Office Only:                            	
Date Rec’d:  _____________
 Time:  _____________            
Burnett County Housing Authority
7350 Main Street East	, PO Box 41
Webster, WI 54893

Application for Occupancy

This application does not obligate you or the Housing Authority of the County of Burnett in any way. Please complete the entire form.  
			
Indicate the communities in which you desire rental housing:

        FAMILY UNIT 			VOUCHER			ELDERLY/DISABLED UNIT

___ Webster         ___ Danbury  		___ Section 8	 	 	        ___ Siren  ___ Webster 
___ Grantsburg    ___ Siren  				

Applicant’s Full name:								 Age:		
Social Security Number:				 Sex:		  Date of Birth:		
Spouse/Co-Tenant:									 Age:		
Social Security Number:				 Sex:		 Date of Birth:			
Mailing Address:											
														
Telephone Number:					 Marital Status:				
								    (Married, Unmarried, Separated, Divorced)
Other Members of Household:
Name		    	  	         	 DOB			Relationship			Social Security #

															

															

Is there any family member(s) in the household that is attending full or part time higher education?  Y or N

Please list two optional contacts that we can use if we can’t reach you: 
Name				Address				Phone # 			Relationship

															

*Note to applicants: If you believe that you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll-free hot line at 1-800-424-8590

A person which meet the definition of disabled or handicapped qualify for a $400 deduction to their annual income when determining rent contribution and certain other deductions. See the attached addendum which defines disabled or handi-capped. If you feel that you qualify and would like to request this adjustment in your income, please check here: ______. If you have indicated your desire to request this adjustment, then we will need only sufficient information to confirm your qualification for this status. Failure to provide this information may result in the denial of these deductions.

Do you have any specific housing requirements, such as a special handicapped accessible unit?																			

Please list below any former rental addresses within the past three years, starting with the present, if now renting:

		Rental Address					Name, Address, Phone # of Owner/Manager

1.														

	
2.														

	
3.														

Is someone legally empowered to act in your behalf?			
Name:									Home Phone #:				
Address:								Business Phone #:			

Are you being evicted?		    Has the rental agreement been terminated?		 
If yes, to either, why?												
Has any household member ever been evicted from a rental unit?		
Are you now living in a government subsidized/assisted unit?			
Have you ever lived in a government assisted unit?	   If yes, where and when: 						
I/We understand as a procedure of processing my application an investigative report may be prepared whereby information is obtained through personal inquires at my home, neighbors, friends, employers, landlords, law enforcement personnel, other governmental offices and agencies. The inquiry may include information as to character, mode of living, and performance in meeting financial obligations.      		 (Initial)

Complete all applicable information for each household member on this page and the next. Attach an additional sheet if more space is needed.  If an item does not apply to you or your household, please put a line through it

	Income and Expense Information

1. Salary/Wages - List gross amount of wages and salaries, overtime pay, commissions, fees, tips, and bonuses before deductions. Indicate sources.
			 Hours per wk / mo. @ $		    per/hr – From 				
			 Hours per wk / mo. @ $		    per/hr – From 					

2. Net income from Business or Profession or Rental or Real or Personal Property.
			$			 Annually From					
			$			 Annually From					

3. Social Security / SSI payments. 		* Medicare Supplement deducted:   Yes (or) No
			$			 Annually From					
			$			 Annually From					

4. Pensions, Annuities, Retirement Funds, IRA Accounts, Interests.
			$			 Annually From					
			$			 Annually From					
						
5. All other income: Include income from all other sources, such as Unemployment, Disability Compensation, Workman’s Comp., Severance Pay, Alimony, Child Support, and Regular gifts of money, VA Benefits, Public Assistance, AFDC, Welfare or any other source.
			$			 Annually From					
			$			 Annually From					
						
6. Child Care Expense: List amount paid by family for the care of minor children under 13 years of age when such care is necessary to enable a family member to further education or to be gainfully employed.
			$			 Annually 
	  Do you receive reimbursement for any or all of the child care expenses from any sources?
			$			 Annually 
	
7. Medical Expenses: (to be completed for households with persons who are handicapped, disabled or over the age of 62) - Include total expenses to be incurred over the next twelve month period not covered be insurance. May include expenses for dental, prescriptions, medical insurance premiums, eyeglasses/contacts, hearing aids/batteries, and cost of live-in resident assistant, monthly payments required on accumulated major medical bills, including that portion of spouses or child’s nursing home care paid from family income.

			$			 Annually From					
			$			 Annually From					

Supplement Insurance is (if app.): 
	Name:								Monthly premium:  $ 			
	Name:								Monthly premium:  $ 			

	
Asset Information - (List all current information for Applicant, Spouse/Co-Applicant)

1. Cash on Hand: (Amount on hand at present time)					$		
						
2. Checking Accounts:
		Account #			 Bank					$		
		Account #			 Bank					$		

3. Savings Account (Including IRA’s)
		Account #			 Where					$		
		Account #			 Where					$		
		
4. Stocks and/or Bonds:
		Type			 Number Owned			Value	$		
		Type			 Number Owned			Value	$		
		Type			 Number Owned			Value	$		

5. Real Estate Owned at Present or Sold Within the Last Two Years:
		
							 Market Value		$		
		(If sold within the last two years, list amount sold for)	$		
		
							 Market Value		$		
		(If sold within the last two years, list amount sold for)	$		

6. Property Sold Under Land Contract
		Original Amount $			
		Outstanding Balance $			
		Terms: $		 per month		 or per year			

7. List All Other Assets Owned
		Type					 Value $			
		Type					 Value $			

*Your signature on this application authorizes the owner/manager of the project in which you are applying for occupancy to contact your prior landlords for information regarding your prior tenancies, to check personal and credit references and to obtain credit, employment and court records.

													
	Applicants Signature							Date

	Spouse/Co-Tenant Signature						Date	

The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service that the Federal laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial status, age and disability to do so. This information will not be used in evaluating your application or to discriminate against you in any way.  However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of individual applicant on the basis of visual observation or surname. 

Race						Ethnicity				Sex (# in family)

        American Indian/Alaskan Native(1)		       Non Hispanic/Latino		       Male
        Asian(2)						       Hispanic/Latino			       Female
        Black / African American(3)
        Native Hawaiian or Pacific Islander(4)
        White(5)

Background/Criminal History:

Has any household member ever been charged or convicted for any criminal activity?	      Yes           No

Has any household member been involved in any criminal activities involving?
		1.	Crimes of physical violence to persons or property? 		       	      Yes           No
		2.	Possession or use of illegal drugs?		       			      Yes           No
		3.	Burglary or theft?				       			      Yes           No
		4.	Sexual assault or rape? 			       			      Yes           No

	I/We certify that the information given to the Housing Authority of the County of Burnett on household composition, income, net family assets, and allowances, expenses, deductions, and personal questions is accurate to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal Law. I/We further understand that false statements or information are grounds for termination of housing assistance and termination of tenancy.
*Warning: Section 1001 of Title 18 of the United States Code makes it a criminal offense to make willful false statements or misrepresentation to any department or agency of the United States as to any matter within in jurisdiction.

Signature of Head of Household:						Date:			

Signature of Spouse/Co-Tenant:						Date:			

Statement Required By the Privacy Act

The USDA- Rural Development (RD) is authorized by Title V of the Housing Act of 1949 as amended (42 U.S.C. 1471 et. seq.) to solicit the information requested on this form. Disclosure of the information requested is voluntary. However, failure to disclose certain items of information may result in a delay in the processing of your eligibility or rejection, except that is unlawful for USDA-RD  to deny eligibility because of the refusal to disclose the Social Security Account Number.  The principle purposes for collecting the requested information are to determine eligibility for occupancy in the USDA-RD financed rental project and to determine the amount of tenant contribution for rent. The information collected on this form may be released to appropriate Federal, State and Local Agencies when relevant to civil, criminal or regulatory proceedings.

Addendum to application for occupancy
	Definitions based upon FmHA Instruction 1930-C, Exhibit B

What is considered a disability: A person is considered disabled if the person meets the criteria of either of the following:

1.	The person has an inability to engage in any substantial gainful activity, but with use of auxiliary apparatus can otherwise participate in gainful activity, by reason of any medically determinable physical or mental impairment, where the disability:
a.	Has lasted or can be expected to last for a continuous period of not less then 12 months, or which can be                                  expected to result in death.
b.	Substantially impedes the ability to live independently.
c.	Is of such a nature that such ability could be improved by more suitable housing conditions.
d.	In the case of a sight impaired person who is at least 55 years old ( within the meaning of sight impairment as determined in Section 223 of the Social Security Act ), is unable, because of the sight impairment, to engage in substantial gainful activity in which he/she has previously engaged with some regularity over a substantial period of time.
e.	Receipt of veteran’s or Social Security Disability payments benefits for disability, whether service-oriented or otherwise does not automatically establish disability.

2.	The person has a developmental disability; a severe, chronic disability which:
a.	Is attributable to a mental or physical impairment or combination of mental or physical impairment.
b.	Was manifested before age 22.
c.	Is likely to continue indefinitely.
d.	Results in substantial functional limitations in three or more of the following areas of major life activity:
(1) Self care
(2) Receptive and expressive language
(3) Learning
(4) Mobility
(5) Self-direction
(6) Capacity for independent living
(7) Economic self-sufficiency
e.	Reflects the persons need for a combination and sequence of special, interdisciplinary or generic care, or treatment, or for other services which are lifelong or extended duration and are individually planned and coordinated.

3.	Individual with handicap:
a.	A person with a physical or mental impairment that:
(1) Is expected to be of long-continued and indefinite duration
(2) Substantially impedes the person or is of such nature that the person’s ability to live independently should be improved by more suitable housing conditions.

4.	The term handicap further means, with respect to a person, a physical or mental impairment which substantially limits one or more major life activities; a record of such an impairment; or being regarded as having such as impairment. THIS TERM DOES NOT INCLUDE CURRENT ILLEGAL USE OF OR ADDICTION TO A CONTROLLED SUBSTANCE. As used in this definition:
a. 	 Physical or mental impairment includes:
(1) Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory; including speech organs; cardiovascular; reproductive; digestive; genitourinary; hemic and lymphatic, skin; and endocrine.
(2) Any mental or physiological disorder such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. The term “ physical or mental impairment” includes, but is not limited to , such diseases and conditions as orthopedic, visual, speech and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, human immunodeficiency virus (HIV), infection, acquired immunodeficiency syndrome (AIDS), mental retardation, emotional illness, drug addiction, and alcoholism.

5.	Major life activities means functions such as caring for one’s self, performing major tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

6. 	Has a record of such an impairment means has a history of, or has been misclassified as having a mental or physical impairment that substantially limits one or more major life activities.

7. 	Is regarding as having an impairment means:
a.	Has a physical or mental impairment that does not substantially limit one or more major life activities but that id treated by another person as constituting such a limitation.
b.	Has a physical or mental impairment that substantially limits one or more major life activities only as a result of the attitudes of others toward such impairment.
c.	Has one of the impairments defined in paragraph 4 a (1) and 4 a (2) of this definition but is treated by another person as having such an impairment.

	* LH: Means farm labor housing loans and/or grants.		

Who is eligible?

Public Housing and Section 8— Voucher is limited to low-income family and individual. A Housing Authority (HA) determination of your eligibility is based on: 
1. Annual gross income
2. Whether you qualify as a person whose an elder, with a disability, or a family status; and
3. US citizenship or eligible immigration status.

If you are eligible, the HA will check your references to make sure you and your family will be good tenants. HA will deny admission to an applicant whose habits and practices may be expected to have a detrimental effect on other
tenants or on the project’s environment.

What is Section 8 — Voucher?

The Section 8 — Voucher program provides assistance for low-income families in the private rental market through the Housing Assistance Payments Program (HAP).  Rental Voucher Holders select a unit from the private rental market. Rental assistance makes market rate housing affordable. Program participants normally pay no more than 30% of monthly adjusted income toward rent and utilities. The HAP subsidizes the balance of the rent to the property owner.

Income Questionnaire

Name of head of household:							 	   			
We need to know about the income that each member of your household expects to receive in the next 12 months. The following is a list of items the government counts as income in determining eligibility for federal housing assistance. Check yes for a particular type of income if any household member gets it. Check no only if no member of the household gets the particular type of income.  ***Warning: Section 1001 Title 18 of the U.S. Code makes it a criminal offense to willfully, make false statements, or any material fact involving the use or obtaining federal funds.	
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*Employment Income
(Includes 18 & older)

Wages		
Salaries
Overtime Pay
Commissions
Fees
Tips
Bonuses
Any other amount earned from working for other people or business.

*Benefit Payments
(Includes lump-sum payments received because of delays in processing benefits, but not lump-sum payment of Social Security or Supplement Security Income)

Social Security
SSI
Worker’s Comp.
Disability pay/benefit
Unemployment benefit
Severance pay
Annuities
Insurance policy payment
Pension
Retirement fund benefits
Death Benefits
Other benefit payment
(e.g. veteran’s disabilities, black lung sick benefits, ect.)

Yes

	

	

	

Yes

	

	

	

	

	

No

	

	

	

No

	

	

	

	

	

*Welfare Assistance
(Includes lump-sum payments received because of delays in processing benefits, but not grants or other amount for medical care or equipment for a disable person)

*Alimony/Child Support
(Includes adoption assistance payments)

*Interest, Dividends 
(Includes any other income from household assets)

*Lottery winning 
(paid in periodic payment)

*Money/Gift given regularly
(Includes rent or utility payment being paid regularly by someone else on behalf of the household.  Does not include Senior Citizen rebates, payment received for Foster Child, gift of groceries)

*Any other source of Income?

Yes

	

	

	

	

	

No

	

	

	

	

	 

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I hereby certify that all the above information is true and correct to the best of my knowledge.

Signature of Head of Household:	   Date: 		

Authorization for the 
Release of Information			
Organization requesting release of information:
	Burnett County Housing Authority
	P.O. Box 41
	Webster, WI 54893
	715-866-8231

Purpose:
The U.S. Department of Housing and Urban Development (HUD) and the above named organization may use this authorization and the information obtained with it to administer and enforce program rules and policies.

Authorization :
I authorize the release of any information (including documentation and other materials) pertinent to eligibility for or participation under any of the following programs:
	Low-Income Rental Indian Housing
	Low- Income Rental Public Housing
	Mutual Help Homeownership Opportunity Program
	Rental Assistance Program (RAP)
	Rent Supplement
	Section 8 Housing Assistance Payments Program
	Section 23 and 10(c) Leased Housing
	Section 23 Housing Assistance Payments
	Section 202
	Section 221 (d)(3) Below Market Interest Rate
	Turkey III Homeownership Opportunities Program
I authorize the above named organization and HUD to obtain information about me or my family that is pertinent to eligibility for or participation in assisted housing programs.

Information Covered Inquires may be made about:
	Child care expenses
	Credit history
	Criminal activity
	Family composition
	Employment, income, pensions, and assets
	Federal, State, Tribal, or local benefits
	Handicapped Assistance expenses
	Identity and marital status
	Medical expenses
	Social Security Numbers
	Residences and Rental History
							
Signatures:

							
	Head of Household			Date

							
	Spouse/Co-Tenant			Date

U.S. Department of Housing & Urban Development
Office of Housing
Office of Housing & Office of Public/Indian Housing		

Individuals or Organizations that may release information: 
Any individual or organization including any government organization may be asked to release information. For example information can be requested from:
	Banks & other financial institutes
	Courts
	Law enforcement agencies
	Credit Bureaus
	Employers, past & present
	Landlords
	Providers of: ( alimony, child care, child support, credit, handicapped assistance, medical care, pensions/annuities)
	Schools & colleges
	U.S. Social Security Administration
	U.S. Department of Veterans Affairs
	Utility Companies
	Welfare Agencies

Computer Matching Notice & Consent
I agree that a Public Housing Agency, Indian Housing Authority, or HUD may conduct computer matching programs with other governmental agencies including Federal, State, Tribal, or local agencies. The governmental agencies include:
	U.S. Office of Personal Management
	U.S. Social Security Administration
	U.S. Department of Defense
	U.S. Postal Service
	State Employment Security Agencies
	State Welfare and Food Stamp Agencies
The match will be used to verify information supplied by the family

Conditions:
I agree that photocopies of this authorization may be used for the purposes stated above. If I do not sign this authorization, I also understand that my housing assistance may be terminated or denied.

							

							
	Family Member over age 18		Date

							 
	Family Member over age 18		Date