Fillable AHP Rental Application (City of Edina)

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AHP Rental Application (City of Edina)

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AHP 02/2020
AHP Rental Application
Applicant Information
Name: Student: Yes No (please circle)
Date of birth: SSN: Phone:
Current address:
City: State: ZIP Code:
Own Rent (Please circle) Monthly payment or rent: How long?
Previous address:
City: State: ZIP Code:
Owned Rented (Please circle) Monthly payment or rent: How long?
Co-applicant Information
Name: Student: Yes No (please circle)
Date of birth: SSN: Phone:
Current address:
City: State: ZIP Code:
Own Rent (Please circle) Monthly payment or rent: How long?
Previous address:
City: State: ZIP Code:
Owned Rented (Please circle) Monthly payment or rent: How long?
Income and
Asset
Total Monthly Income (Include all family gross income): $
Income Sources (check all that apply)
Wages/Self-Employment
SSI/SSA
Pension/Annuity
Child Support
Investment/Interest
Income
Workers Compensation
TANF/Public Assistance
Other________________
Total Value of Family Assets (Assets include all bank accounts, investment
accounts, and real estate):
$
Emergency Contact
Name of a person not residing with you:
Address:
City: State: ZIP Code: Phone:
References
Name: Address: Phone:
I authorize the verification of the information provided on this form as to my credit and source/s of income.
Signature of applicant: Date:
Signature of co-applicant: Date:
AHP 02/2020
Government Data Practices Act
Disclosure Statement
Print name(s) of Household Members signing this form:
The City of (“City”) that provided the funding for the development of the property listed
below is asking for this private information that relates to your application to occupy, or continue to
occupy, a unit in the following property (“Property”).
Property Name:
Some of the information you are being asked to provide may be considered private or confidential under
the Minnesota Government Data Practices Act (MGDPA), Minnesota Statutes Chapter 13. Section
13.04(2) of this law requires that you be notified of the matters included in this Disclosure Statement
before you are asked to provide that information. The owner/agent of the Property may also ask you to
supply information that relates to your application. The owner’s/agent’s request for information is not
governed by the Minnesota Government Data Practices Act.
1. The City of Edina, Minnesota for the Affordable Housing Program (AHP) is asking for information
necessary for the administration and management of a local program to provide housing for low
income families. Some of the information may be used to establish your eligibility to initially
occupy, or to continue to occupy, a unit in the Property. Other information may be used to assist
the City in the evaluation and management of some of the programs it operates.
2. As part of your application, you are asked to supply the information contained in the following
attachment.
Attachment 1 – Inclusionary Housing Program
The Attachment has two parts: Part A and Part B
3. The information asked for under Part A of the attachment may be used by the City and/or
owner/agent to establish your eligibility to participate in the Inclusionary Housing Program or
occupy an affordable dwelling unit in the Property. If you refuse to supply any portion of the
information asked for under Part A, you may not qualify for initial or continued occupancy of a unit
in the Property.
4. The information asked for under Part B will help the City in the evaluation and management of
some of the programs it operates and your supplying of this information will be helpful to the City.
AHP 02/2020
Failure to provide any of the information asked for under Part B will NOT affect whether or not you
qualify for initial or continued occupancy of a unit in the Property.
5. The owner/agent may also ask for information to determine whether or not it will rent a unit in the
Property to you. If you supply, or refuse to supply, any information requested by the owner/agent,
it will NOT affect a decision by the City, but could affect the owner’s/agent’s decision to rent a unit
to you. The determination by the owner/agent is separate from the City’s determination and the
City does not participate, in any way, in the owner’s/agent’s decision.
6. All of the information that you supply will be accessible to staff of the City (and its agents) and
may be made available to staff of the Office of the Minnesota Attorney General, the United States
Department of Housing and Urban Development (HUD), the United States Internal Revenue
Service (IRS) and other persons and/or governmental entities who may have statutory authority to
review the information, investigate specific conduct, and/or take appropriate legal action including
but not limited to law enforcement agencies, courts and other regulatory agencies. The information
may also be provided by the City to the owner’s management agents of the Property.
7. This Disclosure Statement remains in effect for as long as you occupy a unit in the Property and are
a participant in the program(s) identified above.
I was (We were) supplied with a copy of and have read this Government Data Practices Act Disclosure
Statement and the Attachment identified above.
Head of Household, Spouse, Co-Head and all household members age 18 or older must sign and date:
Applicant/Tenant signature Date
Applicant/Tenant signature Date
Applicant/Tenant signature Date
Applicant/Tenant signature Date
Applicant/Tenant signature Date
AHP 02/2020
Attachment
Affordable Housing Program (AHP)
Part A (Required to determine eligibility)
1. Information regarding the household composition including the name(s) and age(s) of all members in the
household.
2. Student status.
3. The amount and source of all earned and unearned income of all household members.
4. The type, value and income derived from all household assets.
5. The type, value and income derived from all household assets disposed of for less than fair market value
within the past 2 years.
6. Current and/or previous housing history (for program eligibility, if applicable).
Part B
1. Race
2. Ethnicity
3. Gender of head of household
4. Receipt of Public Assistance and Type of Assistance (MFIP, Section 8, GRH, etc.)
5. Homeless Household
6. Disabled Status
7. Household Type (single, elderly, disabled, etc.)
11/2019
Property Address: ____________________
Affordable Housing Program (AHP)
STUDENT STATUS SELF-CERTIFICATION
FIRST NAME:
TO BE COMPLETED BY APPLICANT / RESIDENT:
A.
Are you student at an institution of higher education? _____ Yes _____ No
“Institution of higher education” includes post-secondary vocational institutions, “proprietary institutions of
higher education” which prepare students for “gainful employment in a recognized occupation,” and
accredited post-secondary colleges and universities. If you are not sure, please mark “yes” and we will
verify the status of your institution.
If you have answered no, please skip the following questions in (B) and sign below in (C).
B.
If you answered yes, please complete the following questions and sign below in (C):
Yes No
1. Are you a full-time student? _____ ____
2. Are you disabled? _____ ____
If yes, were you receiving Section 8 assistance as of November 30, 2005? _____ ____
3. Are you at least 24 years of age? _____ ____
If no, please list birth date:________________
4. Are you a veteran of the United States military? _____ ____
5. Are you married? _____ ____
6. Do you have a dependent other than a spouse (e.g. dependent child) _____ ____
7. Will you be living with your parents? _____ ____
If no:
a. Are your parents receiving or eligible to receive Section 8? _____ ____
b. Are you claimed as a dependent on your parent’s tax return? _____ ____
c. Have you maintained a household separate from your parents or
guardians for at least 1 year? _____ ____
8. Are you a graduate or professional student? _____ ____
9. Were you an orphan or a ward of the court through the age of 18? _____ ____
10. Are you classified as a Vulnerable Youth? _____ ____
11. Are you a student for whom a financial aid administrator makes a
documented determination of independence by reason of other
unusual circumstances? _____ ____
C.
________________________________ __________________________________
Signature Print Name
________________________________
Date
LAST NAME:
AHP 02/2020
UNDER $50,000 ASSET CERTIFICATION
for use with HRA's Affordable Housing Program Only
For households whose combined net assets do not exceed $50,000.
Compl
ete only one form per household; include assets of children.
Household Name: Unit No.
Development Name: City:
Compl
ete all that apply for 1 through 4:
1. My/our a
ssets include (enter n/a in (A) if you do not own the respective asset):
(A)
Cash
Value*
(B)
Int.
Rate
(A*B)
Annual
Income
Source
(A)
Cash
Value*
(B)
Int.
Rate
(A*B)
Annual
Income
Source
$
$
Savings Account(s)
$
$
Checking Account(s)
$
$
Include online accounts such
as GoFundMe, Fundly, etc.
Cash on Hand
$
$
Cash cards used to
receive government
benefits or other income
$
$
Certificates of Deposit
$
$
Money market funds
$
$
Stocks
$
$
Bonds
$
$
IRA Account(s)
$
$
401K Account(s)
$
$
Keogh Account(s)
$
$
Trust Funds
$
$
Equity in real estate
$
$
Land Contracts
$
$
Lump Sum Receipts
$
$
Capital investments
$
$
Life Insurance Policies (excluding Term)
$
$
Other Retirement/Pension Funds not named above:
$
$
Personal property held as an investment** :
$
$
Other (list):
PLEASE NOTE: Certain funds (e.g., Retirement, Pension, Trust) may or may not be (fully) accessible to you. Include only those amounts which are.
*Cash value is defined as market value minus the cost of converting the asset to cash, such as broker's fees, settlement costs, outstanding loans, early withdrawal
penalties, etc.
**
Personal property held as an investment may include, but is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary personal
property such as, but not necessarily limited to, household furniture, daily-use autos, clothing, assets of an active business, or special equipment for use by the
disabled.
2. Within the past two (2) years, I/we have sold or given away assets (including cash, real estate, etc.) for more than $1,000 below
fair market value (FMV). Those amounts equal a total of: $ (enter the difference between FMV and
the amount you received).
3. I/we have not sold or given away assets (including cash, real estate, etc.) for less than fair market value during the past two (2)
years.
4. I/we do not have any assets at this time (do not check this box if you have entered any numbers in section 1, above).
The net family assets (as defined in 24 CFR 813.102) above do not exceed $50,000 and the annual income from the net family assets is
$
(enter the total of all (A*B) Annual Income in section 1 above). This amount is included in total gross annual income.
Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our
knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False,
misleading or incomplete information may result in the termination of a lease agreement.
Applicant/Tenant
Under $50,000 Asset Certification
Date
Applicant/Tenant
Date
Head of Household
Demographic Information
Head of Household Demographics 1 of 1 AHP 02/2020
Instructions: This form is to be completed by the head of household only after occupancy has been
approved. Your approval for occupancy will not be affected if you choose not to respond. The owner
will submit this information to The City of Edina for assessment of households being served by its
financing programs. Your cooperation is much appreciated.
Housing Information (this section to be completed by owner/agent)
Property Name
Minnesota Housing D#
Building Address
Unit #
Head of Household Information
Name
Date of birth
(month/day/year)
/ /
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
I choose not to respond
Gender
Female
Male
I choose not to respond
Race
(check all that apply)
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/
Other Pacific Islander
White
I choose not to respond
Number of household
members
Adults (including head of household)
Children under age 18 residing in unit
Is any household member
mobility impaired requiring
features of an accessible
unit?
Yes
No
I choose not to respond
Is any household member a
person with a disability
other than mobility
impairment?
Yes
No
I choose not to respond
Main source of household
income (check only one)
Salary/wages
Self-employment
Social Security
Retirement /pension/annuity
Alimony/child support
Interest/dividends/rental income
Unemployment/disability
Public assistance
No income
AHP 02/2020
AFFORDABLE HOUSING PROGRAM (AHP) LEASE ADDENDUM
Resident Name:
Address:
Lease Date:
The Property in which you are leasing received funding from the Affordable Housing Program. This program is
designed to provide housing to low income individuals and families.
This addendum will be in effect for the duration of your occupancy.
By signing this Agreement, you and all adult household members acknowledge that you have read, understand
and agree to the following provisions:
1. Affordable Housing Program. The Unit must comply with the Affordable Housing Program. Resident's rights
under the Lease are subject to Program requirements.
2. Unit Occupancy. Only the residents named on the Lease are permitted to occupy the unit.
3. Income Certification. Resident has executed an Income Certification Form prior to moving into the Unit, and
Resident shall complete and execute further Income Certification Forms at Management's request not less than
annually hereafter. Upon Management’s request, Resident shall certify Resident’s household income and/or
assets to Management or any governmental or quasi-governmental agency in a manner satisfactory to
Management.
4. Recertified Income. Resident acknowledges that the annual recertification of Resident's household income
must meet the limitations imposed by the Program. (Resident’s initials) ________
5. Information Supplied. Resident certifies that the information supplied by Resident to determine Resident's
qualifications to rent the Unit, including Resident's Application and Income Certification, is accurate, complete,
and true in all respects. Submission of inaccurate, incomplete, or false information at any time is a breach of
lease for which Resident can be evicted.
6. Increased Income. If, upon annual recertification, Resident's household income exceeds 140% of the applicable
Program limit, Management may meet with Resident to review the status of the household’s qualification under
the Program. If the household no longer qualifies, Management may terminate Resident’s lease.
7. Certain Changes. Resident shall notify Management immediately in writing if Resident's household size
changes, anyone in Resident’s household becomes a full-time student, or Resident begins to receive HUD
assistance. Management may immediately terminate this Lease if Resident’s student status disqualifies the Unit
under the Program. Management may adjust Resident's rent and/or utility allowance if Resident begins to
receive HUD assistance. (Resident’s initials) _________
8. Student Eligibility. AHP adopted the Section 8 Housing Choice Voucher program restrictions on student
participation found at 24 CFR 5.612 and excludes any individual that:
AHP 02/2020
1. Is enrolled in a higher education institution;
AND
2. Is under the age of 24; and
3. Is not a veteran of the US Military; and
4. Is not married*; and
5. Does not have a dependent child(ren); and
6. Is not a person with disabilities; and
7. Is not otherwise individually eligible, or has parents who, individually or jointly, are not eligible on the
basis of income
* Effective August 1, 2013 same-sex marriages are recognized as marriages for student eligibility
purposes.
ALL RESIDENTS MUST IMMEDIATELY REPORT TO MANAGEMENT ANY CHANGE IN STUDENT STATUS. (Resident’s
initials) __________
9. Cooperation with Management. Resident shall cooperate with Management so that Management complies with
the Program. Resident will timely respond to Management requests related to Program documents,
verifications, and certifications. This includes but is not limited to timely attending meetings, signing
verifications, and providing requested information. Resident agrees to sign a new lease upon the completion of
annual certifications, if requested or required by Management.
10. Termination/Non-Renewal. Management may terminate or refuse to renew the Lease or file an eviction action
for the following reasons:
Serious or repeated violation of the Lease. This includes but is not limited to Resident’s violation of this
Agreement. (Resident’s initials) _______
Violation of applicable federal, state, or local law. (Resident’s initials) _______
Refusal/Failure to complete paperwork required by the Program. (Resident’s initials) _______
Other good cause, including if Resident’s continued occupancy of the Unit violates Program requirements.
(Resident’s initials) _______
I have read and agree to the provisions above and understand that failure to comply with these provisions
constitutes material non-compliance with this lease and establishes good cause for termination, nonrenewal of
the lease, or eviction action.
________________________________________________ __________________________
Resident’s Signature Date
________________________________________________ __________________________
Resident’s Signature Date
________________________________________________ __________________________
Management’s Signature Date
Affordable Housing Program (AHP)
RESIDENT NOTIFICATION LETTER
As a resident of (name of property), a property supported by the CITY OF
EDINA, MINNESOTA, a Minnesota statutory city, and the HOUSING AND REDEVELOPMENT AUTHORITY OF THE
CITY OF EDINA, MINNESOTA, you have certain rights stated in your lease and the attached Lease Rider. Your
landlord must follow city and state rules for the Affordable Housing Program. One of the important protections
provided by federal law is that you cannot be evicted from your home or have your tenancy terminated without
good reason or “good cause.”
Your landlord may not evict you or terminate your tenancy (including refusing to renew your lease) without good
cause. Good cause is (a) serious or repeated violation(s) of the material terms and conditions of your lease. The
landlord must state, in writing, the good cause in any eviction, lease non-renewal or termination of tenancy
notice. If you did not do what your landlord claims in the notice, or if you think it was not serious enough for
your lease to be terminated or not renewed, you can ask the landlord if there is an appeal process. If there is no
appeal process, you may request that the termination be retracted and discuss your reasons why. If you receive a
notice of eviction, you have a right to contest the eviction in court by explaining to the judge why you disagree
with the reasons for terminating your lease. Visit www.lawhelpmn.org to see if you qualify for free or low-cost
legal assistance.
In addition, your landlord may not increase the amount of rent stated on your lease more than once annually.
The attached Lease Rider should already be signed by your landlord. You and all members of your household age
18 or older must also sign the Lease Rider in order to make it part of your lease.
The Lease Rider needs to be signed each time you sign a new lease. If at any time additional adult household
members enter the unit or a child who lives in that unit turns 18, they should add their signature to the existing
Lease Rider with the current date.
Your landlord also has a legal obligation to comply with the statutory requirements found in Section 601 of the
Violence Against Women Reauthorization Act of 2013 (VAWA).
Under VAWA, you may not be denied admission, denied assistance, terminated from participation, or evicted on
the basis that you are or have been a victim of domestic violence, dating violence, sexual assault or stalking, if you
otherwise qualify for admission, assistance, participation or occupancy.
You should have received the following when you were approved for occupancy or at some time during your
occupancy:
• HUD Form 5380 – Notice of Occupancy Rights under the Violence Against Women Act; and
• HUD Form 5382 – Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and
Alternate Documentation.
The landlord must also include these documents with any notice of eviction, lease non-renewal or termination of
tenancy. You may also have signed a VAWA Lease Addendum.
If you have any questions concerning this matter, please contact your resident manager,
, or your landlord at (phone and email).
Sincerely ,
Property Representative Name (print and sign) Date
AHP 02/2020
Affordable Housing Program LEASE RIDER
(attach to resident lease)
Property Name:
Building/Unit #:
Head of Household Name:
The Lease dated is hereby amended by adding the following provisions:
1.
Owner/Landlord may not evict or terminate the tenancy (including refusing to renew this Lease)
except for good cause. Good cause means (a) serious or repeated violation(s) of the material
terms and conditions of the Lease. Any eviction, lease non-renewal or termination of tenancy
notice must be in writing and must state the specific violation(s). The notice must comply with all
requirements of Minnesota law and other applicable programs.
2.
Owner/Landlord may not increase the lease rent more than once annually, regardless of the term
of the Lease.
To the extent that any terms contained in the Lease or any other agreement between the owner and the
tenant contradict the terms of this Lease Rider, the provisions of this Lease Rider shall control.
By signing below, I indicate my consent to this Lease Rider:
Property Representative Name (print) (signature) Date
*************************************************************************************
By signing below, I indicate my consent to this Lease Rider. I/we have been given a copy of this Lease
Rider.
Resident Name (print)
(signature)
Date
Resident Name (print)
(signature)
Date
Resident Name (print)
(signature)
Date
Resident Name (print)
(signature)
Date
AHP 02/2020
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AHP Rental Application (City of Edina)

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Completed 13 February 2021

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