College Housing Assistance Program Checklist

Please ensure that all of the below forms are a part of your
packet prior to submittal. Incomplete packages WILL NOT
be accepted. Since this housing program focuses on
homelessness, please see next page for definition of
homelessness. In the application, the program
representative will ask you questions that will allow the
program to validate your homelessness status.
Documents required at submittal for eligibility and determination:

TCC/THA Program Application

TCC/THA Participant Obligations
THA General Release
THA Debts Owed
THA Supplement to Application for Federally Assisted Housing
THA Asset Certification
THA Declaration of Eligibility

Documents required for THA determination once eligibility has been

confirmed:
Identification
o Adults: Copies of Photo I.D and Social Security Cards
o Children: Copies of Social Security Card and Birth Certificate
o Alien Registration/Permanent Resident Card only
Income Verification
o Social Security/SSI Income: Award Letter
o Employment: paystubs-most recent 3 months and employers fax
number
o Child Support: Payment history print out
College Housing Assistance Program Checklist
[last revised October 7, 2014]

page 1

o Unemployment: pay stubs-most recent 3 months

o TANF,GAU, or VA: statements-award letters
o Pension, retirement or other statements-most recent 3 months or
award letter
o Self-Employment: Last filed income tax with profit and loss statement
o All other sources of income
Definition of homeless: A household that is:
(1) In an emergency shelter or in a transitional housing facility; or
(2) Is a client of a case-management program serving the homeless.
Definition of at serious risk of homelessness: A household that is
experiencing any of the following:
(1) Unable to meet basic housing expenses such as rent, mortgage, or
utilities that will result in the loss of permanent housing;
(2) Residing in a motel/hotel due to loss of permanent housing and lacks
the resources to remain;
(3) Has lost permanent housing and is living temporarily with a friend or
family member and cannot be placed on the lease;
(4) Eviction notices that will result in loss of permanent housing;
(5) Pending unlawful detainer notices that will result in loss of permanent
housing;
(6) Recent history of serious housing instability;
(7) Is a victim of domestic violence; or
(8) Is facing discharge from a public institution (e.g. incarceration,
hospital etc.) without a housing discharge plan.

College Housing Assistance Program Checklist

[last revised October 7, 2014]

page 2

TACOMA HOUSING AUTHORITY

College Housing Assistance Program Application
THA Form (#) REM-CHP-01
You must be an enrolled T.C.C. student registered for or attending classes to participate in this program. Please
complete this application and attach other requested materials before submitting to the Tacoma Community College,
Counseling and Advising Office (Bldg. 7). If there are incomplete portions of the application or attachments are
missing, it will be returned to the applicant for resubmission. Resubmission must occur during open application period
for additional consideration. Submission of this application does not guarantee an award; please continue your
search for housing. Inaccurate or misleading statements may be grounds for disqualifying the application.
A. Applicant Information (Head of Household)
Name: (Last, First, Middle)
Gender: (M/F)

Social Security #:

Date of Birth

Ethnicity/Race (optional)

Student ID #:

Current Address:
City:

County:

State:

Zip code:

Contact Telephone:

May we leave messages at this number? Yes No

Emergency Contact Telephone:

May we leave messages at this number? Yes No

TCC email address:

Program of study:

Basic Eligibility Questions

1.
2.
3.
4.

Do you currently owe money to any Housing Authority? Yes No

Are you enrolled in less than 12 credits at Tacoma Community College? Yes No
Are you below a 2.0 GPA? Yes No
Do you still need to complete a FAFSA? Yes No

If you answered yes to any of these questions, you are disqualified from participation in this program.
Priority Screening Questions
1.
2.
3.

Are you a participant of Opportunity Grant, Worker Retraining, Work First, Basic Food Employment and Training,
Passport to College, College Bound, Fresh Start, Spruce or Veteran Services? Yes No
Are you homeless? Yes No
a. Are you seeking housing in Tacoma? Yes No
If you are not homeless, are you at serious risk of homelessness? Yes No

If you answered no to any of these priority screening questions, you may still proceed with your application
but your order of priority may be low.
College Housing Assistance Program Application
THA Form # REM-CHP-01 [October 8, 2014]

Page [1]

Definition of homeless: A household that is:

1) In an emergency shelter or in a transitional housing facility; or 2) Is a client of a case-management program
serving the homeless

Definition of at serious risk of homelessness: A household that is experiencing any of the following:
1) Unable to meet basic housing expenses such as rent, mortgage, or utilities that will result in the loss of permanent housing;
2) Residing in a motel/hotel due to loss of permanent housing and lacks the resources to remain; 3) Has lost permanent
housing and is living temporarily with a friend or family member and cannot be placed on the lease; 4) Eviction notices that
will result in loss of permanent housing; 5) Pending unlawful detainer notices that will result in loss; 6) Recent history of
serious housing instability; 7) Is a victim of domestic violence; or 8) Is facing discharge from a public institution (e.g.
incarceration, hospital etc.) without a housing discharge plan.

Reason for homelessness or risk of homelessness: (Circle all that apply)

Eviction
Family Crisis

Domestic Violence
Medical Issues

New to Tacoma
Loss of income

Substance Abuse
Natural Disaster

Other, please list: __________________________________________________________________

REQUIRED: Please explain in further detail how your circumstances fit into the above definitions and what caused you to
leave your last permanent residence:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________

What agencies are you currently working with to resolve your homelessness? _________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

College Housing Assistance Program Application

THA Form # REM-CHP-01 [October 8, 2014]

Page [2]

B. Income Information

Head of Household: ________________________________________________

Income includes but is not limited to the following sources: (Circle all that apply.)
Employment

Self-Employment

Unemployment

Pensions

TANF/GAU/DSHUS

L&I

Alimony

Annuity/Interest

Security/SSI/SSA/SSD

VA

Child Support

If your income exceeds the 30% of the area median income, you are not eligible for this program. For
a current update on the income limits, please visit the THAs website at www.tacomahousing.net.

ADULT FAMILY MEMBERS: (All persons 18 and older must be listed, head of household first.)

Name:
Last, First, Middle

Sex

Social
Security No.

Date of Birth

Place of Birth

Relation to Head
of Household

Marital
Status

Alien
Registration
# (if
applicable)

CHILDREN: (List all children under 18 years of age who currently reside in your household permanently)
Name:
Last, First, Middle

Sex

Social
Security No.

Date of Birth

Age

School
Name

Relation to Head of Household

Absent
Parents
Name

If divorced or separated, ex-spouses name: ___________________________________________________________________

Address of Absent Parent of Child: ___________________________________________________________________________

College Housing Assistance Program Application

THA Form # REM-CHP-01 [October 8, 2014]

Page [3]

Students: (List any full time students, 18 years or older, except head of household, spouse or co-tenant)
Name:
Last, First, Middle

School Name

Address

Enrolled (Y or N)

Phone #

Please list all income for all members of your household: List other members of your family from oldest to
youngest:
Name: Last, First, Middle

Income Source

College Housing Assistance Program Application

THA Form # REM-CHP-01 [October 8, 2014]

Monthly
Amount

It Employed, employer

Hours

Weekly
Amount

Page [4]

I have included the documentation listed on the checklist as required with submittal of this application for eligibility and
determination.
I declare that the statements provided on this application are true and correct to the best of my knowledge.
Signatures:

Date:

Head of Household

Spouse/Co-Tenant

Adult Family Member

Adult Family Member

Adult Family Member

Adult Family Member

WARNING: Title 18, Section 1001 of the United States Code states that a person is guilty of a felony for knowingly and
willingly making false or fraudulent statements to any department of agency of the United States.

THA is committed to equal opportunity. It does not unlawfully discriminate on

the basis of race, color, national origin, religion, gender, disability, age, familial
status, marital status, sexual orientation, veteran or military status, or gender
identity.
THA will reasonably accommodate the needs of disabled persons. THA has
units accessible to persons with disabilities. It will also reasonably modify units
as necessary to meet the needs of disabled persons.

THAs Civil Rights Compliance Coordinator is responsible for coordinating THAs

compliance with the law. He or she can be reached at (253) 207-4421.

College Housing Assistance Program Application

THA Form # REM-CHP-01 [October 8, 2014]

Page [5]

TACOMA HOUSING AUTHORITY

College Housing Assistance Program Participant Obligations
THA Form (#) REM-CHP-05
1. I understand that I am required to report online at www.tacomahousing.net any changes in
income and/or household composition within 10 days of the occurrence.
2. I certify that the house or apartment will be my only residence. I will not sublease my assisted
residence and will not allow anyone to live in my unit that is not on the lease.
3. I must allow Tacoma Housing Authority (THA) to perform Housing Quality Standard (HQS)
inspections with reasonable notice. Federal regulations state I am responsible for all damages
caused by my family and guests. Unit abuse, owing rent and unpaid utilities may result in
termination of housing assistance.
4. I understand I must receive approval from THA before allowing anyone to move into my unit. I
must also receive permission from THA before I move. I must notify THA if I will be away from
my unit for more than 30 days. I must make all requests in writing.
5. I understand that I must notify THA in writing if a person moves out of my unit within 10 days of
the occurrence. I may be required to provide proof of where the person is now living.
6. I understand it is my family obligation to cooperate in supplying all information needed to
determine my eligibility, level of benefits, or verify my true circumstances. I understand I must
provide social security cards, birth certificates or other required documents for household
members. Cooperation includes attending pre-scheduled meetings, completing and signing all
needed forms.
7. I understand I may not make additional payments of any kind to the landlord that are not included
in the lease and approved by THA and to do so is considered fraud.
8. I understand I must comply with all provisions of my lease and not commit any serious or
repeated violations of the lease. I must pay my family share of the rent and utilities.
9. I understand that my mailing address is for the sole use of authorized household members and
may not be used by any other persons.
10. Household members cannot commit fraud, bribery or any other corrupt or criminal act in
connection with any federal housing program, including receiving another housing subsidy for
my unit or any other unit under any federal, state or local housing assistance program. The
household may not own any deed, title or claim to the unit. I understand I may not rent from any
person related to any member of my household.
11. Household members my not engage in any drug-related criminal activity, alcohol abuse or violent
criminal activity, including threatening, abusive or violent behavior toward THA personnel or
other criminal activity that threatens the health, safety, or right to peaceful enjoyment of other
residents.
12. I understand that knowingly supplying false, incomplete, or inaccurate information is punishable
under Federal or State criminal law. I will also be required to repay assistance overpaid on my
College Housing Assistance Program Participant Obligations
THA Form # REM-CHP-05 [October 8, 2014]

Page 1

behalf and may be terminated from the program. I certify that all the information I provide to
THA is true and accurate.
13. Any household caught manipulating income to remain eligible for the program will be
terminated.
14. I will be seeking housing within the Tacoma Housing Authority jurisdiction. Details on the
boundaries of this jurisdiction are available from THA upon request.
15. I will remain enrolled in Tacoma Community College full time, 12 credits during the Fall, Winter
and Spring quarters and for at least 1 credit during the Summer quarter. In the case of
emergencies that may affect my enrollment, I may ask THA to temporarily waive this
requirement. I must ask for this waiver my enrollment status changes.
16. I pledge full cooperation with the TCC Work Force Education Specialist assigned to assist me in
fulfillment of program related conditions. This includes but is not limited to:
a. Regular meetings with the Work Force Education Specialist;
b. Working with the Work Force Education Specialist to develop an employment plan prior
to completion of TCC program. This includes but is not limited to working with the
Career Center for resume and job application assistance.
c. Setting short and long term goals;
d. Regularly discussing progress and challenges; and
e. Following up on recommendations made by the Work Force Education Specialist.
17. I agree that I will participate in a Financial Literacy workshop before the end of my second
quarter of enrollment in this program. The College Housing Assistance Program staff member
will identify the workshop particulars.
18. I agree to allow THA and Tacoma Community College to share individually identifiable
information about myself and my family. This will include the following
a. School data - test scores, attendance, etc. between the college and THA so that THA can
determine if the project is helping to improve student achievement.
b. Share information on student success in education and economic progress so that THA
and TCC can determine how to best support my needs as a participant.
19. I understand that if I do not maintain THA and TCC eligibility for this program, I will receive
notification of termination and the housing assistance will end 30 days after the notification.
a. A hardship may be requested to grant a one (1) month extension to the housing assistance
that would otherwise end because of any of the following reasons:
i. The term limit of three (3) years;
ii. the participants graduation from TCC; or
iii. the end of the participants TCC enrollment.
20. I agree to complete an exit questionnaire to assist the program with improvements.
21. I understand that the College Housing Assistance Program is limited to 3 years of enrollment at
Tacoma Community College and requires that I maintain both TCC and THA eligibility
throughout. Further, these program benefits are not transferrable to another institution.
22. I understand that rental deposits and utility payments, unless utilities are a part of the rent, are not
covered under the College Housing Assistance Program.
College Housing Assistance Program Participant Obligations
THA Form # REM-CHP-05 [October 8, 2014]

Page 2

23. I understand that THA and TCCs ability to provide this assistance depends on the continued
availability of government funding and regulatory authority to allow for it. If that funding or
authority ends or diminishes, then my assistance may end as well.
I have read and I understand the above Participant Obligations. I understand that failure to comply with
them may result in denial of admission, an obligation to repay assistance overpaid on my behalf, and /or
termination from the College Housing Assistance Program. All adults, 18 years and older must sign this
form.
__________________________________
Head of Household

____________________________
Date

__________________________________
Adult Family Member

_______________________________
Adult Family Member

__________________________________
Adult Family Member

_______________________________
Adult Family Member

College Housing Assistance Program Participant Obligations

THA Form # REM-CHP-05 [October 8, 2014]

Page 3

TACOMA HOUSING AUTHORITY

General Release of Information
THA Form (#) REM-MTW-01
I authorize Tacoma Housing Authority (THA) and the U.S. Department of Housing and Urban Development
(HUD) to obtain the information listed below for the purpose of determining my eligibility to receive and
continue receiving housing assistance. THA may use this release to make inquiries or secure information from
any source whatsoever, including a person, business, or organization that has, or may have, any information
listed below. If THA makes any negative determination(s) based upon the information obtained, I will have an
opportunity to contest such determinations. If I participate in the Project-based or Mod Rehab program, I also
authorize THA and the owner and/or manager of the building in which I reside to share with each other any
information needed to verify my continued eligibility and suitability for subsidized housing. This consent
expires 48 months after I sign it.

Information necessary to authenticate preference claims;

Rental history records and references, including but not limited to, information about the ability to
pay rent, the ability to abide by the rules of the lease, take care of rental property, and get along well
with neighbors;
Non-residential references from individuals with whom a professional relationship has been
established, and references from neighbors, community, and relatives;
References from employers, including wage and salary information, and job performance;
Criminal history, including fingerprint submission where necessary to effect positive identification;
Information on payment history and balances owed to utility companies including but not limited to
TPU, Puget Power, WNG;
Credit reports;
Services provided by individuals or agencies which are relevant to the ability to pay rent, take care of
rental property, and get along well with neighbors and community;
(HUD only) U.S. Social Security Administration and U.S. Internal Revenue Service;
Income and asset information from any source, including State Wage Information Collection
Agencies, for all family members;
Immigration status, citizenship status, and legal identity verification;
School registration for minor children, and for family members over the age of 18 where required to
establish program eligibility;
Registration in educational or vocational training programs including information about
participation/completion of such programs;
Verification of disability or handicap and shelter plus programs, if necessary for program eligibility
(not including details of actual disability or handicap);
Verification of need for reasonable accommodation, if requested;
Credit reports and/or tenant screening reports from private screening contractors;
Outstanding debts to other housing agencies.

Head of Household (printed name)

Signature

Date

Co-Head, Spouse, Partner, or Other Adult (printed name)

Signature

Date

Other Adult (printed name)

Signature

Date

General Release of Information

THA Form # REM-MTW-01 [October 8, 2014]

Page 1

Authority: This release of information is in lieu of the HUD-9886 Authorization for the Release
of Information/Privacy Act Notice.
Who must sign the consent form: Each member of your household who is 16 years of age or
older must sign the consent form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the household become 16 years of age.
Criminal background checks will be run on anyone in the household 16 years of age or older.
Failure to sign consent form: Denial of eligibility or termination of benefits is subject to THAs
grievance and Housing Choice Voucher informal hearing/review procedures as well as THAs
Public Housing informal review/grievance process.
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is
authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.),
Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42
U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543)
requires applicants and participants to submit the Social Security Number of each household
member who is six years old or older. Purpose: Your income and other information are being
collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount
your family will pay toward rent and utilities. Other Uses: HUD uses your family income and
other information to assist in managing and monitoring HUD-assisted housing programs, to
protect the Governments financial interest, and to verify the 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 regulatory investigators and prosecutors. However, the
information will not be otherwise disclosed or released outside of HUD, except as permitted or
required by law. Penalty: You must provide all of the information requested by the HA,
including all Social Security Numbers you, and all other household members age six years and
older, have and use. Giving the Social Security Numbers of all household members is
mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to
provide any of the requested information may result in a delay or rejection of your eligibility
approval.
Penalties for misusing this consent: HUD, THA and any owner (or any employee of HUD,
THA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of
information collected based on the consent form. Use of the information collected based on this
form is restricted to the purposes cited on the form. Any person, who knowingly or willfully
requests, obtains or discloses any information under false pretenses concerning an applicant or
participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or
participant affected by negligent disclosure of information may bring civil action for damages,
and seek other relief, as may be appropriate, against the officer or employee of HUD, THA or the
owner responsible for the unauthorized disclosure or improper use.

General Release of Information

THA Form # REM-MTW-01 [October 8, 2014]

Page 2

OMB No. 2577-0266

Expires 04/30/2013

U.S. Department of Housing and Urban Development

Office of Public and Indian Housing
DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS
Paperwork Reduction Notice: The information collection requirements contained in this notice have been approved by the
Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3520) and assigned OMB
control 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 displays a current valid OMB control
number.
NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:
Public Housing (24 CFR 960)
Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
Section 8 Moderate Rehabilitation (24 CFR 882)
Project-Based Voucher (24 CFR 983)
The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public
Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or
involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is
maintained within HUDs Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs)
and their management agents to verify employment and income information of program participants, as well as, to
reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in
ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct
amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD
regulations at 24 CFR 5.233.
HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the
conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what
information the PHA is required to provide HUD, who will have access to this information, how this information is used
and your rights. PHAs are required to provide this notice to all applicants and program participants and you are
required 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 of
birth, and Social Security Number.
The following adverse information is collected once your participation in the housing program has ended, whether you
voluntarily or involuntarily move out of an assisted unit:
1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed
(i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges
such 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; and
3. Whether or not you have defaulted on a repayment agreement; and
4. Whether or not the PHA has obtained a judgment against you; and
5. Whether or not you have filed for bankruptcy; and
6. The negative reason(s) for your end of participation or any negative status (i.e. abandoned unit, fraud, lease
violations, criminal activity, etc.) as of the end of participation date.

April 26, 2010

Form HUD-52675

OMB No. 2577-0266

Expires 04/30/2013

2
Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.
How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of
family income and composition for existing participants. PHAs will be able to access this information to determine a
familys suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to
families who have previously been unable to comply with HUD program requirements. If the reported information is
accurate, your current rental assistance may be terminated and your future request for HUD rental assistance may be
denied for a period of up to ten years from the date you moved out of an assisted unit or were terminated from a HUD
rental assistance program.
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 of
participation date.
What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its
implementation 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 HUDs initial denial of your request to have access to your records maintained
by HUD.
3. To have incorrect information in your 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 denial.
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 termination information reported about me?
You should contact the PHA, who has reported this information about you, in writing, if you disagree with the reported
information. The PHAs name, address, and telephone numbers are listed on the Debts Owed and Termination Report.
You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the
information and provide any documentation that supports your dispute. Disputes must be made within three years
from the end of participation date. Otherwise the debt and termination information is presumed correct. Only the
PHA 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 HUDs EIV system.
However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the
bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with
documentation of your bankruptcy status.
The PHA will notify you in 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
determines that the disputed information is correct, the PHA will provide an explanation as to why the information is
correct.
This Notice was provided by the below-listed PHA:

I hereby acknowledge that the PHA provided me with the

Debts Owed to PHAs & Termination Notice:

Signature

Date

Printed Name
April 26, 2010

Form HUD-52675

OMB Control # 2502-0581

Exp. (11/30/2015)
Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Check this box if you choose not to provide the contact information.
Applicant Name:
Mailing 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 for Contact: (Check all that apply)
Emergency
Unable

to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent

Assist with Recertification Process

Change in lease terms
Change in house rules
Other: ______________________________

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicants application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.

Signature of Applicant

Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUDs assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)

TACOMA HOUSING AUTHORITY

UNDER $25,000 ASSET CERTIFICATION
THA Form (#): REM-VERI-05
(NOTE: If your assets exceed $25,000, do not sign this form)
Head of Household Name: _________________________________________________
Net Household Assets
Does not include:

Includes:

Cash value of real property, savings,

stocks, bonds, and other forms of
capital investments, after deducting
reasonable costs that you would have
after disposing of them.
Value of any business disposed of
for less than fair-market value
(including any held in trust, but not
in a foreclosure or bankruptcy sale)
during the two years before the reexamination, may be counted.

Furniture and automobiles

Interests in Indian trust land and the
equity in a housing cooperative unit
or in a manufactured home in which
you live.
A trust fund will not be considered
an asset so long as the fund
continues to be held in trust.
In the case of a separation or divorce
settlement, it will not be considered
to be for less than fair-market value
if the household has received
something meaningful other than
cash

Please initial below:

I/We do hereby swear under penalty of perjury that each of the following statements is true:
_________ I/We have reviewed the definition of Net Household Assets. I understand that Net
Household Assets includes, but is not limited to, any monies in banks, credit union accounts, real
estate, stocks or bonds, retirement funds, certificates of deposit, personal property such as coin
collections, gems, jewelry or antiques used for investment.
_________ I/We certify that my/our household assets do not exceed $25,000.
The value of my household assets is: $___________
_________________________________________________
Applicant/Resident Signature

__________________
Date

_________________________________________________
Applicant/Resident Signature

__________________
Date

Assets Under $25,000 Certification

THA Form # REM-VERI-05 [October 14, 2014]

TACOMA HOUSING AUTHORITY

Declaration of Eligibility Status
THA Form (#) REM-LSNG-106
This form asks for information. You must provide this information as part of your application
for assistance. THA needs evidence of the citizenship and immigration status of each member of
your household.
1.
2.

3.

For U.S. citizens, evidence consists of a signed declaration of U.S. Citizenship. The
THA may require verification.
For noncitizens who are 62 years of age or older and are receiving assistance as of
September 30, 1996, the evidence consists of:
a. A signed declaration of eligible immigration status; and
b. Proof of age document.
For all other noncitizens, the evidence consists of:
a. A signed declaration of eligible immigration status;
b. A signed verification consent form;
c. INS verification which says you and your child(ren):
i. Are lawfully admitted for residence as an immigrant (this includes
admission through temporary residence status);
ii. Entered the U.S. before 1/1/72 and have continuously maintained
residence since that date;
iii. Refugee status, asylum status, or approved conditional entry; or
iv. INS parole, withheld deportation or amnesty status.

Verification Consent: Evidence of eligible immigration status may be released by the THA to
(1) HUD, and (2) U.S. Citizenship and Immigration Services (USCIS) for purposes of
verification of immigration status. HUD may release evidence of eligible status only to USCIS
for purposes of establishing eligibility for financial assistance.

Please Note: Tacoma Housing Authority will only contact USCIS to verify
eligibility of immigration status and will not report ineligible members. You
may choose not to state if you or any members are either a U.S. Citizen or
have Eligible Immigration Status

Declaration of Eligibility Status

THA Form # REM-LSNG-106 [November 4, 2014]

Page 1

(Check One)
Head of Household Adult Family
Member
_______________________________
Print Name
I CERTIFY THAT I AM (Check one)
a U.S. Citizen
a Non-Citizen with Eligible Immigration
Status
choosing not to state if I am a U.S. Citizen
or have Eligible Immigration Status

(Check One)
Spouse Co-tenant Adult Family
Member
_______________________________
Print Name
I CERTIFY THAT I AM (Check one)
a U.S. Citizen
a Non-Citizen with Eligible Immigration
Status
choosing not to state if I am a U.S. Citizen
or have Eligible Immigration Status

(Please complete the following only if there are minor children in the family and you are the
responsible adult family member).
I certify that the following minor children listed in my household are (please check appropriate
box(s) and list the name and birth date):

Name
a U. S. Citizen:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________

Birth date
___________________
___________________
___________________
___________________
___________________

a Non-Citizen with Eligible Immigration Status:

_____________________________________
_____________________________________
_____________________________________
_____________________________________

___________________
___________________
___________________
___________________

choosing not to state if they are a U. S. Citizen or have eligible immigration status
_____________________________________
___________________
_____________________________________
___________________
_____________________________________
___________________

I declare under penalty of perjury under the laws of the State of Washington and the Immigration
and Naturalization Services that the above is true and correct to the best of my knowledge. I
hereby grant THA permission to verify immigration status with the Immigration and
Naturalization Service.
______________________________________
Head of Household/Adult Signature

________________________
Place and Date

______________________________________
Spouse/Co-Tenant/Adult Signature

________________________
Place and Date

Client No. ___________________

Declaration of Eligibility Status
THA Form # REM-LSNG-106 [November 4, 2014]

Page 2