar parael proposito indicado arnba. Si yo no firmo esta Autorizacion, yo entiendo tambien que mi ayudade envoltura se puede negada o puede ser terminada.

lefe del Hogar Firma Fecha

Otro Adulto Firma Fecha

Jtro Adulto Firma Fecha

SELF DECLARATION FOR ASSETS STATEMENT

Information *—^.^^^*mmm^mm^i^^^^m^l^^^^mm^^^^m.^^lll^+1

Participant (Head of Household) &rtnt Name) Social Security Number

Oato of Birth Contact Number

Types of AssetsAssets include, but are not limited to the net cash value of:

r Checking and/or Savings Accounts> Real Property» Stocksx Bonds' Other Forms of Capital Investments' Any Income Distributed from a Trust Fund

I certify that, to the best of my knowledge and belief, that my household does not have assets,vith a net value exceeding 550,000 and that all of the information on this DeclarationStatement, is true, correct, complete, and made in good faith. I understand that failure toreport assets greater than 550,000 and that I provide a false statement on any part of• his declaration may be grounds for termination of my Housing Choice Voucher, andmay be punishable by fines or imprisonment.

1 understand that any information I give, may be investigated for purposes of determining"ontinued eligibility.

I consent to the release of information for sole purpose of any third party inquiry.

'articipant's Signature Gated

Witness1 Signature Gated

; act Ion 1001 of Title 18 of the United 3tatea Cod* make* it a criminal offense, to knowingly make false statements ormisrepresentation to any department or Agency of th» United State* to any matter within ita Jurisdiction and ham

tstaotimhed penalty of flnea up to S10Q,OOO and/or imprisonment not to exceed 3 years.

OECLARACION PERSONAL

PARA LA AFIRMACION DE ACTIVOS

fnformac/6n General,

Participant* (Jef* de Hogart (Hombre an Letra de moidet -Vumaro do SaguroSocial

, 1 .Pacha da Nacimianto Mumaro da Contacto

Tipo do Activos ___«___«»^^^^ . ^_____«____„^Los activos incfuyen, pero no sa Hmitan al valor del efectivo neto de:

.- Cuentss Corrientes y/o Cuontaa do Ahorros*• ai&noa Raices> Ace ion 03> 3onoa> Otraa Formas Da Inversion** Capitate*> Cualquier ingreso da distribuida do fondos fiduciario

Cartifrcr 3l mejor de mi conocimiento y creencia, qua mi composicion familiar no tiene

3Cti- i valor neto que excede 350,000 y que toda la informacion sobre esta declaracidnc,-= ^ra la afirmacion de activos es verdad, correcto. completo, y hecho de buena re.

Ej.;;endo que si falto de proveerle los activos mayores de $50,000 y que la informacibn

----^rcio^ada en esta declaracion es falsa en cualquier parte puede ser argumentos para la

-"' "voucher" y pueden sera castigable por multas o encarcelamiento.

fo entiendo, que cualquier informacibn que de, puede ser investigada con Objeto detfeterminar mi continua elegibilidad

/o consiento, al lanzamiento de informacion dada para propositos de cualquier indagacibn:e terceros.

;r;rma Particioante Fscha

.-irma de Festigo Fecna

1QQ1 of rit/9 ta of thm Unit** Statmm Cod* trrafrmm it * criminal efforts* to knowingly matr* fals* statements ormaruprmsintatlon to any Q«p#rtm»nt or Agency of the United State* to any matter within its jurisdiction and ha*

!*tat}llshect oenalty of fines up ta 310O.OOO ana/or imprisonment not to exceed 5 years.

SELF DECLARATION FOR INCOME STATEMENT

information ^^___

Participant (Head of Household) (print Name) \ Security Number

Oat* of Birth Contact Number

Types of Incomes:Incomes include, but are not limited to the gross cash value of:

' Employment

* Family Operated Business* Social Security' Periodic Payments from Annuities* Cash Contributions from non-household members* State/Federal Assistance Benefits> Alimony / Child Support Payments' Income from Assets*• Armed Services Benefits' Lottery Winnings

I certify that, to the best of my Knowledge and belief, that my household does not have incomeexceeding 55,000 and that all of the information on this Declaration Statement, is true, correct.:omplete, and made in good faith. I understand that failure to report income greater than $5,000md that I provide a false statement on any part of this declaration may be grounds fortermination of my Housing Choice Voucher, and may be punishable by fines or imprisonment.

I understand that any information I give, may be investigated for purposes of determining continuedeligibility.

I consent to the release of information for sole purpose of any third party inquiry.

'anticipant's Signature Dated

/Vitness1 Signature Dated

faction 1001 of Title 13 of the United States Code makes it a criminal offense to Knowingly matte false statements ormisrepresentation to any Oepartment or Agency of the United States to any matter within its jurisdiction and has

jenatty of fines up to $10O,OOO and/or imprisonment not to exceed 5 years.

0ECLARACJON PERSONAL

PARA LA AFIRMACION DE 1NGRESOS

Information General',

Participant* <J*f* dm Hogar) (Nombrm 0ft L*trm d» mold*) Numero d* SoguroSocial

i— - *•— •—~—~

Fscha da Nacimiento Mumaro d* Contacto

Tfpo da IngresosLos Ingresos /nc/uye/r, pero no so limitan al valor del grueso af&ctivo det

- Empleo- iVegoc/o Familiar'*- Seguro Social*•• Pngos periodicos do anualldades' Contribuciones en efoctivo por personas o famillaraa external*" Asistencia do beneflclos por al Estado/F&doralr Pension Alimentlcia o pension matrimonial- Activos- Benoflcios por las fuerzas armadas" Ganancias de la loteria

Certiflco que, al mejor de mi conocimiento y creencia, qua mi composicion familiar no tiene.nqresos con un valor que excede $5,000 y que toda la informacion sobre esta declaracidnpersonal oara la afirmacion de activos es verdad, correcto, completo, y hecho de buena fe.

iHntiendo que si falto de proveerle los ingresoa mayores de 55,000 y que la informacionoroporcionada en esta declaracion es falsa en cualquier parte puede ser argumentos para laisrminacibn de mi Voucher" y pueden sera castigable por multas o encarcelamiento.

/o entiendo, que cualquier informacion que de, puede ser investigada con objeto dedeterminar mi continua elegibilidad

Yo consiento, al lanzamiento de informacion dada para propdsitos de cualquier indagacion>.1e terceros.

,cirma Partic/oante Fscha

rirma de festigo "echa

'action 1001 of Tltt* Iff vf tf?# f/n/ta* 3tat*9 Cod* mate* it a criminal offmns* to ftnowmqty ma** Sate* stmtftn*ntm orn,sr*ar»s*ntatlon to *ny 0*pmrtm*nt or Agency of thm Unitad State* to any mattmr within it* jurisdiction and has

t4tattiisn»€t penalty of fin** up to $1OQ,QOO and/or imprisonment not to oxc«*d

FLAT RENTS

All Public Housing Tenants have the option to pay either a flat rent or anncome-based rent as their monthly rent. For example, if you live in a 2-bedroom unit whose flat rent is S852 and your income-based portion of the rent.s S9QO, you the have the option of selecting to pay $852 or $900 as yourmonthly rent.

Flat rents are as follow:

0 Bedroom S 6221 Bedroom 3 7062 Bedroom S 8523 Bedroom S 10204 Bedroom 5 11665 Bedroom $11663 Bedroom $1166

Households will have the option of changing from the basic rent determinationformula of 30% of adjusted gross income to flat rent once every 12 months asdefined by the date of the last change to flat rent. HANH will make exceptionsto this rule in the case of a family's financial hardship. Households using flatrent will need to have their income verified once every three years.

HANH will inform each household of any changes (increases or decreases) tothe flat rent amounts and provide at least 30 days notice to any rent changethat may take effect.

Please check one of the boxes below regarding whether or not you wishto pay a flat rent amount (see above) or an income-based rent amount of5 -

•Hi Yes, I elect the flat rent option

i i No, I do not elect the flat rent option

Q Yes, I d o elect t h e income based rent amount of $ .

Print Name (Head of Household)

Head OT Housenold Signature Oate

:echa

Fija

Los residentes de Vivienda Publica tiene ia opcion de pagar una renta fija ocenta basada se su ingreso mensual para su alquiler mensual. Por ejemplo, siusted vive en un apartamento de 2 dormitories donde la renta fija es de S852 yla renta basada en su ingreso es de S900, usted tiene la opcion de escoger siJesea pagar 5852 o S900 mensualmente.

Los hogares tendran la opcion de cambiar de renta basica que es 30% de suingreso mensual a una renta fija una vez cada 12 meses como definido por lefecha de su cambio de renta fija. HANH hara excepciones a esta regla encasos de dificultad financiera. Hogares pagando la renta fija tendran que tenersu ingreso venficado una vez cada tres anos.

HANH informara cada hogar de cualquier cambio (aumento o reduccion) a lasrentas fijas y proveera un aviso de 30 dias de cualquier cambio de renta quesea efectivo.

Favor de escoger una de las opciones con respecto a si usted desea o nodesea pagar renta fija o una renta basada en su ingreso.

Las rentas fijas son las siguientes:

0 Bedroom 5 6221 Bedroom 5 7062 Bedroom '5 8523 Bedroom 3 10204 Bedroom $11665 Bedroom 511663 Bedroom 51166

C] Si, Yo escojo la renta Fija

iZI No. Escojo la renta Fija

H] Yes, Yo escojo la siguiente renta basada en mi ingreso de $ .

Nombre (Jefe de Hogar)

riirna de Jefe <Je Hoqar Fecha

W-9}v Ociccec <~£Qf)

Request for TaxpayerIdentification Number and Certification

Give form to therequester. Co netsend to the IRS.

-: jj

i 7*

.i.ra 'J9 anew

•ec^ jccrccr 4te oo*. i J .rdividuuLSO'8 orocr'elor '__j 0-^fDorjtion i_j I'jrtnersnip

__ L ntad ,-iLJn-tv corroany. fr'.lor ire ia* oassiiicJtion iC-jiSiega/aea •jntity. C-corooration. pioartnersruoi >

marrow, sireot. and apt. jr suits no.) s rztre jna jouress

!v. jute, jria

'axpayer Identification^Number JT1N)

orEmployer identification numb*r

Enter '.our TIN in re appropriate box. Tr-g TIN provided must match tna name given an Line 1 to avoid | Social security numbwjackup wnnhoiding. For individuals, mis '3 >our social security number (SSN), However, for a resident;iien, icie cropnetor, or cisreqamed entity, see the Part I instructions on page 3. For other entities, it is,our emrjiovef ider.tiTication numoer |E|N), If you ao not nave a number, see How ro get a HN on page 3.

Note, it :re account is in -nore than one name, see the cnart on page 4 tor guidelines on wnosenumber to enter.

J^?TffTO Certification „ _.•Jnder penalties of perjury, 1 certify that:1 T'ra number snown on ihi3 torrn is mv correct taxpayer identification number tor t am waitinq Tor a number to be issued to me], and2 I im rot subject to backup withholding because: la) I am exempt from backup withholding, or to) I have not been notilied ov the internal

Hovenue Service ilRS) that 1 am suoiect to backup withhoiamg as a result ot a failure to report all interest or oividenaa. or ic) :ne irts has•-•jiitied 'Tie trat I am no longer subiect to backup withholding, and

3. I am a U S. citizen or other U.S. person (defined delow).Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup•'jiifinoldinq because you nave failed to report ail interest ana dividends on your tax return. For teal estate transactions, item 2 does not apply.r0r mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirementirrangement OR A), and generally, payments other tnan interest ana Dividends, you are not required to sign the Certification, but you must^roviae your correct TIN See the instructions on page 4.

3iqnHere

Signature ofU.S. parson

General Instructionslection references are to tna Internal Revenue Code unless

•,tnerwise notea.

Purpose of Form•\n who is regunea to file an information return with theRS must obtain your correct taxpayer identification number (TIN)

•o report, :or example, income paid to you, real estate•ransactions, mortgage interest you paid, acquisition or-;Danaonment ot secured property, cancellation of debt, or•lontributions you made to an IRA.

•j-:e Form W-9 only if you are a U.S. cerson (inducing ai^sident anen), to provioe your correct TIN to tne person•^Questing it tthe requester) and, .vnen applicable, to:

1 (!ertifv that the TIN you are giving 13 correct (or you are.vailing :or a numcer to oe issued),

2. Certify that you are not subiect to backup withholding, or: C'aim exemption from backup withholding if you are a U.S.

•rxernpt payee, if applicable, you are aiso certifying that as a'J-3 person, your jilocabie share ot any partnership income frcmi U.3, trade or business 13 not suoiect to the withholding tax on-. "ijn cartncrs 3hare of ei'ectiv^v connected income,

V4nta. If 3 nauester qivea you a form other than r-'orm *V-9 to-Bluest /our TiN. v'-u must use tre -eauesier 5 'nnn >f t is

iy similar to tnis Form ,'13.

Definition ot a U.S. person. For 'ederai tax purposes, /ou are^nsidereo a U.S. person it you are:

• An individual wno is a U S. citizen or U 3. resident a.ien.• A partnership, corporation, company, or asspciation created ororganized m the United States or under the 'aws of tne UnitedStates.» An estate {other than a foreign estate), or• A Domestic trust (as defined >n Regulations section•jQI.7701-7).Special rules tor partnerships. Partnerships that conduct atrnae or ousiness in the United States are generally required tonay a withholding tax on any foreign partners' share of income•rom such business. Further. >n certain cases where a Form W-9has not been received, a partnership is required to presume that• t partner >s a tofeign person, and pay iha withholding tax."herefore, if you are a U.S. person that is a partner m apartnership conducting a trade or business m tne United States,provide Form W-9 to the partnership to establish your U.S.status and avoid withholding on your share of partnership;'.come.

The person wno gives Form W-9 to the partnership 'orpurposes of establishing its U.S. status and avoicmg w.thhciamg;n 'is allocable snare of net income from the partnership

a trade or easiness m :he United States '5 n themg cases:

U 3 owner ot 3 : sreqaraed ent;tv and rot the entity,

W-9

„ W-9(5P)J'ov Jit; -jmore Jo J01 1)

" n irTmL'ri -' 'Ke r-ejsurv• vr.il fV1. •!"«,« iefvra

Soiicitud y Certiflcacion del Numerode Identificacion del Contribuyente

formulario alsolicitante. No loen vie al /flS.

• ,r0J8 * ancjs.ii.ujo curresoonaenta Dora .a C astncac.on trouUna 'ederai- j !"d.v duo^rroresano oor cxanfa

- j ~ j,,: eoad a-vjrv.Ts cei; no 0 -cc.eaad aron'o-a -lai i oo 3 J^ Soc edad cc ecnv,j i J i-' 'Je>comiso<caudal nar

t "5 i '~ ,j j. jd rrfSDoi'saniiidaa .imitada. Anote la c'33ificacion (rtujUna [C-Soc. .momma del doo C. 3-5oc jnomrra aei nc-o d.

.13 .L_

C recc en uii-rrero. cane v .loanamenlo u ancina) iorrora v direction dai soncilanie icoc.onai>

. estauo v t-:a.go aostji i

i-c!a eccai

Numero de identificacion del contnbuyente (TIN)

•Jum«fO d» s«gufo social

NOrrwo d* idvntificacidn d«( cm picador

,19 su r-.u.'rnfo da ujent.licacion liel conlnbuveme en al encasuiado correseondienta el nur^ero de identification dalMtricuveme t ena qua ccncordar con el noircre erov sto en 'a unea Nornnre' cctfa evtar igretenoon aaic:onai del"cuesto. t^ara 09 .ndividuos, eata 0s au numoro ce segu'o social rSSNI, Sin amDarqo, aara un ontraniflro resiaante,-'T-Lresario ^or cuenta crnoia o enndad no ccnsiderada seoaJaoa. vea !as instrucciones cara la Parte 1 en 13 paqma 3. Para::ras entiaaaes. as su nurrero da .dentiticac:on catronal itiN). Si no tiane un numero, vea COmo oblvnvr un TIN, en 13

igma 3.Nota: Si la cuena esta a nombre ce mas da una persona, vea ta tabla en la pagina 4 paraluesoramiento sorjre que nomore debe escnbir. \

Certif icacionno pena da periurio. vo aeclaro que:SI numero qua aDafece en uste formulario 03 mi numero de identification del contnbuvente correcto (o estoy esperando gue me asignen un numero) y

rio estoy auieto a la retencion adicional da impuestog porqua: (al Estoy exento de la retencion aaicional o ib) No he sido rotificaoo por el Servicio..:9 Impuestos internes (*HS) de aue estoy sujeto a la retencion auicional de imnuestos como rcsultado de no declarer toaos los mtereses o

el IRS me ha notificado que ya no estoy suieto a la retencion adicional y

). Soy ciudadano da los EE.UU. u otra persona de los Estados Unidos (que sa detlne qespuea).I nst rue clones para la cortiftcacion. Tiene que tacnar la partida 2 anterior si el IRS le ha notificado que usted en estos momentos esia suieto a la'••isncion aatcional de imouestos porqua no declare todos los interesas y dividendos an su declaracidn da impuestos. Para las transacciones de bienes"nueoles. la oanida 2 no corresponds. Para los intereses hinotacarios paqados. la adquisicibn o apanctono de bienes asequrados. la cancelaaon ae: ducJas, ias contr;bucionRs a un arregio de jubilacion individual tiff A) y, por lo general, los oagos que no sean intereses y dividendoa. no se le reauiera'•rmar li certilicacion. pero !:ene que oroveer su numero de identificacrbn del contnbuvente correclo. Vea las instruccciones an la oaqma 4,

F'"ne I Firm, d. laAqUI carsona d» loa eE.UU. *• Ptchm *•

Instrucciones generates d« oaraona d« loa EE.UU. Para orooositos tr'DLLonsidara una oersona uo 'os EE.UU. si us.

cs 'eoeraiea. J

is sHcciones a 'aa cuaiea se '63 naca rn'arencia son del Codiqo federal O-nuesloa :nt9rno3. 3 .-reroa que •sa iriuioua oe otra Tianera.

Propbsito del formulario. • i [je'3ona a rjj;en s^ :q ">qu-«ra creseniar una doclaracion ante el i'HS sara'cintar intorrracion tiona que ootaner el lurrcro rJe identification del. - • t r nu'.anla i r.'.'J] -orrecto <JB u'ited cara caciarar. sor ^-efnoio. ngreso^ qne •«

• i uaqado a j^ted. iransaccionw ue Dienea inmuaoias. intoreses nioctocanoa nue, ,;ed caqo, auau'S.c'on 3 toandono da rjienes aserjuiados. ^ancaiacion da-. 'ijLlas Q CGntr'Duc;onos d"O uaied nizo 3 arreqios tHA.

.'je tfi f'jfmij'ario '//-4iSP) 'o ^1 Forr^u'arso W-9. ^n inrjie^j 50(0 51 *?3 ijna. .'<3ona da as cE.UU i rve'uyenao a un o*tranjero rcaidanio) cara croveene sj• .u-^ro aa denMicacion del eoninDuventa iJlfJ\o a a persona dua ss o

• : 'c la -31 soncitantei v. c,:jndo ">a aDi'Q^a. :ara:

: j f t i t icar a-e ei !~lfJ TUB esta lacilitando n9 cDrricto (o quo "sta o-ireranrlojra a'jtt se '8 aS'qne un -^rreroj,

' L'.jrtil car QUB no asta suielo a la retencion jidicional de irrrjuastos o

• ijn ndividuo aue es emtladano o extraniero r^s,cjenia de 'CS cE.'JU ,

• 'Jna aocieoad coiectiva. aocieuafl anonima. corrcama o dsocucion creaca ur-;anuada en ios EE.UU- o naio ias 'eyes ae IDS tE UU. .

• un cnuOai nereditano <que no 3ea un cauUal nerndiiano uxiraiuero).

• Jn ' 'leicomisc dorresiico icomo se del'ne en '3 s^cc on J01 / /01 - / ',1 'a.'••v^iaiT-eniaciOn).

Reglai «sp»cial*s para la« «oci«dadas col»ctlva». A as soc'edades co'eciua. .e 'Jflser^oenen activicadcs con-ijrciaiea o ja noiacroa en 03 dE UU nor a;oneral ge 'eg require oaqar un imouesto da retencron soort loda DJiliCiDacion•"i log 'nqresos ae 5OC;O9 exiran,ef03 orocodontes ae 'al .^eqoc o. Adorras. qn. ;rtos casos an loa qua un h'ormulario VV-9(SP) 'a KorTU'ano W-9, on 'nqteaj no

• iva snjo rocioido, 59 reduiera aue 'a socieuad ccioct.va auo aa aor SUDUBSIO au. i socro **s torsona axiran:ora y quo aeoe oaqar ei 'rouesto de rr?'erc,on. Por o

• i-ifo. 11 i.srnd 99 una persona da los tt-UU. qua us "sociO on uiia soc'oaad.- Qttivj 'jL,a Jesempena -ict/'i'lacos ccn-ercia.e* T ae ""fjoc is «n 01 h£ ULJ ..rovnaie un f-grmuiario vV-9(SPl lo un Fcrrnijiario vV-9, en "q:03) a .a sociedad

','J!ectiva oara esraoiecer 3u condic-on 'ia esladoumdense y »vtar 'a r.?igncion. ,nra -;u Panic'caciOn asiqnaoio 'le -saos •nrjfogos.

.W-9(SP),n.v

Housing Authority of the City of Mew HavenSelf Sufficiency £ Service Policy ("SSS Policy")

A.

The Quality Housing and Work Responsibility Act of 199$ requires that all non-exempt (see-lefmiuons) public housing adult residents (18 or older) contribute eight 18) hours per month ofcommuni ty service (volunteer work) or participate in eight (.8) hours or training, counseling,ci.isses or other activities that help an individual toward self sufficiency and economicindependence, Hiis is a requirement of the Public Housing Lease.

B. Definitions

Community Service - volunteer work which includes, but is not limited to;• Work at a local institution including but not limited to: school, child care center, hospital,

hospice, recreation center, senior center, adult day care center, homeless shelter, indigentfeeding program, cooperative food bank, etc.:

• Work with a non-profit organization that serves PHA residents or their children such as:L3oy Scouts. Girl Scouts. Boys or Girls clubs. -4-H program. PAL. Garden Center.Community clean-up programs, beautification programs, other youth or seniororganizations;

• Service as a HANH Buildina Attendant;• Work at HANH to help improve physical conditions;» Work at HANH to help with children's programs;• \Vork at HANH to help with senior programs;• Helping resident organizations or neighborhood groups with special projects, such as

rood Banks and community gardens;• Serving as an officer of a IRC or other Resident organization, serving as a Board

Member or" VOICES, or serving on another Resident Advisory Board; and• Caring tor ihe children of other residents so they may volunteer.» NOTE: Political activity is excluded.

Self Sufficiency Activities - activities that include, but are not limited to:• Job readiness programs;» Job training programs:• ( i I :D classes;• Substance abuse or mental health counseling;• English proficiency or literacy I reading; classes;» Apprenticeships;• Budgeting and credit counseling;• Aiiv kind of class that helps a person toward economic independence: and• r ' l i l l t ime student status at any school, colleue or \ < j c a t i o n a l school.

Exempt Adult - .m adult member ot the family• !s o2 years of aye or older.• lias a disability that prevents him/her from being gainfully employed;• Is the Cviretaker of a disabled person:» U working at least 30 hours per week: or» (s participating in a welfare to work program.

C. Self-Sufficiency 0* Service (SSS) Requirements

1 . Hie eight (31 hours per month may be either volunteer work or sell"sufficiency programCavity, or a eomrjination of the t\vo.

2. At least eighuS) hours of activity must be performed each month. An individual may not- k i p a month and then double up the following month, unless special circumstances warrant.-aeeiai consideration. HANH will make the determination of whether to allow or disallow adeviation from the schedule.

". Activities must be performed within the communuy and not outside the jurisdictional area ofUANH.

4. Family obligations

> At lease execution or re-examination, all adult members (18 or older) of a public housingicsident family mustD provide documentation that they are exempt from SSS requirement if they qualify for

,111 exemption, and;•>) sign a certification thai they have received and read this policy and understand that if

•.hey are not exempt, failure to comply with the SSS requirement will result innonrenewal of their lease.

• At each annual re-examination, non-exempt tamiiy members must present a completed. iGcumemation form (to be provided by HANH) of activities performed over the previous'Avelve (12) months. This form will include places for signatures of supervisors.Instructors, or counselors certifying to the number of hours contributed.

• I f a family member is found to be noncompliant at re-examination, he/she and the Headif Household wil l sign an agreement wi th HANH to make up the deficient hours over the

next twelve I 12) month period.

:. Change m exempt status:

• i f . '.luring the twelve ( 1 2 ) month period, a non-exempt person becomes exempt, it is'.us/her responsibility to report this to HANH and provide documentation of such.

« ' f. Jur ing the twelve i 12 ) month period, an exempt person becomes non-exempt, it is' . i : ; /her r e spons ib i l i t y *o rjport 'his to H A N H . H A N H w i l l provide the person w i t h ihe

Riccrdina/CerTiilcation documentation torm and a list of agencies in the community thatprovide volunteer and/or training opportunities.

I.X Viuhority obligations

\ To the greatest extent possible and practicable. HANH will:• Provide names and contacts at agencies that can provide opportunities tor residents.

Deluding disabled, to fu l f i l l their SSS obligations; and• Provide in-house opportunities for volunteer work or self sufficiency programs.

-. 1 I A N H will provide the family with exemption verification forms andAeeording/Certilicaiion documentation forms and a copy of this policy at initial application.nid at lease execution.

3. HANH wi l l make the final determination as to whether or not a family member is exempt;:om the SSS requirement. Residents may use HANH's Grievance Procedure if they disagreeuth HANH's determination.

4. Noncompliance of family member:

• At least thirty (30) days prior to annual re-examination and/or lease expiration. HANHwill begin reviewing the exempt or non-exempt status and compliance of familyiiiembers:

• If HANH finds a family member to be noncompliant. HANH will enter into anAgreement with the noncompliant member and the Head of Household to make up theleticient hovirs over the next twelve t 12) month period;

• 1 f. at the next annual re-examination, the family member still is not compliant, the leaseA i l l not be renewed and the entire family w i l l have to vacate, unless the noncompliantmember agrees to move out of the unit:

• I'he family may use HANH's Grievance Procedure to protest the lease termination.

Autoridad de vivientlu tie iu Ciudad de New Haven( Housing Authority of the City of New Haven)

Pnl i t i ca sobre independencia economica y scrvicios <Pol i t i ca «SSS»)

V. Antecedentes

L.i lev <obre vmeudas dj calidad y responsabilidad laboral (Ouali ty Houang and WorkIvosponsibil i ty Act) dc IsWS requiere que todos los residemes adultos imayores de 18 unos) de' iMendas publicas que no esien exentos (ver deriniciones) contnbuyan con ocho (81 horas:nensuales de servtcio comunitano urabaio voluntario). o part icipenen ocho (8 ) horas deoaoaeuacion. asesoramiento. clases u otras actividades que ayuden a una persona a lograr

• ndependencia economica. Esto constituye un requisite del Contrato de atquiler de viviendas

!3. Deilniciones

Servicio comunitario: trabaje voluntario que inciuye. a titulo enunciativo:• trabajo en una insiitucion local, incluidos pero sin Umitarse a el los. escuelas. centros de

c in dado de nines, hospitales, centres recreatives. centres para la tercera edad. centres dedia para adultos. retuy,ios para indigentes. programas de alimentacion de indieentes.hancos aliinentarios cooperatives, etc.;

» rraoajo con una oruanizacion sin fines de lucro que sirva a los residentes de PHA o a susr.irios, tales como: nmos exploradores, ninas exploradoras. clubes de ninos o ninas.programa 4-H. PAL. centre de jardineria. programas de limpieza comunitaria. programas• ic remodelacion. otras organizaciones para jovenes o personas de la tercera edad;

• nrestacion de servicios como un asistente de construction de HANH:• trabcijo en HANH para mejorar las condiciones n'sicas;• rranajo en HANH para ayudar en los programas para nines:» t r aba jo en HANH para ayudar en los programas para personas ancianas;• Liyudar a las organizaciones de los residentes o grupos vecmales con proyectos especiales

Lome, por eiemplo. bancos de alimentos y jardines para la comunidad;• nrestar servicio como un tuncionario de TRC u otra organizacion de re^sidentes. como

Miembro del Directono de VOICES o en otro Dircctono de asesoramiento al residence; y» aiidar ninos de otros residentes para que estos puedan hacer trabajo voluntario.• ACLAfLXCION: se excluye la actividud politica.

\ct ividades de independencia economica: actividades que incluyen, a t i tu lo enunciativo:• programas de preparacien laborai;• programas de capacitacion laboral;• elites de UED;• L;csorumiento :sobre abuso dc ^ustancias o --aiud mental;• . -1- i .ses sohre i lomimo del ingles o aJ tube t i smo ( I c c t u r a ) ;

.isesoramiento ^obre presupuestos y creditos:cuaiquier t ipo de ciase que ayude a una persona a iourar independencia jconomica; y

de alumna a tiempo complete en coda escuela. umversidnd o escneia

\ Ju l to exento: un miembro adulto de ia tamilia que• js mayor de o2 urios;• nrt-senia una di^capacidad que le impida tener un empteo:• cs el cuidador de una persona discapautada;• iraoaia al menos 30 boras por semana: o• namcipa en un proLirama de bienestar laboral.

(_". Requisites de independencia economics y servicio (SSS)

I . Las ocho i.S) horas mensuales pueden ser de trabajo voluntario o de una actividad,x jrtenecienie a un programa de independenciaeconomica. o una combinacion de ambos.

:. Deben realizarse. como minimo. ocho 18) horas de actividad por mes. Una persona no podra-altearse un mes y luego duplicar sus horas al mes siuuieme. a menos que existanurcunstancias especiales que avalen una contemplacion especial. HANH determinara si.imonza o no una desviaciort del cronograma.

.}. Las actividades deben realizarse dentro de lacomunidad y no ruera del sector jurisdiccionaldo HANH.

-i. Obliyaciones del urupo familiar

• Al mo men to de la hrma del contrato de alquiler o de !a nueva evaluacion para obtener lax'certiiicacion. todos los integrantes adultos (mayores de 18 anos) de un grupo familiarresidente de una vivienda publica deben:D presentar documentacion de que se encuentran exentos del requisite SSS en caso de

'.alitkar para una exencion; yb ) t'irmar una certificacion de que han recibido y leido la presence polttica. y que

•jomprenden que. en caso de no estar exentos, el incumplimiento del requisite de SSS:X'.suitara en la ne renovacion de su contrato de alquiler.

• f:n cada evaluacion anual para obtener la recertiticacion. los imeurantes del urupofamiliar que no se encuentren exentos deben presentar un tbrmulario de documentaciun.•ompleto (entreiiado por HANH) respecto de las actividades realizadas durante los• i l t i m o s doce ( 12) meses. Cite tbrmulario mcluira cspacius para las lirmas de.upervisores. mstructores o asesores que certillquen la cantidad de horas destinadas a laict ividad.

• i - . ' i caso de que un inteerante del (irupo f ami l i a r no cumplicre con lo requendo ai;•. mc-mo 1^ !a nuc'."i ' jviuiacmn. ol n o l l a v i . - i iere de ho*!ar '.leber:in r i rmar un auuerdo

.:on HANH para compensar (as horus ialtanies durante e! proximo pcriodo dc doce ( i-

Modiricacion en ia condicion de exento:

• _-n uaso de uue. Jurante ei periodo de doce 1 1_) meses. una persona no exema cahticare;jra la c.xencion. es su responsabtiidad informal a HANH y presemar la Jocumeiuacion:e respaldo,

• tin caso de que. durance el periodo de doce ( i _ ) meses. una persona exenta perdiere suvondicion Je tal. cs su rcsponsabilidad intbrmar a HANH. HANH le brmdara a la persona-•I rbrmulario de Kegistro/Certitlcaciori y un lisrado de eniidades en la comunidad que

oportunidades de volunrariado y/o capacuacion.

I). Obligaciones de la autoridad

! . Al mavor li'mire posibie y viable. HANHdebera:• Brindar nombres y contactos de entidades que ot'rezcan oportunidades a los residentes.

mduyendo a los residentes discapacitados. para cumplir con sus obligaciones de SSS: y• hnndar oportunidades en el lugar para frabajo voluntario o programas de independencia

jconorraca.

.. MAMH !e entreaaraal urupo familiar tbrmuiarios de veriticacion de exencion y dei^-egisiro/Ceniticacion y una copia de la presente poiftica ai momento de solicitud iniciai y a'.A nrma del contrato dc alquiler.

?•. [(ANH tomara la determinacibn final respecto de si un intearame de la ramiiia queda exento.iel requisite de SSS. Los residentes podran utilizar el Proccdimiento dc presentation Jejuejas de HANH en caso de no estar de acuerdo con la determinacion de la Autoridad.

-i. Incumpiimiento de un intecrame de la t'amilia;

• Vi menus treinta (301 di'as antes de la nueva evaiuacion anuai y/o del vencimiento del.:ontrato Je ulquiler, HANH comenzara a revisar las condiciones de exento/no exento y el•- i impl imiento de los inteurantes de la t'amilia.

• Rn caso Je que HANH de.scubriere que un inteyrante de la t'amilia ha incumpiido aluunole los requisites, eelebrara un acuerdo con el integrante incumplidor y el jetede houara'in de compensar las horas r'altantes durance ei proximo periodo de doce i 12) meses.

• Fn caso de que. al momento de la proxima evaiuacion anual, el intecrante de la tamilia.iun no hubiere cumplido. el contrato dc alquiler no se renovara y la tamil ia cntera deberaic.saloiar la unidad. a menos qu^ el inteurante incumplidor acepte mudarse de la unidad.iVncedimientos de nre.sentacion de quejcts:

turd H:\\'hT ?I

?p

Housing Authority of the City of New HavenLease Addendum for Self-Sufficiency & Service Requirements

1'he Quality Housing and Work Responsibility Act of W8 requires that all non-exempt (see, ic l iniuons) public housing adult residents ( I S or older) contribute eight (8) hours per month ofcommunity service {volunteer work) or participate in eight (8) hours of training, counseling,classes or other activities that help an individual toward self sufficiency and economicindependence. The specific terms and conditions of this requirement are specified in HANH's^elf-Sufficiency & Service (SSS) Policy, which is provided at lease-up and recertifications. andis ava i lab le at HANH's central office and Property Management Offices.

This lease addendum incorporates the following provisions as terms of HANH's lease;

Tenant Obligationsr.ach adult in the Tenant household must perform at least 8 hours per month of qual i fy ingcommunity service or self-sufficiency activities unless HANH determines that the adulthousehold members exempt from this requirement. As specified in HANH's Self-Sufficiency *&Service Policy, exempt adults include elderly persons, persons who are disabled, and personswho are already employed.

\'onrenewal of Lease due to Noncompliance with SSS requirementsi his lease shall be automatically renewed for successive terms of one year unless a lenanthousehold is found to be noncompliant with the terms of HANH's Self-Sufficiency & ServicePolicy and its requirements. The Policy specifies:

» At least thirty (30) days prior to annual re-examination and/or lease expiration. HANHwi l l begin reviewing the exempt or non-exempt status and compliance of familymembers:

• If HANH finds a family member to be noncompliant. HANH will enter into anagreement with the noncompliant member and the I lead of I lousehold to make up thedeficient hours over the next twelve (121 month period:

• If. at the next annual re-examination, the family member still is not compliant, the lease•.vil l not be renewed and the entire family wi l l have to vacate, unless the noncompliantmember agrees to move out of ihe unit;

i iricvance Procedures:Residents may request a grievance hearing on HANH's determination of noncompliance

i inc luding HANH determinations of exemption) and may exercise any available judicial remedyu> neek redress from HANH's nonrenewal of the lease because of such determination.

/ have received and read a copy nf HANH's Self-Sufficiency £ Service Policy and I agree tocomply with its requirements and the Lease Addendum terms specified above.

^nature Date

Autoridad de vivienda de la Ciudad de New Haven( Housing Authority of the City of New Haven)

Xpendice ;il contrato de alquiler respecto de los requisites de independenciaeconomica v servicio

La Icy Mibre viviendas de calidad y responsabilidad laboral (Quality Housing and WorkResponsibility Act) de 1998 requiere que todos los residentes adultos imayores de IS anos) de\s publicas que no esten exentos ( ver detmiciones) contribuyan con echo i-S) horasmensuales de servicio comunitario (trabajo voluntario). o panicipen en echo (8) horas de•japacitacion. asesoramiento. clases u otras actividades que ayuden a una persona a lograrindependencia economica. Los terminos y condiciones espectficos de este requisite se detallanen fa Politica de independencia economica y servicio (SSS. por sus siglas en ingles) de HANH. lacual se brinda al momento de la tlrma del contrato de alquiler y de las recertiticaciones. y .sejncuentra disponible en la oficina central de HANH y en las Oricinas de Administration deInmuebles.

1:1 presente apendice al contrato de arrendamiento incorpora las siguientes disposiciones comorerminos y condiciones de este ultimo:

Obliqaciones del inquilino< 'ada inteurame adulto del hogar del inquilino debera realizar al menos 8 horas mcnsualcs de•ervicio comunitario o actividades de independencia economica habilitantes. a menos que HANHJeterminare que los integrantes adultos del hogar se encuentran exentos de este requisite. Segunlo espeeiticado en la Politica de mdependencia economica y servicio de HANH. los adultos

s incluyen a las personas ancianas. personas discapacitadas y personas que ya tienen

\'o rcnoyacion del contrato de alquiler dehido ajnc_umplirrng_nto_de los r_equisitps_de SSS1:1 contrato de alquiler se renovara automaticamente por plazos sucesivos de un ario a menos que!os inteizrantes del hogar de un inquilino no hubieren cumplido con los terminos de la Politica de.ndependencia economica y servicio (SSS) de HANH y sus requisites. La Politica especiricaque;

• Al menos treinta ( J O ) dias antes de la nueva evaluation anual y/o del vencimiento deljonirato de alquiler. HANH comenzara a revisar las condiciones de exento/no exento y el..•umplimiento de los integrantes de la ramiiia.

• En caso de que HANH descubriere que un integrante de la ramiiia ha incumpiido alguno•lo ios rcquisitos. cciebrara un acuerdo con el integrante incumplidor y el jeie de hogar atin de compensar las horas laltantes durante el proximo periodo de doce ( 1 2 ) meses.

• hn caso de que. al momento de la proxima evaluation anual. el integrante de la ramil iainn no hubiere cumplido. el conirato de alquiler no se renovara v la ramiiia entera debera

• losalojar la unidad. a menos que el integrante incumplidor acepte mudarse de la unidad.[Yocedimientos do presentacion de queja.s:

Procedimienios de reclames.Los residentes podran solicitar una audiencia para presentacion de quejas respecto de laijeierminacion de HANH del ineumplimiento (mcluyendo las determmaciones de exencion de[ I ANH) y podran cjercer todo reeurso legal disponible a fin de buscar resarcimiento debido a la,10 renovacion del alquiier de pane de HANH en base a dicha determinacion.

lie recibido v leitto una copia ile la Politica de indepenitencia economica y servicios dev aciierdo cinnpiir con sns requisites y con los tertninos y conditions del Apendice al contratoJe uiquiler ifue se detallan anteriormente.

l ; irma Fecha

HANH Notice of Exemption Status DeterminationSelf-Sufficiency and Service Requirement

i-IUD reauires eacn adult public housing resident to comply with Self-Sufficiency and Service (SSS)-.^quiremems as a condition of the lease. A copy of this policy was provided with your certification•j jperwork. Additional cooies or the SSS policy are available at your Asset Management Office andHANH's main oifice at 380 Orange St. This form states HANH's determination of the exemption statusof eacn adult in your household. Please note that, if adult members of your household fail to comply,viin the SSS requirement, it may affect HANH's renewal of your lease at your next annualrec3nificat!on.

••lame of Adults Exemption Status Reason for Exemption

Adults who are EXEMPT are not subject to the SSS requirement. Adults who are NOT EXEMPT aresubject to the SSS requirement. The basic SSS requirements are specified below.

Non-exempt adults are subject to the requirements of HANH's SSS policy, which include:• You must participate, at least 8 hours per month, in approved self-sufficiency or community

service activities. The self-sufficiency and community service activities that are eligible forsatisfying this requirement are specified in HANH's SSS policy. If you would like more.nrormation about eligible SSS activities, please contact your Asset Management office orHANH's Service Center.

• Your requirement to participate in SSS activities will begin on the same date that this HANHcodification of your household's rent becomes effective. You must maintain documentation ofyour compliance with this requirement. The form on the back of this page may be used todocument your SSS activities.

• At your nousehold's next annual recertification. you are responsible for providing HANH with• locumentation of your compliance with the SSS requirement. HANH will need to receive third-nrty verification of your compliance — direct verification from the employers or organizations:riat you worked with during the past year.if an adult household member fails to satisfy the SSS requirement, it will affect HANH's renewal•;f the housenold's lease, as specified in the SSS policy. __

Exemptions from the SSS requirement are specified in the SSS policy. The most common exemption:^!oqones include:

• ciderty persons tage 62 and older)• Persons with a disability who are unable to comply with the requirement• Persons who are already working or pursuing other self-sufficiency activities

'f vou believe HANH's determination is incorrect, please contact your caseworker, whose name and• •none number are provided below. You will be required to provide verification related to your

status, if you disagree with HANH's determination of your exemption status, you mayin accord with HANH's Grievance Procedures,

j.AMH Caseworker: _ -198-3800 ext.

i .--we i <nsaoih tv trat prevents me from working ' :: im rh-? ^jrenker of a cerson \vnn .1 aisaDiiitM! am woiKing ji .east JO hours a week ' it inn J ruil-;.ime stuoenfli jm uanicioating ;n a V/eifare to Work Program i .! im exerrct from Welfare to Work requirements! •

! :to net ,reet one or the above categories for exemption i ;

Provide verification or disability, unless it s on rile with HANH.^ Provide veriTication from employer^ rfovide verification from school" Provide verification from agency

I rnve receiyed a copy of HANH's (SSS) Policy, and I have read i understanq the contents of tne oolicy.i unaerstand that failure to comply with this requirement may result in nonrenewal of my family 5 lease.

'L4nature Cate

of Adult:certify mat I dm exempt from the SSS requirement because:

--,m iiqs 62 or oldert 1have a disability that prevents me from working i iim [he caretaker of a nerson with a disability ]3m working at least 30 hours a week i ;.im a rull-time studenti___^]im participating in a Welfare to Work Program L—J

nm exemot from Welfare to Work requirements! I

-Jo not meet one of the above categories ror exemption i ;

Tovicle venncation of disaoihty. unless it is on rile with HANH." .Ji"cvide venncation rrcm employer^ ,Jrnvide verification rrom school- . :roy:ne venncation from naency

,:ave received a cccy or HANH's iSSS) Policy, -.ina I have read .'i understand the contents or :ne ooncy.that failure 10 comply with this requirement may result in nonrenewal of my ramily 5 'ease.

^unification of Exemotion statusjvif-Suificiency and Se/v/ce Requirement

'O -^vjires e:3cn id LI it cuoitc nousinq resident to cornnlv with Self- Sufficiency and Stir/ice tSSS):ui, •'"vnrs as ) •j;:or.io/7 ..v r^ .r?jse 4 .roo1/ of" *Ns CC//GV .5 .3tfac/?ed; :'?'s rcrm '.v// .-le'Q nANHoin11!^ Miein^r . -.)u. -,nn -yin^r }<:iast <ti?mvers or '.our nousencid. .ira e\e/nor <Tcm :"9 requirement<r-> \.,.\e'.;r :o :."e ••I'.vjirerrenr

crovide trie 'Allowing certification'j/r;e or Aduit:• -anifv that I jm exempt from the SSS requirement because:

62 or oldert ihave a disaoihty that orevents me from working I i.im the caretaKer of a cerson with a disabilityL^,im working at least 30 hours a week I !nm a njil-time studentl __••im carticioatinq in u Welfare to Work Program l_.-jitn exemot from Welfare to Work requirements! |

do not meet one of the aoove categories for exemotion 1 ,

;roviOe venrication GT Jisaoility, uniess it is on file with HANH.- Provide venncation ircm emoioyer^ r-vovide verification Trom scnool^ Provide verification from agency

have received a copy of HANH's (SSS) Policy, and I have read & understand the contents of the colicy.jmersiand that failure to ccmciy with this requirement may result in nonrenewai cf my family s 'ease.

'rut I a/77 e\emot from (he SSS requirement Cecause:

un .vje o2 or olcieri. _ ie -i usability thai prevents me from workingtne caretaker of a person with a disabilit

jm worKing at least 30 hours 3 week I _am a fuil-time student! _ iam participating in a Welfare to Work Program •jm axenrtDt from Welfare to Wcrk requirements* I

do not meet one of the above categories for exemption I i

:rovide verification of disability, unless it is on rile with HANH," Provide verification from employer" Provide verification from school*~ Provide verification from agency

have received a copy of HANH's (SSS) Policy, and I have read A understand the contents of the policy,understand that failure to comply with this requirement may result in nonrenewal of my family's lease.

31 gnature __^_____ Date

Name of Adult:I certify that I am exempt from [he SSS requirement because:

! ,3m aqe 62 ori have a disability that prevents me from working L_~I am the caretaker of a person with a disability |I am working at least 30 hours a week I II am i full-time student! 1i am participating in a Welfare to Work Program L II am exempt from Welfare to Work requirements) I

I do not meet one of the above categories for exemption I i

Provide verification of disability, unless it is on rife with HANH."• Provide verification from employer- Provide verification from scnool- Provide verification from agency

I '"aye received a copy of HANH's (SSS} Policy, and I hgve read A understand the contents of the policy.! understand that failure to comply with this requirement may result in nonrenewal of my family's lease

.'onature Cate

Verification of Participation inSelf-Sufficiency and Community Service Activities

Name or Participant:

Employer/Agency Name:Address: __Contact Person: _____Phone #: Fax*:

To Employer or Agency: HANH thanks you for maintaining records of this person's participation inself-sufficiency- or community service-related activities. During the next year or so, HANH will ask youto provide third-party verification of this participant's activities with your organization. Please maintaincopies of this form until it has been received by HANH, or for at least 2 years from the start date. Ifyour organization has a different form that you use for recording such activities, your own form isequally acceptable.

Date \s ', Work/Service Performed I Signature ;

This form may be duplicated.

zmployer/Agency: Please maintain a copy of this form for at least 2 years. During this period, HANH'.viil contact you for third-party verification of the participant's activities.

Participant: Please maintain a copy of this form until your household's next certification is complete.

iiuusir.t; Authority of the City of New HavenLease Addendum for Drug-Free Housing

11 consideration of the execution or renewal of the lease for the dwelling unit identified in the.oa.se. HANH and sou agree to the following terms and conditions of HANH's "one-strike"

jviction policy tor criminal activity on HANH premises and for drug-related criminal acti\y on•r oil" the premises:

1 . You. any member of your household, or a guest, visitor or another person under your•ronirol >hall not engage in criminal activity in common areas, or on the grounds thatthreatens [he health, safety or right to peaceful enjo\ment of other tenants or employeesnf HANH or any drug-related criminal activity on or off the premises tjr developments.

I. You. any member of your household, or a guest or visitor or another person under yourcontrol shall not engage in anv act intended to facilitate criminal activity which threatens'he health, safety or rmht to peaceful enjoyment of the tenants or employees of HANH orany drug-related criminal activity on or off the premises or developments.

:. You. any member of your household, or a guest or visitor or another person under yourcontrol shall not permit the dwelling unit to be used for or to facilitate criminal activitywhich threatens ihe health, safety, or right to peaceful enjoyment ot the tenants oremployees of HANH or drug-related criminal activity, regardless of whether theindividual engaging in such activity is a member of the household or a guest or visitor.

4. Neither you nor any member of your household shall engage in the illegal manufacture,-ale. distribution, use or possession of illegal drugs at any location, whether on or oif11ANH property.

5. Neither you nor any member of your household, a guest or other person under thetenant's control shall engage in acts of violence including, but not limited to. the unlawfuliischarueof firearms on or off the premises and developments.

n. VIOLATIONS OF ANY OF THE ABOVE PROVISIONS SHALL BE A MATERIALVIOLATION OF THE LEASE AND GOOD CAUSE FOR TERMINATION OFTENANCY. A single violation of any of the provisions of this addendum shall bedeemed a serious violation and material noncompliance with the lease.

7. (t is understood and agreed that a single violation shall be good cause for termination of'his Lease and that proof of any of the violations named above shall not require an arrestor criminal conviction, but shall he by a preponderance of the evidence.

S. This Lease Addendum is incorporated into the Lease executed or renewed this dayBetween HANH and tenant.

D A T E : DATE:

IANH REPRESENTATIVE Head of Household

Ministerio iie V'ivlenda tic ia Ciuuau lie Mew Haven(Mousing Authority of the City of New Haven)

Vpendice al contrato de arrendamiento en respaldo de las v iviendas libres de

i - .n eomraprestacion de la firm a o renovacion del contrato de ulquiier de la imidad de \a klentiticadu_ ' i i d inencionado documento. H A N H \d acuerdan regirse por los Mguiemes lerminos \sic la p u l n i c a de de.salojo de HANH basada en « u n solo crror» en v i r tud de la realizaeion de actividadesi e l i cnvns en las instalaciones de HANH y de actividades delictivas relacionadas con drogas. dentro ol u c r n de las instalaciones:

1 , Ni listed ni m 11 turn integranre de su \i\. invitado. visita u otra persona bajo su supervision,podran llevar n cabo mnguna actividad delictiva en las areas comunes o en el terreno, qiie.inienace la salud. la seauridad o derecho at goce pacitlco de otros inqui l inos o empleados de11ANH. ni n inguna actividad del ic t iva relacionada con drogas, dentro o f'uera de las instalaciones0 cumplejos habitacionaies.

2. Ni listed ni n i n u u n integrante de su v iv ienda. invitado, v i s i t a u otra persona bajo su supervis ion,podran llevar a cabo ningun.acto_destinado_a prornover una actividad delictiva que amenace la-alud. seguridad o derecho al goce pacitlco de otros inquilinos o empleados de HANH. nininguna actividad delictiva relacionada con drogas. dentro o f'uera de las instalaciones ocomplejos habitacionaies.

j. N'i listed ni ninui'm integrante de su hogar, invitado. v i s i t a u otra persona bajo su supervision,podran permitir que la unidad de vivienda se ut i l ice para l levar a cabo o prornover una acnvuladJc l ic t iva i|iie amenace la salud. seguridad o derecho de goce pacitlco de otros i n q u i l i n o s oempleados de HANH, o una actividad delictiva relacionada con drogas. independientemente de sila persona que realiza dicha actividad es un integrante del liogar o un invitado o visita.

4. Ni usted ni niniiiin integrante de su hogar podran participar en la tabricacion. venta. distribution,'iso o posesion de drogas ilicitas en nint^t ina ubicacion. va sea dentro o tiiera de la propiedad deHANH.

?. Ni usted ni n i n g u n integrante de su hogar. invi tado u otra persona bajo la supervision deli i i q u i l i n o , podran llevar a cabo actos de violencia, incluvendo, a t i tu lo e jempl i f lca t ivo . el disparoil ici to de armas de fueao dentro o f'uera de las instalaciones y complejos habitacionaies.

•x LAS VIOLAC10NES DE CUALOUIERA DE LAS DISPOSICIONES ANTFRIORESt (JNSTITUIRAN UNA VIOLACION SUSTANCIAL DEL CONTRATO DE\KRENDAM1F.NTO Y UNA CAUSA SUFICIENTE PARA LA RESCISION DEL MISMO.

1 'na sola violacion de ahzuna de las disposiciones de este apendice se considcrara como unavmlac ion urave y un i n c u m p l i m i e n t o sustancial del contrato de arrendamiento.

'. 9ueda comprendido y acordado que una sola v io lac ion consti tuira causa sutlciente para la;vicisi6n del contrato de arrendamiento y quo la evidencia de aliiuna de las violacioncs.ncncionadas con antenoridad no requenra un arresto m condena penal; sin embargo, si-uiistituiran una preponderancia de evidencia.

^. L! presents apendice al contrato de arrendamiento queda incorporado a dicho contrato cclebrado> ' ix-novado el dia de hoy cntre H A N H y el i n q u i l i n o .

i rC ' i lA: I-'ECHA:

l iPRESEN I'AN I'E DE HANH '-.-re uc v iv ienda

Authority ot the City ot New HavenPolicy on Installation utf Satellite Dishes

!us document; out l ines the po l i cy of the Housing Auihonty of New Haven, C T regardingjMuent in s t a l l a t ion or sate l l i te dishes, This policy implements signif icant restrictions on:-.e ab i l i ty or' residents to ins ta l l satellite dishes or other communications devices w i t h i noinmon areas or shared spaces. These restrictions cul ly comply w i t h guidelines set by:e Federal Communications Commission (FCC).

.1 accordance w i t h FCC guidelines. l iANH residents may ins ta l l sa te l l i te dishes only

.nuer all ot the fo l lowing conditions:

1. Satellite dishes ninv not exceed one meter in diameter..\esidents are not allowed to install satellite dishes that exceed one meter t 3 Feet jinches) in diameter.

2. Satell ite dishes mav he installed only inside of apartments or on resident'se patios Inhere these existl.

satel l i te dish installation is restricted to locations under the full and direct controlof the resident in accordance with a [ease, fhis includes inside of apartments or• > n decks or porches that are for the exclusive use of the resident withoutBasement. Satellite dishes cannot be installed on common area walls, in common.ireas. on roots or canopies. Satellite dishes cannot be installed on any porches urpatios that are for the exclusive use of (he resident if those areas require easementiccess by other residents.

3. Satellite dishes mav not he installed in a manner that could cause damage toJMii ldinas or injury to persons. »r in a manner that would allow them themi mm em to fall on people or property.

Clamp mountings must be used rather than drilling holes in railinas or exterior•'.ails during installation of satellite dishes ( w i t h i n the limits set out in this policy).Mounting of satellite dishes may not be done in a manner that harms the bui ld ing-•nvelope or in a manner that poses a risk to electrical wiring, water pipes ur other'-".aiding systems or components. No pan of the satellite dish may protrude orjxiend bevond the .side of a balconv. wail or window.

Satel l i te dishes must he professionally installed.\ny installat ion ot dishes ( w i t h i n the l imi t s set out in this po l i cy ) must be.umpleted by quali t ied installers. Installers must carry l i ab i l i t y and worker 's:ompensation insurance at levels consistent with HANH policy, local and State.aw. Instal lers must produce proof of l i ab i l i ty and workers compensation:isurance to obtain HANH permission for instal lat ion.

5. Residents must obtain written permission from HAMH before instal l ing.lU'llite dish equipment.

Ins t a l l a t i on of satellite dishes ( \ v i t h i n the limits set out in this po l i cy ) can occuri i iy .uter resident and installer have received the wr i t t en approval of HANH.

i l A N H \v i l l not unreasonablv \vuhhold such approval, as long as al l requirements.-Jt out in ihis policy are met. HANH wil l require detailed mlbrmation from theresident and installer concerning the nature and location of the installation, and11ANH will ensure chat the installer possesses all necessary insurance before..oprovmg installation.

it. Indemnification :ind Resident ResponsibilityResident agrees to hold harmless and indemnity the Housing Authoruy of New; taven. including its employees and agents and representative from any claim or'awsuit arising from the ownership, installation or use of satellite dishes. Resident-hall be responsible for all costs associated wiih installation ( w i t h i n the limits setout in this policy), maintenance and removal of the satellite dish.

Ministcrio de VivienJa de la Cludaii de New Haven(Mousing Authority of the City of New Huven)

I 'ol i t ica sobre la inst i l lat ion de antenas satelitales

_i presence documento describe la pol i tka de la . \utondad de Vi \a de New Haven.."ounecticut. respecto de la instalacion de antenas satelitales de pane de los residences.!=ra polmea implementa restncciones s iamfkai ivas sobre la capacidad de los residentes:•: nisialar antenas sateiirales u otros dispositivos de eomunicaeion dentro de las areasjmunes o espacios compartidos. Estas restncciones cumplen mtegrcimente con los.neamientos estipulados por la Comision Federal de Comunicaciones i Federal

Commission - FCO.

''Mirbrme j Ins lineamiemos de la FCC. los residentes de HANH podran instalar antenas.ueli tales solamente de acuerdo a las siguientes condiciones:

1. l.a.s_ante_nas satelitales no podrnn tener mas tje unjne^ro dejlia metro.No se permite a los residentes instalar antenas satelitales que tengan mas de unn e i r o i j pies. 3 pulgadas) de diametro.

1. La.s antenas satelitales podran instalar^e solamente dentro de losilepartamentos o en los patioa nriv_a_ijos de los residentes (t'ii_lovcaso_3 <iugvorrespjindaj.La instalacion de antenas satelitales se encuentra restnngttda a los lugares bajo ei•:ontrol total v directo del residenie, conrbrme al contrato de arrendamiento. £ito'iicluye la pane mtenor de los departamentos o las terrazas o porticos que scan de;so exclusive del residente y que no cuenten con servidumbre. Las anrenas•atelitales no podran instalarse en las paredes de las areas comunes. Jentro de las.ireas comunes, nt en los techos o toldos. Las antenas satelitales no podran-nstalarse en nmuun portico o patio que sea de uso exclusive del residence siiichas areas requieren ei acceso de otros residentes en virtud de una servidumbre.

j. Li_is_ante_nas sajclitales no podran instalarse de forma_tai_qae pudienn'-ni.sar un dano a los edificios ojeisiones a las persojias^ ni de forma nil tjueiMHJieran iiencrar_ji.ue_ei_equipo_c_aii;;|_sj)bre personas o hienea.' )cben utilizarse montaies asegurados con pmzas en luuar de taladrar hoyos en. :clcs o paredes extenores durante la instalacion de las antenas saielitales I dentro

!<_• Ins l imi tes establecidos en esta pol i t ical . LI montaje de antenas sateiitates no;oUra realizarse de forma tal que darie la esiructura dc la propiedad o de forma taijue presence un nesgo para ia instalacion electnca. carierias de agua u otrosi^i^mas o uomponentes del cdilicio. Nintzuna pane de la antena satelital podraui?r<, lsaJir ni extenderse mas alia del lateral de un balcon. pared o ventana.

1. -AS untenas sutciitaies deben instalarse de t'orma nrot'esinnaj.!Vda mstaiaeion de antenas saielitales (dentro de los limites establecidos en esta/ o h s i c a j debe :;er realizada por instaiadores cemlicados. Los instaiadores Jeben. - M i t a r con un aeguro de responsabilidad e mdemnizacion de trabajadores a ;ui: ; \ e l que c iunpla con la pol inca de HANH y la leuislacion local y cMatal . L^s: lit j t adores deben presemar una prueba de responsabilidad y un senuro de

•udemnizacion de trabajadores a tin de obtener el permiso de HANH para la.istatacion.

Los residentes deben obtener el permiso escrito de HANH antes de in.stalar elde In untenu satelital.

i.a instalacion de antenas satelitales identro de los limites establecidos en esta, 'oiitica) podra realizarse unicainente luego de que el residente y el instalador'uibieren recibido la autonzacion escrita de HANH. HANH no reiendra dichaimonzacion de t'orma irracional. siempre que se cumplan todos tos requisites.stipulados en esta politica. HANH requerira inlbrmacion detallada de pane del.csidente y el instalador respecto de la naturaleza y lugar de la instalacion. y r^ei^euurara de que el instalador cuente con todos los seguros necesanos antes deiprobar la instalacion.

Indemnizacion v re.snonsabilidad del residenteLl residente acuerda liberar de responsabilidad e indemnizar a la Autoridad de'v'ivienda de New Haven, incluidos sus empleados, mandataries y represemantes.Je cuaiquier reclamo o accion leual que surja en virtud de la propiedad.instaiacion o utilizacion de antenas satelitales. El residente sera responsable derodos los costos asociados con la instalacion (dentro de los limites estlpulados en.sta politica). mantenimiento y remocion de la antena satelital.

Memorandum ot" UnderstandingInstallation of Satellite Dish

I. I 'arties: Hie parties to this Memorandum ot" Understanding regarding.ustaikuion of a satellite dish i Referred to as MOL'1 are the Housing Authority ofNew I laven. CT. ( Referred to as HAMH). and

i Referred to as Resident(s). ' Sometimes collectively ret'erred to as the "Parties")

2. Residential Location

The above-named resident hereby stales that he/she resides at the residence listedabove.

•3' Terms: The resident(s) agrees that he/she will install a satellite dish at the aboveresidence location in full conformity with the HANH Policy on Installation ot'Satelli te Dish. A copy of this policy is attached to this agreement and may beobtained from the HANH Asset Management Office at 360 Orange Street. NewHaven. CT.

4. Default: In the event that Resident installs a satellite dish in a manner that doesnot conform to the HAMH policy regarding the installation of satellite dishes,then Resident agrees and understands that such improper installation mayconstitute a violation of his/her lease agreement with HANH. Resident agrees-aid understands mat he/she is responsible for correcting and/or removing anyimproperly installed satellite dish and shall also be responsible for any costsassociated therewith.

5. 1 ndemnificatiqn: Resident(s) hereby agrees to h old harmless and indemnifyHANH. their officers and directors, employees, agents, representatives andassigns from any claims and/or lawsuits asserted HANH. their officers anddirectors, employees, agents, representatives arising from the ownership,installation or use of satellite dishes.

6. Read, Understood and Voluntarily Signed MOU: Resident!s) states that he/shehas read this MOU and that he/she fully understands the agreement and'.oluntarily agrees to abide by the provisions of the agreement.

Resident is) Date HANH Date

Memorando de entendimientoInstalacion de antenas satelitales

Partes: las panes de este Memorando de entendimiento respecto de la ins ta lac ion Je'menus satcl i tales idenommado .MOD. por sus siglas on ing le s ) son la Autondad JeV i v i c n d a de New Haven. Connecticut, (denommada HAMHX v

Icnominado el «Residente»). .\lgunas veces se uti l iza el termino ^Partes» parai te r i r se a eilos en forma colect iva) .

. rbicacion residential

1:1 Residente rnencionado con anterioridad declara por medic del presence que reside enla \ i v i e n d a mencionada antenormente.

3. Terminos v condiciones: el Residente acuerda que instalara una nntena sateli tal en laubicacion residencial mencionada antenormente de plena conrbrmtdad con la Poh'ticade HANH respecto de la instalacion de antenas satelitales. Se ad junta a este acuerdouna copia de la mencionada politica y puede obtenerse de la Otlcina de Gestion deActives de HANH. sita en 360 Orange Street. New Haven, Connecticut.

4. Incumplimiento: en caso de que el Residente instale una antena satelital de forma talque no cumpla con la politica de HANH respecto de la instalacion de antenas

ateli tales. el Residente acuerda y comprende que dicha instalacion indebida puedeconstituir una violacion de su contrato de arrendamiento con HANH. LI Residente-icuerda y comprende que es responsable de corregir y/o retirar todas las antenasatelitales instaladas de forma indebida y que tambien sera responsable por todos los

-ostos asociados a esta actividad.

5. Indcmnizacion: por medio del presente, el Residente acuerda l iberar deresponsabilidad e indemnizar a HANH, a sus encanzados y directores. ompleados.inandatarios. representantes y herederos de cualquier reclame y/o accion legal contra1 i ANH. sus encargados y directores, empleados, mandataries y representantes quepudieren surg i r en v i r t u d de la propiedad. instalacion o ut i l izacion de antenasatelitales.

'). MOl' It'ido. comnrendido v Urmado cnj'orrna vojuntaria: el Residente acuerda,iue ha leido el presente MUU y que comprende integramente el acuerdo y accpta enfo rma vo lun ta r i a c u m p l i r con sus disposiciones.

c h a I I A N h i

Application — Exemption, from Minimum Rent of S50

For Households that are currently paying the Minimum Rent of $50.00:Households with an annual income below 52,500 annually shall pay the minimumrent of $50.00. All families placed on minimum rent must be informed of theExemption from Minimum Rent and the ability to have Minimum Rent waived. Allresidents on minimum rent with the exception of elderly and person withdisabilities must be referred to the Family Self Sufficiency Program.

I f a family is unable to pay the minimum rent because of a financial hardship theramily may be eligible for a temporary or long term waiver from paying MinimumKent. Minimum Rent can be waived once during a twelve month period. Thislimitation does not apply to Elderly and Disabled families. Families may receivef h i s exemption more than once during a twelve month period if at least one adult isengaged in the Family Self Sufficiency Program. HANH will suspend theminimum rent requirement for 90 days effective as of the first of the nextmonth after the date this application is received.

A family is automatically exempt from Minimum Rent for 90 days when thefollowing occurs:

1. When the family has lost eligibility or is awaiting eligibility determinationfrom a Federal, State or local assistance.

2. When the family would be evicted because it is unable to pay the minimumrent.

3. When the income of the family has decreased because of changing<:ircumstances, including loss of employment, death, or other event.

4. Other circumstances determined by HANH to be reasons to waive theminimum rent requirement.

While the request for exemption from Minimum Rent is reviewed, HANH willnot pursue eviction for non-payment of rent.

For Long Term exemption from minimum rent (more than 90 days), the minimumrent is suspended immediately until the Hardship Committee meets to determine.vhether the hardship is temporary or long term and implements a recommendation.

:nl!c;uion tor M&

[f the exemption from the mmimun rent of $50 is determined to be temporary youwill have the right to enter into a reasonable repayment agreement with HANH for"he amount of the minimum rent that was suspended.

Any family that is unable to attend the meeting due to a disability may requesta Reasonable Accommodation. Please contact Teena Bordeaux at 203-498-SSOOX1507.

, 'LJlicjt ioti mr MR._' '.il

Solicitude— Exenciont del alquiler minimof de S5tt

i'ara familias que actualmente pagan el alquiler minimo de $50.00:Las familias con un ingreso anual infenora 52,500 pagaran el alquiler minimo deS50.00. Todas las tamilias que pagan un alquiler minimo deben ser inlbrmadas de'a Exencion del alquiler minimo y la posibilidad de quedar exentas del alquilerininimo. fodos los residentes que pagan un alquiler minimo, salvo los ancianos y[as personas con discapacidades, deben ser referidos al Programa deAutosutlciencia Familiar.

Si una familia no puede pagar el alquiler minimo debido a una dificultad.inanciera, la familia puede ser elegible para una exencion temporal o a largo plazodel pago del alquiler minimo. El alquiler minimo se puede eximir una vez duranteun penodo de doce meses. Este limite no se aplica a las tamilias de ancianos ydiscapacitados. Las tamilias pueden recibir esta exencion mas de una vez duranteun periodo de doce meses, siempre y cuando al menos un adulto participe en elPrograma de Autosuticiencia Familiar. La Autoridad de Vivienda de la Ciudadde New Haven < HANH) suspendera el requisite de alquiler minimo durante 90dias a partir del primer dia del mes siguiente a la tec ha en que se recifaa estasolicitud.

Una familia queda automaticamente exenta del alquiler minimo durante 90 diascuando ocurra lo siguiente:

1. Cuando la tamilia haya perdido la elegibilidad o este esperando unadeterminacion de elegibilidad de un programa de asistencia local, estatal ofederal.

2. Cuando la tamilia este a punto de ser desalojada por no poder pagar elalquiler minimo.

3. Cuando los ingresos de la familia hayan disminuido por distintascircunstancias, que incluyen la perdida del empleo, el tallecimiento u otrascircunstancias.

4. Otras circunstancias que la HANH determine como motivos para eximir elrequisito de alquiler minimo.

Mientras se revise la solicitud de exencion del alquiler minimo, la HANH noordenara el desalojo por la talta de pago del alquiler.

XV1

Cn los cases de exencion a largo plazo del alquiler minimo (mas de 90 dias), eiliquiler minimo se suspende inmediatamente hasta que el Comite de Dificultades•e reuna oara determinar si la dificultad es temporal o a largo plazo, e irnplemente:iia recomendacion.M se determina que la exencion del alquiler minimo de S50 es temporal, usted•endra derecho a llegar a un acuerdo de pago razonable con la HANH por el montoiel alquiler minimo suspendido.

La Camilla que no pueda asistir a la reunion debido a una discapacidad puedesoiicitar una adaptacion razonable. Pongase en contacto con Teena Bordeauxllamando al 203-498-8800, e\t. 1507.

'ill Je Etcn

Application— Exemption front Minimum Rent:

Please check either Ves or No

€ Yes, I want to apply for Exemption from Minimum Rent.€ No, I do not want to apply for Exemption from Minimum Rent.

Please till in below;

Name:

Address:

City, State. Zip:

Telephone it:

Signature: Date:

Reason:

Nameot 'HANH Representative

n tor M R Fx^rnonon

Solicitude— Eiencidtt del alquiler minimo

Marque "Si" o "No"

€ Si, deseo soiicitar la Exencion del alquiier minimo€ No, no deseo soiicitar la Exencion del alquiler minimo

Complete los siguientes datos;

Nombre:

Domicilio:

Ciudad. estado, codigo postal:

Numero de telefbno:

Firma;

Motive:

Fecha:

Nombre del Representante de fa HANH:

AM

Application for Tfereti Rent Waiver:Hardship Exemptions

Consistent with HANH's Moving to Work Rent Simplification Policy, Households that.re experiencing exceptional expenses that create a financial hardship may request a rentreduction. Rent reductions must he based upon financial hardship related to extraordinaryvieductions or extraordinary cost of living. This request is to be rumished in writing.

Extraordinary DeductionsA hardship review and rent reduction can be requested by the family if its un-reimbursedmedical, un-reimbursed childcare expenses and/or un-reimbursed disability attendant careand auxiliary apparatus expenses exceed S6.000.00 annually.

Extraordinary Cost of LivingA hardship review and rent reduction can be requested by the family if its monthly totalshelter costs (tenant paid rent plus paid utilities), when combined with un-reimbursedmonthly medical expenses, as determined in accordance with 24CFR Part 5.611 (a)(3)(i),disability attendant care and apparatus allowance, as determined in accordance with 24CFR Part 5.611 (a)(3)(i i) and/or reasonable childcare expenses as determined inaccordance with 24 CFR Part (a)(4). exceed forty (40%) of a family's monthly income(.monthly income is defined as Annual Income divided by twelve).

All requests for Hardship Review and rent reductions shall be referred to and reviewed by:he Hardship Committee. Should a resident request hardship review but fail to attend thescheduled meeting, one opportunity to reschedule will be provided. If the resident fails toittend the second scheduled appointment no timber attempts to reschedule will be mademd HAiNH will determine that no hardship exists.

Rent Waiver Application

Solicited para eximir ei alquiler escalonadaExencion por diffcultadca fihancierag

Dt; ucuerdo con la Politica de simpliricacion de alquiler del Programa de empleo de laAutondadde Viviendade la Ciudad de New Haven (HANH), las t ami lias quej.xpenmenten gastos e.xcepcionales que les t*eneren una diticultad rinanciera pueden>olicitar una reduccion del aiquiler. Las reducciones del alquiler deben basarse en lasliricuitades rinancieras relacionadas con las deducciones extraordinarias o el costo devtda extraordinano. Esta solicitud debe presentarse por escrito.

Deducciones extraordinariasLa tamiiia puede soiicitar una revision de su dificultad tinanciera y una reduccion del.ilquiler si sus gastos medicos no reembolsados, sus gastos de cuidado de ninos noreembolsados y/o sus gastos por asistencia en el cuidado de personas discapacitadas y poripuratos auxiliares no reembolsados exceden los 56,000.00 anuales.

Casto de vida extraordinarioLa tamiiia puede soiicitar una revision de su diticultad tinanciera y una reduccion del.ilquiler si sus costos totales de albergue (alquiler mas servicios pagados) combinados conlos izastos medicos mensuales no reembolsados. determinados segun el Titulo 24 delCodigo de Regulaciones Federales (CFR) Seccion 5.611 (a)(3)(i), sus gastos por.isistencia en el cuidado de personas discapacitadas y por prestacion de aparatos,determinados segun el Hrulo 24 del CFR Seccion 5.611 (a)(3)(ii) y/o sus gastosrazonables de cuidado de ninos. determinados segun el Titulo 24 del CFR Seccion 5.611(a 1(4), exceden el cuarenta por ciento (40%) de los ingresos mensuales de la tamiiia (losingresos mensuales se detinen como los ingresos anuales divididos por 12).

Codas las solicirudes de revision de dificuitades rinancieras y reduccion de alquiler seranrereridas al Comite de Revision de Diricultades y seran revisadas por el mismo. Si un-esidente solicita una revision de dificultades rinancieras pero no asiste a la reunionprogramada. se ie bnndara una oportumdad para reprogramar la reunion. Si el residenteno asiste a la segunda cita programada, no se realizaran mas intentos por reprogramar la:ita y la HANH determmara que no existen dificultades.

ic i tud oara 0x11111 r ci . i l u u t l c r escaiuiiudo

Application foe Tiered Rent WaiverBTardsMp Exemptions:

Please check either Yes or No

I Yes, I want to apply tor a Hardship Review for Exceptional Expenses

No, I do not want to apply for a Hardship Review for ExceptionalExpenses

Please fill in below:

Name:

Address:

City, State, Zip:

Telephone #:

Signature:

Reason:

Date:

HANH Representative Signature

:--'rcd Rent W'liver Voplicat ion

Sollcitud para; esimir ek afquiler escalonadoExenciott por diffcultacf ies ffnancicra»

Marque "Si" o "No"

f~~| Si, deseo solicitar la revision de dificultades tlnancieras por gastosextraordinarios

No. no deseo solicitar la revision de dificultades tlnancieras por gastosextraordinarios

Complete los datos sr«uientcs:

N ombre:

Domicilio:

Ciudad, estado, codiuo postai:

Numero de telefono:

Firma:

Motivo:

Firma del Representante de la HANH

.'h'citud n;ira c.xnnir cl .ikmilor escalonado

ELM CITYj.nivi.;-; r > : S

Karen DuBois-Walton

*!iis is to cxrtifv that I have read and received a copy if the residentsRight to Request 3 Reasonable Accommodation

[ have also nad the rights explained to me in a clear and concise manner.I understand these rights as they apply to me.

Signature Date

-Ijme (Printed)

"his is to certify that I have received a copy of "Protect your family from Lead in your Home"

Signature Date

Print flame

-Jdress

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN

Applicants and Residents Rightto Request a Reasonable Accommodation

i f you have a disability and you need:• A change or waiver in the rules or policies of the property\program to make it easier to live

n your unit, use the common facilities or participate in the special programs located on theproperty;

• A physical modification in your apartment or to some other feature of the property in which.vould make it easier for you to reside in your unit or use the facilities located on theproperty;

» A more eTfective means of communication to provide official information or permit you tocontact the management office.

Then you can request these modifications or expectations as to how the property or programconducts its operations by making a request for a Reasonable Accommodation. The right to,-equest a Reasonable Accommodation is established under federal and state law.

if you have a physical or mental limitation (Disability), which meets the legal definitions underfederal and state law, and have a request that is not too expensive or does not require afundamental change to the nature of the program and this request will provide you with improvedjccess to the program and facilities of the Authority, then we will try to fulfill your request.

You make this request in writing (with our assistance, if needed) using a ReasonableAccommodation Request Form. If you need assistance completing the Request form, we canassist you. If you need more information about our procedures, we will explain them in manner that:s fully comprehensible by you. If this requires the use of sign language or another alternative formof communication, we will attempt to meet your needs.

We will give you an answer within thirty (30) calendar days if our receipt of a ReasonableAccommodation Request unless there is a problem getting the information we require to verify the3ppropnateness of the request. If we require more time we will notify you and explain the reasonfor the delay. We will let you know if we require more information or if we would like to propose analternative solution, which has an equal outcome to the accommodation requested.

If we turn down your accommodation request, we will provide a reason, and you will have anopportunity to provide additional information before we consider the matter closed.

You can obtain a Reasonable Accommodation Request Form at the Service Center, The AssetManagers office, and the Main Office 360 Orange Street, New Haven 06511

Yes, I would like to request a Reasonable Accommodation for my household

No. I would not like to request a Reasonable Accommodation for rny household

'•lame

.•qnature Security*

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN

YOUfrRIGHTTO REQUEST ACCOMMODATIONS^DISABILITY

Persons with disabilities have the right to request reasonable accommodations

"sderal laws provide specific rights and protections to ensure equal opportunity for persons withDisabilities. HANH will make reasonable accommodations in our rules, policies, practices, or:ervices, including modifications to our public housing apartments, when such accommodations2re necessary to afford a person with disabilities equal opportunity to use and enjoy their housing,or to equally participate in or access HANH's housing programs and services.

How to request an accommodation of disability

HANH's "Request for Accommodation of Disability" form provides the necessary information andjuthonzations. HANH's reasonable accommodation forms are available at all HANH offices.HANH will provide assistance if needed to help you complete these forms.

You should receive a written response to your request within 30 days. If HANH is not able to make3 decision on your request within that time period, or if HANH requires further verification, HANHMil notify you in writing.

HANH will require verification of your request

HANH requires the following verifications of requests for accommodations of disability by aphysician or other licensed practitioner that you have authorized for this purpose.

• Verification that the person is a qualifying person with disabilities.• Verification that there is a direct relationship between the nature of the person's disabilities

and the accommodation requested.• Verification that the accommodation is necessary for the person to have equal opportunity

'.o use and enjoy their HANH housing, or to equally participate in or access HANH'shousing programs and services.

HANH has established a "Verification of Accommodation Request" form that your doctor orlicensed practitioner should use to provide verification. This form is available at all HANH offices.^oproval of reasonable accommodation requests will depend upon verification of the specificstandards that are specified in the 'Verification of Accommodation Request" form. You may submitdoctor's tetters, but please note that doctor's letters often do not include the specific verificationsrequired for reasonable accommodations and, in most cases, will require additional verification of•he standards provided in the "Verification of Accommodation Request" form.

HANH's Reasonable Accommodations Coordinator

; f you have questions or would like additional information about an accommodation request, youmay contact HANH's Reasonable Accommodations Coordinator:

~:-ena Bordeaux: 50 Orange Street, New Haven, CT C6511-hone: (203) 498-8800 ext. 1002rix: '^03)-197-3723~:rnil: ;borrieaux(d)hanh-ct.Qrq

HOUSING AUTHORITY OF THE CITY OF NEW HAVEM

YOUR RIGHTTOREQUESrACCOMMODATIONS OF DISABILITY

Las personas con incapacidades tienen el derecho da pedir comodidades razonables

LJS iteyes federates proporcionan los derechos y protecciones especificas de asegurar ta<}ualdad da oportunidades para las personas con incapacidades. HANH hara comodidades;3zonables en nuestras reglas, politicas, practicas, o servicios, incluyendo modificaciones anuestros apartamentos de vivienda cuando tales comodidades son necesarias a una personacon incapacidades dar cportunidades de igualdad para utilizar y gozar de su vivienda, oparticipara igualmente adentro o tendra acceso a los programas y de los servicios de cubierta-je HANH

dComo pedir una comodidad por alguna incapacidad?

La forma de HANH el 'Request for Accommodation fo Disability" provee la informacibn y laslutonzaciones necesanas. Esta forma esta disponible en todas las oficinas de HANH. HANHf3Cilitara ayuda si es necesano para llenar el formulario,

Usted debe recibir una respuesta escnta a su peticibn en el plazo de 30 dias. Si HANH nopuede tomar una decision a su peticibn dentro de ese plazo, o si HANH requiere venficacibnjdicional, HANH le notificara por escrito.

HANH requerira la verificacion a su peticion

HANH requiere las venficaciones siguientes a su peticion para las comodidades razonables deincapacidades a su medico o de otro medico que usted ha autorizado para este fin.

• Venficacion due la solicitante es una persona con incapacidades.• Verificacion que hay una relacidn directa entre la naturaleza de las incapacidad de lapersona y la comodidad solicitada.• Venficacion que la comodidad es necesaria para que la persona tenga igualdad deoportunidades de utilizar y de gozar de su vivienda, o participar igualmente adentro ofaner acceso a los programas y a los servicios de cubierta de HANH.

HANH ha establecido una forma para la "verificacion de la peticion de comodidad" que sudoctor o medico autorizado debe utilizar para proporcionar la verificacion. Esta forma esta'jisDonrble en todas las oficinas de HANH. La aprobacibn de las peticiones razonables de la•:omodidad dependera de la verificacion y los estandares especificas que se detallan en laforma. Usted puede someter cartas de su doctor, favor de observar que las cartas del doctor noincluyen a menudo las venficaciones especificas requeridas para las comodidades razonablesy, en la mayoria de los casos. no requenran la verificacion adicional de los estandares.oroporcionados.

Coordrnador da HANH para la solfcitud de las comodidades razonable es:

Ce tener alguna pregunta o de necesitar alguna informacibn adicional sobre su solicitud estapeticibn de comodidad. usted puede comunicarse con la coordinador de HANH:

7eena Bordeaux>30 Cranqe Street. Mew Haven, CT C3511-hone: (203) 498-3800 ext 1002?3x: '203)497-3723

[NO-INCOME AFFIDAVIT

Tate: 3ecert Month: ELM CITYcommunities

Head of Household Name:

Applicant/Tenant Name: _

Address:

SSN:

•-•iHiSinji -iuincritv Ol New i-Mve

Karen OuBois-WaltonExecutive Director

You are either an applicant for, or participant in, a federally funded housing assistance program. Pteaseprovide the information requested and return to our office personally or via mail in the enclosed self-addressed stamped envelope as quickly as possible to avoid delay of your benefits in the housing ChoiceVoucher Program (Section 8).If you have any questions, please call at (203) 498-8800, Ext

LEASE NOTE: THIS FORM MUST UK NOTARIZED

_, hereby swear and affirm that I do NOT have any income. ThisIincludes but is not limited to income from any of the following:

1. Wages, Public Assistance (TANF, GR, etc.), Social Security, SSI, etc.;2. Child Support, Alimony, or regular monetary gifts from family or friends, etc.;3. Assets (homes, stocks, etc.; may be inherited property);4. Interest Income from Savings, Checking, Christmas Club and other bank accounts, IRA's, Certificates of

Deposit, Money market Funds, Credit Unions, etc.;5. U. 5. Saving Bonds, Stocks or Bonds of any kind;6. Pensions, Annuities, Retirement Funds, etc. (this includes benefits you may receive from being a

beneficiary of a life insurance or retirement plan);7. Whole Life Insurance;3. Real Estate Property, Earned Income Tax Credit, etc,;9. Burial Plots; and/or10. ANY OTHER INCOME (includes tips, property sold, babysitting, etc.).

Aoplicant/Participant Signature: Date

Subscribed and sworn to before me, a Notary Public, in and for County of

3nd State of Connecticut, on

this _day of , 20 .

Notary Public Signature

My Commission Expires

Bousing Authority of the City of Mew Haven's Elm City Communities;-:iO Oronce Street, P.O. Box 1912, New Haven, CT 06511.103) i^-8BOO • r"0f203) 497-8341 ••.vww.newn.ivenrousinq.arg

AFFIX SEAL HERE

**" \! Rle 1 S. Section I t j f l l Dl'-htf 1 'niieij Stales < \nie. -.tiles :h;it j cerson 'Aho kn<mmHiy ind '.villinaiy makes nl^::uiduli:iH ,t;itements to ,mv department or ^eney or" the L'nited Slates iJuvemment is guilty ol'i r'elonv.

DECLAKACION UK iNINGtiN liNGKESO

Mez de Recert: ELM CITYcommunities

\'ombre Oe Prmicipame:

Direction CiuJad/Estado

• j r , iicif* Aotnontv of *.«w n nen

Karen DuBois-Waltondirector

L'sted es un solicrtante o pariicipante en un prog ram a de avuda de vivienda fondada federalmente. Favor deproporcionjr la information requeririi a nuestra oficina personalmente o via el corrco en el sobre estampado,into diriaido y encerr.ido tan ripidamente como posible para evilar la demora de sus beneficios en elprograma de Seccion S Vivienda Publica Otro programs patrocinados. Si usted tiene cualquiera pregunta,;ior favor de llamar ;i| C03) 498-8800, Ext .

OTIC'IA: ESTK FOUMIJTAKK) TIENE OUR NOTARISADA

. juro y conlirmo que yo10,

\ tengo ingreso. H»to inciuye pero no es limitado a ingreso de cualquier de lo siguiente:1 . Los sueldos. la Ayuda Estatal (TANF, GR, etc.), el Seguro Social. SSI. etc.;2. El Apoyo del nino. la Pension, regalos monetarios regulares de la familia o amigos, etc.;.V Las ventaias [hogares. las acciones. etc.; la propiedad puede ser heredada);4. [rmresos de fnterese de Ahorros. Cuenta Corremie. el Club de la Navidad y otras cuentas

'\incarias. IRA's, los Ceniticados de deposito, los Fondos del mercado monetario.\creditan las Uniones. etc.:

5. Bonos de E.U.. las Acciones o Vinculade cualquier tipo;i. Las pensiones. las Anualidades. los Fondos de la Jubilacion. etc. (Esto inciuye los

reneticios que usted puede recibir de beneflciario de un plan de seguros de vida o Jubilacion);7. Los Seguros de vida enteros;M. La Propiedad de bienes raices. el Credito Ganado de Impuesto de renta. etc.;L > . El entierro frama; y/oi 0. CUALQUIER OTROS LNGRESOS (inciuye pumas, la propiedad vendio. el cuido de

:iinos. etc.)i;irma de Solicitante/Participante Tec ha

Subscribed and sworn to before me, a Notary Public, in and for County of

jnd State of Connecticut, on

this day of , 20 .

Notary Public Signature

My Commission Expires

AFFIX SEAL HERE

Authority or t-he '^,tr/ cf new Haven's Elm City CcnimunitiesOrnnae Sfrcet, QO. Box 1912, n*?w Haven, CT 06511) --H-riBOO • rTO/203) 497-.S34.J - '.vww r.'v/nivpn^nusr.^rr

•:MB NO. 2577 0266 p.<pires 04/30/2013

U.S. Department of Housing and Urban DevelopmentOffice of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONSPiperwork Reduction Notice: The information collection requirements contained in this notice have been approved by theOffice of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 {44 U.S.C. 3520) and assigned OMBcontrol number 2577-0266. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and a

person is not required TO respond to a collection of information unless the collection disolays a current valid OMB controlnumber.

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:Public Housing (24 CFR 960}

• Section 3 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)

• Section 3 Moderate Rehabilitation (24 CFR 882)

Proiect-Based Voucher (24 CFR 983)

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to PublicHousing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily orinvoluntarily terminated participation m one of the above-listed HUD rental assistance programs. This information ismaintained within HUD's Enterprise Income Verification *E1V) system, which is used by Public Housing Agencies (PHAs).ind their management agents to verify employment and income information of program participants, as wetl as, toreduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD inensuring that families are eligible to participate in HUD rental assistance programs and determining the correctjmount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUDregulations at 24 CFR 5.233.

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at theconclusion of your participation in a HUD rental assistance program. This notice provides you with information on whatinformation the PHA is required to provide HUD, who will have access to this information, how this information is usedind your rights. PHAs are required to provide this notice to all applicants and program participants and you arerequired to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

What information about you and your tenancy does HUD collect from the PHA?The following information is collected about each member of your household (family composition): full name, date ofbirth, and Social Security Number.

The following adverse information is collected once your participation in the housing program has ended, whether you/oluntarilyor involuntarily move out of an assisted unit:

1. Amount of any balance you owe the PHA or Section 8 landlord (up to 5500,000) and explanation for balance owed! i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other chargessuch as damages, utility charges, etc.); and

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and3. Whether or not vou have defaulted on a repayment agreement; and4. Whether or not the PHA has obtained a judgment against you; and5. Whether or not you have filed for bankruptcy; and6. The negative reasoms) for vour end of participation or any negative status (i.e. abandoned unit, fraud, lease

notations, criminal activity, etc.) JS of the end of participation date.

OMB No. 2577-0266 Expires 04/30/2013

',Vho will have access to the information collected?This in formation will be available to HUD employees, PHA employees, and contractors of HUD and PH As.

How will this information he used??HAs will have access to this information during the time of application for rental assistance and reexamination ofrid-iily income and composition for existing participants. PHAs will be able to access this information to determine afimily's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance tofamilies who have previously been unable to comply with HUD program requirements. If the reported information isAccurate, vour current rental assistance may be terminated and your future request for HUD rental assistance may bedenied fora ceriod of up to ten years from the date you moved out of an assisted unit or were terminated from a HUDrental assistance orogram.

How long is the debt owed and termination Information maintained in EIV?Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end ofparticipation date.

What are my rights?in accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to itsimplementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:1. To have access to your records maintained by HUD.2. To have an administrative review of HUD's initial denial of your request to have access to your records maintained

by HUD.3. To have incorrect information in vour record corrected upon written request,4. To file an appeal request of an initial adverse determination on correction or amendment of record request within

30 calendar days after the issuance of the written dental.5. To have your record disclosed to a third party upon receipt of your written and signed request.

What do I do if I dispute the debt or termfnatfon information reported about me?You should contact the PHA, who has reported this information about you, in writing, if you disagree with the reported.nformation. The PHA's name, address, and telephone numbers are listed on the Debts Owed and Termination Report.You have a right to request and obtain a cooy of this report from the PHA. Inform the PHA why you dispute theinformation and provide any documentation that supports your dispute. DisputesjjriustJ3e majjg._wjthjn_three_vgar_sfrom the end;_o_f_ participation date. Otherwise the debt.and termination ijiformation is^p/esurned correct. Only thePHA who reported the adverse information about you can delete or correct your record.

Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUO's EIV system.However, if you have included this debt in vour bankruptcy filing and/or this debt has been discharged by thebankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA withdocumentation of your bankruptcy status.

rhe PHA will notify you m writing of its action regarding your dispute within 30 days of receiving your written dispute.If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA'Jetermmes that the disputed information is correct, the PHA will provide an explanation as to why the information iscorrect.

This Notice was provided by the below-listed PHA: I hereby acknowledge that the PHA provided me with theDebts Owed to PHAs & Termination /Votlce:

or" ."S. ..010

"ignature

Dinted Name

ID. LEASE SIGNATURES

iv Mtininej below, HANH and the fenantts( enter into ihis lease and auree to all the Terms ;iml; niuitions ut' (he Lease.

IANH Representat ive

ol Household i\ne

hher Adult

A d u l t r )a ie

Other Adult Date

Tenant's Certification of Non-committal of fraud

, i ierebv ce r t i fy t h a t 1, ;ind other members ol nav Household.have not commuted fraud in connecaon w i t h anv federal housing program. I fur ther cer t i ty tha t allhiformaiion or documentation submitted by mvself or n i h e r household members 10 H^VNH in con nee (ion.v i ih :niv tcderat housing program (heiore and dur ing the lease term) are true and complete to [he best ot;.iy knowledge and belief.

Tenant's Certification of Receipt of Materials

i . , ' . i t j r ' jbv ce r t i fy t ha t [ have received the mate r ia l s marked bv:iv inu ia i s below and dial I unuersiand ihe terms, Conditions and remilations set forth therein.

Lease Addendum lor Drug Free HousingS u i t Suf f ic iency :ind Service Policv anu Lease AddendumResiden t Handbookr-!ANH Gricviince PolicyI.^ad-Uased Paint I n f o r m a t i o n pamphle t! ?-CUS()nable Accommodation Procedures and FormsSchedule of Maintenance OiartiesPet Ownership AgreementD a t e l i n e Dish PnlicvN u i s a n c e Complaint FormI n c i d e n t Repurt Form

love-Out N o t i f i c a t i o n Form

!i:i\ sido actualizado. Las viviendas que hubieren extravindo o danado su Manual recibiran una copia dei cL'inplazo por una mbdica suma. la cual se eslipulara en el Cronot>rama de curyos por manienimicnto.

lit. FIRMAS DEL CON TRATO HE AKRENDA.YIIENTO

Mcdiante la suseripcion a continuation. HANH y el Inijuilino uclebran el presente contra to de arrendamiento\n reqirse por sus terminos y condieiones.

Je HANH I\'i:ha

de vivienda l^cha

Ccrtitlcacion del Inquilino sabre la inexisteneia de fraude

E! que suscnbe. . por la presente certifies que ni el ni otros integranres de sulionar han cometido fraude respecto de n in sun programa federal de vivienda. Asimismo. ceninca que toda lamtbrmacion o documentacion presentada ante HANH por el que suscnbe u por ofros mtearantes del hosar enrolacion a cualquier proyrama federal de vivienda (antes y diirante ef plazo del alquiier) cs vernz y complera a su leal,_iber v entender.

("ertificaeion del Ittquilino sobre la recepcion de materiales

l-.l que suscribe. , por la presente certiflca que ha recibido los materiales'narcados con sus inicinles y que comprende los terminos. las condiciones y las regulaciones que en ellos se

n.

,\pendice al contrato de arrendamiento en respaldo de las viviendas libres de drosasIMlitica de independencia economica y servicios y apendice al contrato de arrendamientoManual del residentePolitita de presentacion de quefas de HANHrolleto con mformacion sobre la utilizacion de pmtura a base de plomoI'rocedimientos v rbrmularios de solicitud de adaptaciones razonables'.'rotiounima de carsios por mantenimientoVcuerdo de posesion de mascot as''olftica sobre la instaiacion de antenas sateliralesf7ormulario de queias por molestiasCormtdario de denuncia de incidentes.':urmulario de notifkacion de mudanza f'uera de la unidad

\? .\TION! OF ^F^TTCrM "*' 4 ST * TL-i 1 ix* \ iV_/i J W r ^j d v.- i I V> i ^ _- i -r O l i v i

>Jor ice to applicants and tenants: In order to be eligible to receive the housing assistanceBought, each applicant tor or recipient of housing assistance must be l a w f u l l y w i t h i n theU n i t e d States. Please read the Declaration statement carefully and sign and return to thei lousing Authority's Admissions Office. Please feel free to consult with an immigrationlawyer or other immigrat ion ex pen of your choosing.

certify, under penalty of perjury, that to:he best of my knowledge, I am lawfully w i t h i n the United States because:

[ 1 i am a citizen by birth, naturalized citizen or national of the United States.

1 have e l ig ib le immigration status and I am 62 years of age or older (anach proof of age).

I have eligible immigration status as checked below (see reverse side of this form forexplanations). Attach INS Jocument(s) evidencing el igible immigration status and

luned verification consent form.

[ ] Immigrant status under*! 00 l(a)( 15) or 10l(aX20) of the 1NAOR:[ ] Permanent residence under #249 of 1NAOR;[ ] Refugee, asylum or conditional entry status under #207, 208 or 203 of the

INAOR:f 1 Parole status under #212(d)(f) of the INAOR:[ ] Threat to l i fe of freedom under #243(h)of the INAOR;[ I Amnesty under f*254 of the INA

Signature ot Family Member Date

[ ] Check box if signature of adult residina in the uni t is responsible for a child named on.:atement above.

; 1A: Enter INS/SAVE Primary Verification # Date

Warning: 18 U.S.C. 1001 provides, amon^ other things, that whoever knowingly andwi l l fu l ly makes or uses a document or writing containing any false, fictitious or fraudulent>tatement or entry, in jny manner within the jurisdiction of any department or agency ofthe United States, shall be lined not more than S10.000 or imprisoned for not more than tlvevears, or both.

reverse side for footnotes Tnd in s tn i c r inns l

!Tie fo l lowing footnotes pertain to noncitizens that declare eligible immigration status inv i n e uf the fol lowing categories:

F.ligiblejm migration status and 62 years of age or older: For noncitizens who are 62 years of,^e or older or who wi l l be 62 vears or' age or older and receiving assistance under a Section 214jjwrea program on June 19. 1995. I t ' you are eligible and elect to select this category, you must.iclude a Jocument providing evidence of proof of age. No further documentation of e l ig ib le

status is required.

Immigrant status under tOifaX 15) or H)l(a)(201 of IN A: A noncitizen lawfully admitted for.•ermanem residence, as defined by 10l(a)<,2l)) of the Immigration and Nationality Act UNA), as.-n immigran t , as defined by 1 01 (a 1(1:51 of the IN A. S U.S.C. 1 I0!(a)(20)and I10i(a)(15). respectively [immigrant status j. This category includes a.luncinzen admitted under 210 or 210A of the INA (S U.S.C. 1 160 or 1 161), [special agriculturalvorker status) who has been granted lawful temporary resident status.

Permanent residence under 249 of INA: A noncitizen who entered the U.S. before January I ,1972. or such later date as enacted by law. and has continuously maintained residence in the U.S.iince then, and who is not ineligible for citizenship, bur who is deemed to be lawfully admitted:'or permanent residence as a result of an exercise of discretion by the Attorney General under 249of the I N A ( 8 U.S.C. 1259) [amnesty granted under INA 249].

Refugee, nsvlum or conditional entry status undgrj 07^.208 or 203 of IN A: A noncitizen who',s lawfully present in the U.S. pursuant to an admission under 207 of the INA (8 U.S.C. 1 157)[refugee status); pursuant to the granting of asylum (which has not been terminated under 208 ofine I N A (8 U.S.C. 1 1581 [asylum status |; or as a result of being granted conditional entry under:03(a)(7) of the INA (U.S.C. 1 153UX7) before April 1. 1980. because of persecution or fear ofpersecution on account of race, religion or political opinion or because of being uprooted bycatastrophic national calamity [conditional entry status).

l'.iroje status under 212(d1(51 of INA: A noncitizen who is lawfully present in the U.S. as aresult of an exercise of discretion by the Attorney General for emergent reasons or reasonsdeemed strictly in the public interest under 212(d)(5) of the INA (8 U.S.C. 1 182(d)(5) [paroleitatus|.

Threat to life or freedom_under_2_45(aLg_f INA: A noncitizen who is lawfully present in thei,.S. as a result of the Attorney General's withholding deportation under 243(h) ot the INA 18U.S.C. 1253(h)) [threat to l ife or freedom).

Amnesty under 245fa1 of Ihe INA^ A noncitizen lawfully admitted for temporary or permanentresidence under 245(a) of the INA (8 U.S.C. 1255(a)) [amnesty granted under INA 245(a)|.

Instructions to Housing Authority: Following verification of status claimed by personsdeclaring eligible immigration status (other than for noncitizens age o2 or older and receivingassistance on June 19. 1995), the HA must enter INS/SAVE Verification Number and date thati t was obtained. An HA signature is not required.

Instruct ions to Family Member tor Completing Form: On opposite page, print or type firstname, middle ini t ial(s) and last name. Place an "x" in the appropriate boxes. Sign and date atbottom page. Place an "X" in the box below the signature if the signature is by the adultresiding in the un i t who is responsible for the child.

,V.. 1. i-'urm vl

UOU31M; AUTHORITY OK THE CITY OF NEW HAVEN

NOTICE TO ALL APPLICANTS, RESIDENTS AND EMPLOYEES:Reasonable Accommodations for Applicants with Disabilitiea

The Housing Authority ot" the City of New Haven is a public agency that provides equal access tohousing, facilities, and services tor employees, residents, and/or applicants. The HANH is notpermitted to discriminate against applicants on the basis of their race, religion, sex, color, nationaludgin. age. disability or familial status. In addition, the HANH has a legal obligation to provide••reasonaole accommodations" to applicants if they or any family members have a disability.

A reasonable accommodation is some modification or change the HANH can make to its apartments oremployees work environment for procedures that will assist an otherwise eligible applicant with adisability to take advantage of the HANH's programs, facilities, services, and classes. Examples ofreasonable accommodations would include:

• Making alterations to the HANH unit so it could be used by a family member with a wheelchair:» Installing strobe type Hashing light smoke detectors in an apartment for a family with a hearing

impaired member:» Making large type documents, cassettes or a reader available to an applicant with a vision

impairment during the application process;• Making an interpreter available to an applicant with an impairment during the interview:• Permitting an outside agency to assist an applicant with a disability to meet the HANH's applicant

-creening criteria.

An applicant for housing through Low Income Public Housing (L1PH) or Section 8 that has a familymember with a disability must still be able to meet essential obligations of tenancy: they must beable to pay rent, to care for their apartment, to report required information to the Housing Authority, toavoid disturbing their neighbors, etc., but there is no requirement that they be able to do these things.viihout assistance. If there are problems complying with the essential obligations of tenancy, dueto a disability, you may request a reasonable accommodation.

If you or a member of your family have a disability and think you might need or want a reasonableaccommodation, you may request it at any time in the application process or at any time you need aniccommodation. This is up to you. If you would prefer not to discuss vour situation with the HousingAuthority, that is your right. You can request a Request for Reasonable Accommodation form fromthe following departments: Personnel, Executive Office, Service Center (Section 8) or Occupancy(Public Housing), Resident Services, Operations or any Property Manager, HANH, 360 OrangeStreet, New Haven, Connecticut 06511.

[f you require help f i l l ing out that form or need to submit your request in some other way. you shouldcontact the Occupancy Department at 360 Orange Street, New Haven. Connecticut, or any other.Department that is listed above. (Deaf or hearing impaired, please call 1-203-497-8434). If you have.my questions or problems on reasonable accommodation, you should contact Teena Bordeaux,Reasonable Accommodation Coordinator, 360 Orange Street, New Haven, Connecticut 06511,i'honel 203)498-8800, extension 1507.

t..t. Form ffl

it.-1! dit/nptaciitnes

U1TORIDAD DE V I V I E N D A DE LA CILDAD D£ NEW HAVEN(dousing AuChority of the City of New Haven)

WISO A TODOS LOS SOLICITANTES, RESIDENTES V EMPLEADOS:Uiaptaciones razonabies para soiicitantes con discapacidadi-s:

L.i Amoridad Je Viv ienda de la Cludad de New Haven es una entidad publ ica que br inda acceso laua l i t ano LI\ i v i c n d a s , instalaciones y servieios para empleados. residences y<;o soiicitantes. HANH no tiene permitidoJ i sc r imina r soiicitantes en base a su raza. re l igion, sexo, color, nacionalidad. jdad. discapacidad o condic ionfami l i a r . Asimismo. HANH tiene la obliszacion legal de brindar «adaptaciones razonab!es» a los soiicitantes enjaso de que ellos o a lgun iniembro de su fami l i a presenten una discapacidad.

i 'na .idaptacion razonable constituye alguna inoditlcacion o cambio que HANH pueda reali /ar en elJepariamemo o el entorno de trabajo de los empleados para procedimientos que asist iran a un solicitante coni ma. discapacidad que ealifica para hacer use de los programas. instalaciones. servicios y clases de HANH.Eiemplos de adaptaciones razonabies inc lu i rum:

• real izar modificaciones a la unidad de HANH de forma tal que pueda ser u t i l i z a d a por un integrante de lafamilia que se encuentre en silla de ruedas.

• I n s t a l a r detectores de humo con luces parpadeantes tipo estramboticas en un departamento para una t a m i i i acon un integrante con problemas de audicion.

• Porter a disposition de un solicitante con problemas de vision documentos en form a to grande. casetes o unlector durante el proceso de solicitud.

• Durante una entrevista. poner un interprete a disposicion de un solicitante con un impedimento de a lgunt i p o .

• Permitir que una entidad e.xterna asista a un solicitante con una discapacidad a tin de cumpl i r con losenterics de venrlcacion de soiicitantes de HANH.

Los soiicitantes de viviendas a traves del programa de Vivienda piiblicas para personas de bajos ingresos (LowIncome P u b l i c Housing - L1PH) o del Artieufo 8 que tengan un familiar con una discapacidad deberan serira paces de cumplir con las obligaciones I'undamen tales del contrato de alquiler: deben abonar el a lqui le r ,cuidar de su departamento, presentar toda la informacion requerida por la Autoridad de Vivienda. evitarmolestias a sus vecmos, etc., pcro no cxiste ningun requisites mediante el cual deban c u m p l i r estas obligaciones,111 asistencia. Si cxiste algun impedimento para cumplir con las obli^aciones t'undamentales del contratode urrcndamiento. debido a una discapacidad, podra solicitar una adaptacion razonable.

Si listed o a luLin integrante de su l ami l i a presentan unadiscapacidad y consideran que podrian necesitar u desean<ina adaptacion razonable. podran solicitarla en cualquier memento durante el proceso de solicitud o encLia lqu ie r momento en que necesiten la adaptacion. E^ su decision. Si prefiere no debatir su s i tuat ion con laAutoridad de Vivienda. esta en su derecho de no hacerlo. Puede solicitar un t'ormulario <le solicitud dejilaptaciones razonabies en los si^uientes departamentos: Personal, Oficina ejecutiva. Centre de Servicios(Articulo 8) u Ocupacion (Viviendas piiblicas), Servicios al residente. Operaciones o a cualquier «erentede inmuebles, HANH, 360 Orange Street, iN'ew Haven, Connecticut 06511.

Si necesita ayuda para completar el formulario o debe enviar su solici tud de al izuna otra forma, dcbejomunicarse con el Departamento de ocupacion en 360 Orange Street, New Haven. Connecticut , o aiuiin otro'k-partamenioenurnerado con anterioridad. (Personas sordas o con problemas de audicion deben comunicarse ai1-203-497-843-4*. Si t iene a lguna pregunta o inconveniente respecto de las adaptaciones razonabies. debe

•jotmmicarse con Tecna Bordeaux. Coordinadora de adaptaciones razonahles, J60 Orange Street, NewHaven. Connecticut 06511, Tel.: (203)498-8800. cxt. 1507.

n. -/ (uiluptaciunes

A*., t. f- i/i in ft*

HOUSING AUTHORITY OF THE CITY OF NEW HAVEN

REASONABLE ACCOMMODATION REQUEST/ SPECIAL UNIT REQUIREMENT(S)QUESTIONNAIRE

This questionnaire is to he administered to every applicant of the Housing Authority of the City of New Haven( HAiNH), It is used to determine whether an employee, applicant's family, or resident needs special features w i t h i n[heir \vork area or housing unit . The need for special adaptations must be veritled in order to assure the employee'sneeds are met and a limited number of units with special features go to families that actually need the features.

TelephoneAppl icant Name No.Appl icant AddressAppl icant Date of Birthinterview Conducted Bv Date

1-5 For Housing applicants and Residents only[ . The following member of my household has a disability as defined below:

l A physical or mental impairment that substantially limits one or more life activities; or a record of having.uch impairment; or regarded as having such an impairment)

Name: _ _ _ Relationship or association with you*

• f t ' i ^ n the bu half of a minor child, please indicate if you arc tie parent or the guardian.

2. As a result of this disability, I am requesting the following reasonable accommodation: (Please check one or morehexes below.):

Unit

| A barrier-free apartment [ 1 Unit for Vision-ImpairedOne-level uni t 1 U n i t for Hearing-ImpairedAccommodation fora Live-In Attendant [ ] Bedroom £ Bath on 1st floorExtra Bedroom [ j Other

i . Can you and all family members use the stairs unassisted? Yes [ jNo [ |f no. please indicate how HANH should accommodate your family:

4. If you or any of your family members need a live-in aide to assist you. please explain:

/?., 1. Form

i'ornniinrio n. 2 (utlaptacnniex rn-i>mibles>

VUTOR1DAP PE VlVIENPA DE LA ClUPAD DE NEW HAVENi HOUSING AUTHORITY OF THE CITY OF NEW HAVEN)

>OLICITrD DE ADAPTACIONES RAZONABLES/ CUESTIONAR1O DE KEQUISITOSESPECIALES DE LA LMDAD

FI presente cutstionario ilehe entregarse a tmJos los solicitantes de la Autoridnd tie Vivienda ile la Ciiidad de NewUuven i H A N H ) . Se ut i l tea a tin Je determinar si un c-inpleado, fami l ia r del so l ic i t an te o resnienie necesita contar conjjractensticas e;; pec i ales dentro de su area de trabajo o unidad de \ iv ienda . La necesidad de conrar con adaptaciones.^ptfciales Jehe ser \er i r icada a tin de yarantizar el c u m p l i m i e n t o de las necesldades del empleado y que un numero i imitado,:e un idades con caractensticas especiales seadestinado a tamilias que realmente necesilen dichas caracrensricas.

N.° de telefonoNombrede i•ul ic iu imeDomic i l io del-o l ic i tan te _l:ccha de nacimiento del soliciianle __[•ntrevis ta realizada por Fecha ____

1-5 Solnmente para .solicitantes y residentes de viviendaI . l£l sitiuieme intearante de mi houar presenta una discapacidad segun lo descrito a continuacidn:

( nn impedimento risico o mental que limita sustancialmente una o mas actividades de su vida; o un rcgistro• le haber padecido-dicho impedimento; o se consideraque el intearante padece dicho impedimento)

Nomhre: _ . ._ Reiacion o asociaciun con listed*

"M .ictuaun nombre de un inenor. indniue ii u^te J es cl padre o ailor.

I. Coino resultado de esta discapacidad. solicito las simiientes adaptaciones razonables: iMarcar uno o mas•!e ios siizuientes casilleros):

Ijiitljid especial

! ] I . 'n depanamento sin barreras j J Unidad para personas con probiemas de v i s ioni j Un idad de una sola planta ] Unidad para personas con probiemas de audicion

Adaptaciones para un asistente con cama adentro f | Habitacion y bano en el p r imer pisoI l ab i t ac ion ad ic iona l [ Otras

-. /.Ptiecie listed y todos los intesrantes tie su familia ulilizar las escaleras sin asistencia? Si [" | \i la respuesta es No, indique de que forma HANH Jeberia realizar adaptaciones para su familia:

Si listed o aliamo de los inteurnntes de su familia necesitan un asistente con cama adentro para ayudarlos. explique:

n.J? ((ulttptacinnes ntr.onuble'i)

K.A. Form *2 (Continued)2 nj 2

5. [f you checked any of the above listed categories of units, please explain exactly what you need toaccommodate vour situation. Attach additional sheets if needed.

6-7 For employees only

6. W i l l you need a reasonable accommodation in order to perform your job duties? Yes [ } No

7. I f you answered Yes, please explain exactly \vhatyou need to accommodate your situation:

FOR ALL APPLICAxNTS

[ authorize the New Haven Housing Authority to verify that I have a disability and have the need for thereasonable accommodation I have requested. In order to verify this information HANH may contact thefollowing providers: psychiatrist, licensed psychologist, licensed nurse practitioner, licensed social worker,rehabilitation professional, nonmedical service agency whose function is to provide services to the disabledor other expert in the field of(Note: You may present verification directly to HANH).

Mame of Expert:

Title of professional or expert:

Agency, Facility or Institution:

Address:

'hone: Fax:

[ understand that the information obtained by HANH will be kept confidential and used solely to make adetermination on my reasonable accommodation request. Please return this form as promptly as possible so'hat HANH may make a determination on this request.

Si<^n Name: _ Date:Prim Name: _Where the individual with the disability is over 18 and is not the head of household, he or she must also sign

ihe authorization verification.

Signature of person over ! S with a disability: Date:

,'f..-). f-'nrni #2

/- tirirriitunif n. ~2 in,/iif}tiiimit>nf"ft><ii>iitti 2 da >

5. Si ha nuircado a iauna de las eateuorias de unidades enumeradas anteriormente. expl ique exactamente lo quenecesita a f in de adaptar su s i tuacion. Adjunte hojas adicionales en case de ser necesario.

6-7 Solo para empleadns

ix (;Necesitara realizar nna adaptacion razonable a tin de c u m p i i r c o n sus responsabilidades laborales? Si [ ] No

Si la rt'spuesta es Si. explique exactamente !o que necesitara a rln de adaptar su situacion:

PARA TODOS LOS SOLICITANTES

Autorizo a la Autoridad de Vivienda de New Haven a veriflcar que presento una discapacidad y que tengo la necesidadle obtener la adaptacion razonable que he solicitado. A fin de veritlcar esta intbrmacion. HANH podra comunicarse

con los sisuientes prestadores: psiquiatra, psicdlogo matriculado. enfermero matriculado. asistente social matricuiado.protesional de rehabilitacion. entidad de servicios no medicos cuya funcion _sea prestar servicios a las personasJiscapacitadas u otro cxpcrto en el campo de .

i Aclaracion: listed puede presemar la veriflcacion directamente a HANH.)Norn ore del experto:

Htulo del protesional o experto:

iintidad, centre o institucion: __

i^o in ic i l io :

N.° de teletbno: Fax:

Comprendo que la intbrmacion obtenida por HANH se mantendra cumo contidencial y se utilizara unicamente para!omar una decision respecto de mi solicitud de adaptaciones razonables. Presente este fb rmula r io tan pronto como seapos ib le de tbrma tal que HANH pueda tomar una decision respecto de esta so l ic i tud .

Fi rma: Keeha:Nombre en letra de imprema:C.'uando la persona que presenta la discapacidad sea mayor de 18 anos y no sea el jeie Je houar, ul o ella tambien debehrmar la autor izacibn de venticacibn.

Kirma Je la persona mavor de 1 8 anos que presenta la discapacidad: Tcdia

t-'nrniufttrin n. J2 fudaptacinnas rtir.nntthle'i)

cxp. (U9/30/2012)

•Jipplemental and Optional Contact Information tor HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSINGThis form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law ro include as part of your application for housing.;ne name, Address, te lephone number, .md other relevant information of a family member, friend, or soial. health, advocacy, or otherorganization, rhis contact information is for the purpose of iden t i fy ing a person or organization thai may be able to he lp o resolvm^ anvissues that may ,inse dur ing your tenancy or to assist in providing any special car 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,'<->ui if you choose to do so, please include the relevant information on this brm.

i Appl icant .Nnme:

| Mail ing Address:

Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:

E-Mail Address ( if applicable):

Relationship to Applicant:

Reason Cor Contact: (Check all that apply)

I 1 Emergency~_\e to contact you

] Termination of rental assistance| ] Eviction from unit~] Late payment of rent

I J Assist with Recertification ProcessLJ Change in lease termsLJ Change in house rulesZl Other: ___ __^^_

Commitment of Housing Authority or Owner: If you ;ire approved tor housing, this information w i l l be kept as pan of your tenant tile. I ['issues.inse durme your tenancy or i t 'you require any services or special care, we may contact ihe person or organization you listed to ssist in resolvinn theissues or in providing any services or special care to you.

Confidentialitv Statement: The information provided on this form is confidential and w i l l not be disclosed to anyone except as permitted by theapplicant or ;ipp)icable law.

Lct>al Notification: Section n44 ot the Housing and Community Development Act of IW2 ( P u b l i c Law 102-550. approved October 28. 1992)requires eacn applicant for federally assisted housing to be uttered Ihe option of providing information regarding an additional contact person orurbanization. By nccepung ihe applicant 's application, the housing provider agrees to comply \vnh the non-discrimination .ind equal opportunityrequirements ot 21 CFR section 5.105. inc luding the prohibi t ions on discrimination m admission to or participation in federally assisted housingprograms on rhe hasis of race, color, re l ig ion , national origin, sex, disabi l i ty , and familial status under the Fair Housing Act, and the prohibit ion onige discr iminat ion under the Age Discrimination Act of 1975.

^] Check this box if you choose not to provide the contact information.

Signature of Applicant Date

' ; mtormalion col lec t ion rcauiremenu contained m ihn fij.rm were supmii ted to rhe ntfice nl Management and Budget ( < JMBI ikr ihe Paperwork Reduction Act ;>i l ' > ' < 5 i - l l US C. j '01-3510) Hiei t i l i c ieD»rtinu burden 11 i-Mimatea at 13 mmum per response, i n c l u d i n g the t ime tor reviewing inimictions. leaichirtg umig data iourcei. ^thermy and main ta in ing ihe data needed, jud comple t ingvj reviev*in< the collection o ( in form at ion. Section »44 nl ihe Housini j and Comrnunirv Development Act ot 1942 (42 U S.C 13604) imposed on H U D ihe nblmatiDlo rerjuire f i nu j i nn providers.n ic ipa t inu m H U D ' s .issisted housmii pronr.iiris to nrovi i le anv individual or l ami lv ipplvma toruup.incy in riUD-assisted housmn ivnh ihe option to inc lude in 'he iDOIic.mon lor occupancy ihe name.Hies* le lephnne i iumner .ind oiher relev. int mfonn.ition 01 a lamilv member, mend, ir person aisoci.ited w u h * social, l id t f i . idvocacv. nr si i t i i iar oiuanijation. I he ob|ectne ot nrovidmif -,\i\:h[I 'rm.ition n 10 f . i c i l n a t e contnct hv ;he hoiismii provider wi th ihe person nr nrcarKilian ident i r ied bv 'he tenant to .issisl m provutmii any delivery ol services or soecial L-are in ihe t enan t md .issui ' V F - M

i'. Ti -j .us v ' ' ; i . i i i i _ v . , .Lii 's n i .mi; lui i i i i f ilic ••;n.uicv . • < . 'n - i i t enant , i hi-i i i J i ' i j j i c n i e n t - i l app l i c a t i on iniormjiion is i>i be MI lamed bv the liou.nni! provider .ind in .un tamed ,u cun t iden t ia l mii innat ion." iv id ino t i ie i n t f i r m . i t i n n n oisic in ihe i-ti tft . inr.t iwt 'he HI.'D A " > i i t e i i - H o i i > i i n i j I 'mcriin md u vnlimrarv It s i iopurt t siarutorv rei]uin;meiitn ,ind ornuram and manaiiemeni control i that prevent mud. l i e md mnin.m.ii jeinent. In .i tcorrtance ' .v i t l i ihe l'-iper.*«K Koduci ion Act. .in .mencv mav not cunducl nr iponsojand a person i s nu t quired to respond to. a col lec t ion of in fo rmat ion , unless the• ' • f t r i r o n '•< 'nl.i" t i -unr i r lv v Ku l i ) M H c n r r r n l , i np t t ^ i - r

MI.i.-i, •>( J U - H I P M I : i ' " i ' l i c I .i-.v i n ' i s i ' l i n l - rn /c-s I 'v I ' , • : : i i u i ' i - n i i l l f ' I ' U M I I U m i l 4 i ' J . - \ i : l i ' [ i " ie i i l i i i i 0 i in • : . ' l i - i ; t n! l!^' !" t . i r n . i t . , i n ; .-^.^,-'i MK' N , . L ,-,1 %0 1 . , n ' v - . n n ' i v r ! '- .->N i > • •• ' l i i • ' ' • • •

• documents iraducido no conitituve un Jucmnenio uiici.il.

.*" 2CG2-G5S i. 107/31/2012)

'nlbrmacidn Je contacio optional y eompkmemana para solidtantes de asjstencia de v i v i e n d a del HUD

COMPLEMENTO PARA SOLICITED DE VIVIENDA CON ASISTENCIA FEDERALl i - i t e ibrmulario sera proporcionado a cada solicitame de vivienda con asiiwnua rederal

Instrutcioma: Persona u organization de cnnlacto optional: Tiene derecho por ley de inclmr. tomo pane de su solicitud de vivienda. el nombre, laniL-ccion, L-l numero de teletono v otra mtormacidn reievame de un (ami liar, ami go u oraanizacion social, medica. de derensa o de oira mdolc. Estaisnormacinn Je contacto se recopila uori el otajeto de identiticar a una persona u orcanizacion, que puede uyudar a resolver cualquier problems que prdna. u r m r durante su J lqui le r o que puede ayudar a proporcionar cualquier servicio o atencion especial que usied pudiera requenr. Pmlrt aclualizar. quitar

< ) cambiar la informacion que proporciond en este formuJario en cuaiquier momento. No se le Micira que bnnde !a intormacion de este contacto.,-L.TO si escoue hau'erln. inc luva b informacion reievante en este t'ormulano.

• Nombre del solicitame: !

! Oireccwn postal:

! . . _—. ii N." de lelefono: N." de telefono celular:

' .N'ombre de la persona u urbanization de contacto adicional: i

1 Direction: !ii . . — 1: N." tie telefono: N.1* de telefono celular:

Direction de correo electronico isi corresponde):

Relacion con el soiicitante:

Motive del contacto: i.Marcar todo lo que corresponds)

[~j (Emergencia LJ Ayuda con el proceso de recenificacionQ] NO es posible comunicarse con usted I.__J Cambio en los terrninos del arrendamiento[J Rescisiijn de la asistencia de alquikr I j Cambio en las reglas de la casa

Q Dcsalojo de la urudad I | Olro:|~] Pago atrasado de la renia

Citiiipromiso del propietario n tie la uulondad de la vivienda: .Si cs .iprobado para la vivientla, csia informacion sera conscrvada como parte de su archive.!e locaiano. M sunken proDlemas durantc ^u jlquiler n -si requicre de Jlijun servicioo Jiencmn especial, es posible que ros comuniquemos con la persona u• 'rganizai-ion que tncluyjj para que [o ;iyuiie_a_rescilvej; los prnblctnas n !e prpporcione a^gur^seryicio ojitencion especial.

Detlarucion de contldencialidad: La mtormacuin proporcionada en csie ['ormulanocs contidericial y no sera divuleada a nadie salvoseeun io permitido por••I lohcu.inte n ja lev vi genie.

n lenal: La .seccion n44 de la Ley de Desarrollo Comuntano y de Vjvienda ile I'W2 (Lev Publics 102-550. aprobadael 2S de uctubre de 1 W2);MJC que j t_aila inlicitante de vivienca con jsisiencia t'ederal sc le orrezca la opcion de proporcionar mtormacion relacionada con una persona u oreanizacion,:e uoniacto nditional. Al jceptar la solicitud del soiicitante, el proveetlor de vivienda acuerda cumplir con los requisites de iijualdad de opominidades y noiiscnrninaciiin de ^4 CFR "ieccion 5. 105. que mcluve las profiibiciones sobre discnminacion en la admisidn o panicipacion en programas Ue vivienda* coniM.swncta tederal debido a ia rjza. el color de la piel. la religion, el on gen nacional. el scxo, la discapacidad y el esiado lamilior seaun la Ley de Vivienda

J . i s t j . y ) j prnhibici_rin subre drscnminjcion debidp a la euad segun la Lgv_ L-ontra la Pi scrim mac ion porja Edadde

'~J Marque esla casilla si escnee no orooorcionar la informacidn Je contacto.

, ...-uui.iio* -t rn- i .DtlAiunt ie rr.IijnruiLlun Li;ntennnn in o!e !i>rmu|jnu :uenm envuj.is j ij t / jk ina de Adjiuimirji-ii in v r'rcsnpuei<cf \ntiiie r'f Wantinrmrnt --"U iiini\>ei. i j .VIBI tewn ii Ley 'ieJucuufi 'lei Pjceleodc I''i5 (Tf'ulu -W. .et.L-ii)nn .i.sUI- I'-!) J(l C&ligo lie lot EE. UU 1. Se tjltulayue U careuJc deelaratmr ouBlita ti Je 15 ininulin piir respuesu e im;)uye el uempy para revw,n-iniffKin*». nustjr ruenin tie duiui e^i-.ren[e». re™pilor y tnniervar li« Jjlui netesjn.n. y (.-oniDletaf y revujf |j cecopilatiun de U iiifomwciiin. LJ .etxiun 644 'tt U Ley ik Deiamillo Curfiunjionte Vivien.id .Je iV3(T:'iili» 12, -tjfciiin I ;«M <lt\ d« kn SE. U U . I Imptno.il HLD Jj ohliitjtnm <Je .uliLirjj j In* pmveedoiei ile vrviendj.* uiie pjmcipjn rn p^KJjjTHn Ue \ i v i fnd j j con-rt-riL-u ^el HLD-iue pniciirL-iorren J r^ijj Ij, cwnuna, n Jainilui ()ue >»liL-iten la ii.un.iaon de u/U nvientla tun .iMileitcu M HIJD In npctim ile int-lnif en I j M t l i f i n i d H numnre. la jjrrcciun. clnenxmieicK'mit'itTKa inlumutmn rclevJnie Je un rjiniljar, imiiiu u uii4 penunii rrlaciunaoaton una urrfuniiatit in ««.'ial. medicj. Je i jeienij D s.iiiljj- tl . jhre to de prtipurcinrur ul inrurrmtion tflilrUfirl LunrjcroiJiiirJne .lei p(iiv«,lcir Je nvFemJusvi'n U wr>i>nu u ..rajniZJUon nJi'dtilicaiJu p"ir cl Intjluim n.ira i|ue jyuiJe j fmrijjr redo servicioo ircncmn eipectul jl liH.'juno y aviidarlo J,(s , t fr t u j i q u i e r pfnciema dc i l u u i l e r < i u e Muittere -juranw cl Jiuuiler por pjne i W i J u n o Hxaljuii. ii«rj miiinrenjujn ue .uli t i iuu uirnpremenuna .frm,,jnv«vj,|j pur - I pnnwuor .le n-.i*nil» y (ri

- i t ier ilc Lui i i i i lL 'nLUI. I'rcroirtioridr lit n i t i i rmi tc iun «i " . IHLII n:ua IJ-i i.peratnines u«l f"nn:nima u« V ( IK ' IHJJ ^un \miencid i i e l 1-lLD v ;s un J L I O v»i<jntuj-]u i^^-n-i lUj InH rrquisi io^ rc^(j;r*n(or">i v '' • r i - i ' s I* - i i :npni>ir . iLi .m v ;p| -n>«,un.i r^ir.i prtvi-mr jl ( r i i n l e , r l .;ffjTiH..ne v 1 1 T. n j ndn imMrj t iun i '< . i . n t n f T T | p , i j j l r , n ' . i I ev . .e k j - lu tumn •>( P lorle'i. im ii;cn..-u rn r»"iri cuniiiicif nir.x.iii4/. V N.) -e '« MihunrJ J NIU pcrsora uue 'CMJ">™JJ j u,u re tup iUtmnJe ip iKif in ;n ; i i in . ^ivo du« en r j rotupiiatmn .IB Fnmrmatiun Jpjre^Lj un nuinero.:s (.unlf'l Iff U M B . ilido en la . i t iujliujU.