Fill - Free fillable I. Household Composition List everyone who currently lives (State of Louisiana

LAQ Application for Continued Occupancy

Last Revised: 1/2016

Application for Continued Occupancy

Please fill in all applicable blanks and answer all questions. If you need additional space, use a blank piece of paper and

attach it to the application. Case Manager’s Name________________________________________________________

Name of Head of Household:

Street Address: (Unit) (City) (State) (Zip)

Phone

Number:

Alternate

Number:

Address:

I. Household Composition – List everyone who currently lives or will live in your household.

First & Last

Name

Sex

(M, F)

Relation

Head

Race*

Ethnicity

(Circle one)

Head

H NH

* Code for Race: 1 –White; 2- African American; 3-American Indian; 4-Asian; 5-Hawaiian/South Pacific

** Code for Ethnicity: H-Hispanic or NH-Non-Hispanic

1. List any household member(s) 18 years or older who currently attends school full-time and the school

Does not apply:

the household member(s) attends:

2. List any household member(s) who is disabled:

Does not apply:

Will the disabled household member(s) require special accommodations due to their disability? Yes No

If yes, describe accommodation:

3. Do you have a child under the age of 6 who has been tested for lead and was found to have

an elevated blood level? If yes, you will need to provide the LHA with a copy of the test results.

Yes No

4. Has any household member ever been arrested or convicted of a crime (other than a traffic

violation)?

Yes No

If yes, please explain:

Office Use Only: Annual Reexamination – Eff Date:

1690 North Blvd

Baton Rouge, LA 70802

Telephone (225) 763-8700

Fax: (225) 342.2079

LAQ Application for Continued Occupancy

Last Revised: 7/2016

II. Household Income

Complete each of the income sections below and provide income information for all household members. You will need to

provide documentation to verify each type of income your household receives.

1. Earned Income – includes employment and wages of any kind (full-time, part-time, seasonal, self-employment,

temporary employment, cash payment). If you work with a temp agency, list below and estimate your pay.

Do you or any household member receive any earned income? Yes No

Verification – Provide two (2) consecutive paystubs, a payroll print-out/summary, or employer letter; for self-employment:

provide a copy of your most recent tax return (e.g. 1040, 1040A).

Household Member Name

Employer/Source

mation

Amount ($)/year

Name:

Phone:

Fax:

Address:

Name:

Phone:

Fax:

Address:

Name:

Phone:

Fax:

Address:

Name:

Phone:

Fax:

Address:

2. Benefit Income

Does any household member receive:

a. Disability/Worker’s Compensation?

Yes

c. Food Stamps/Welfare?

Yes

b. Social Security or SSI?

Yes

d. Unemployment?

Yes

Verification: Provide an award letter or print-out with current benefit amount.

Household Member Name

Income

Type

Amount ($)

Frequency

3. Other Income

Does any household member receive:

a. Alimony/Child Support Yes No

Case number:

b. Cash or help paying bills from friends/family? Yes No

c. Pension/Retirement? Yes No

d. Foster Care/Adoption Assistance? Yes No

e. Other Income? Yes No

Verification: Provide a statement/award letter/print-out to show how much you currently receive.

Household Member Name

Sou

rce

Source Address & Phone Number

Amount ($)

Frequency

LAQ Application for Continued Occupancy

Last Revised: 7/2016

III. Assets

Do you or any household member have?

If yes, provide current balance and/or amount of income expected to

receive from each source.

Checking

Yes No

Savings/Certificate of Deposit (CD)

Yes No

Retirement Acct (for example, 401K, 403B)

Yes No

Life Insurance Policy

Yes No

Stocks or Bonds

Yes No

Real Estate

Yes No

Other Assets

Yes No

If you answered “Yes” to any of the above, please provide more information about the asset(s) below:

Household Member Name

Sou

rce

Source Address

ash

alu

($)

tere

Rate

Have you or any household member given away or sold assets (including cash) for less than full value in the last

two years? Yes No

If yes, what was the asset?

What was the value of the asset? How much did you receive for the sale of the asset?

IV. Child Care Expenses

Note: Complete Section IV ONLY IF there are children 12 years or younger in the household.

In order to be counted as a deduction the child care must allow an adult member of the household to work, go to

school, or search for a job.

Do you have any child care expenses that are not reimbursed by someone outside your household? Yes No

Verification: Provide a bill from your childcare provider or a printout from a government agency that shows your current

contribution.

Provider Name, Address &

Phone

Number

Name(s) of Child(ren)

Name of

Person

enabled to attend work,

school, or job search

Activity Enabled

(work, school, or

job search)

Cost ($)

Frequency

✔

LAQ Application for Continued Occupancy

Last Revised: 7/2016

V. Medical Expenses

Note: Complete Section V ONLY IF the head of household, co-head, or spouse is disabled or at least 62 years old.

Do you or any household member have any of

the following medical expenses?

Amount of

Expense ($)

Frequency of Expense

Estimated

Annual

Amount

($)

Prescriptions

Yes No

Doctors bills/co-pays

Yes No

Insurance Premiums

Yes No

Hospital bills

Yes No

Other:

Yes No

Verification: Provide any printouts or receipts that you have to support the amount of medical expenses you have

on an annual basis.

VI. Disability Expenses

Note: Complete Section VI ONLY IF one or more household members is disabled.

Do you have any expenses for the care of a disabled household member that enable any member of the household to

work (for example, care attendant, auxiliary apparatus or service animal)? Yes No

Verification: Provide bills or printouts showing how much you pay and how frequently.

Describe

Expense

Estimated Annual Amount ($)

Who is enabled to work?

WARNING! Title 18, Section 1001 of the United States Code: Whoever, in any matter within the jurisdiction of the executive,

legislative, or judicial branch of the Government of the United States, knowingly and willfully— (1) falsifies, conceals, or covers up

by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or representation;

or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent

statement or entry; shall be fined under this title, imprisoned not more than 5 years or, if the offense involves international or

domestic terrorism (as defined in section 2331), imprisoned not more than 8 years, or both. If the matter relates to an offense

under chapter 109A, 109B, 110, or 117, or section 1591, then the term of imprisonment imposed under this section shall be not

more than 8 years.

I do hereby swear and attest that all of the information above about my household is true and correct.

Signature of Head of Household Date

Signature of

Spouse/Co-Head/Other

Adult (18 years or older) Date

Signature of Other Adult (18 years or older) Date

Supplemental and Optional 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.

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:

Commit

men

t 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 confidenti

al 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 applicant’s 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

Check this box if you choose not to provide the contact information.

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 HUD’s 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)

ZERO INCOME AFFIDAVIT

Names of Applicable Adult Household Members: 1:

I hereby certify that I do not receive income from any of the following sources:

A. Wages from employment (including commissions, tips, bonuses, etc.);

B. Income from the operation of a business;

C. Rental income from real or personal property;

D. Interests or dividends from assets;

E. Social Security payments, annuities, insurance policies, retirement funds, pensions or death benefits;

F. Unemployment or disability payments;

G. Public assistance payments;

H. Periodic allowances such as alimony, child support, or gifts received from persons not living in my household;

I. Sales from self-employed resources;

J. Any other source not named above.

I currently have no income of any kind and there is no imminent change expected in my financial status or

employment status during the next thirty (30) days.

I have answered these questions truthfully to the best of my ability.

Signatures:

Head of Household Date

Spouse Date

Other Family Member over age 18 Date

1690 North Blvd

Baton Rouge, LA 70802

Telephone (225) 763-8700

Fax: (225) 342-2079

ref.

Handbooks

7420.7, 7420.8, & 7465.1

form HUD-9886 (7/94)

Original is retained by the requesting organization.

Authorization

for the Release of Information/

Privacy Act Notice

to the U.S. Department of Housing and Urban Development (HUD)

and the Housing Agency/Authority (HA)

U.S. Department of Housing

and Urban Development

Office of Public and Indian Housing

PHA

requesting

release of

information;

(Cross out space if none) IHA

requesting

release of

information:

(Cross out space if none)

(Full address, name of contact person, and date) (Full address, name of contact person, and date)

Authority: Section 904 of the Stewart B. McKinney

Homeless

Assistance Amendments Act of 1988, as amended by Section

903

of the Housing and Community Development Act of 1992

and

Section 3003 of the Omnibus Budget Reconciliation Act of

1993.

This law is found at 42 U.S.C.

3544.

This law requires that you sign a consent form authorizing: (1)

HUD and the Housing Agency/Authority (HA) to request verifi-

cation of salary and wages from current or previous employers; (2)

HUD and the HA to request wage and unemployment

compensa-

tion claim information from the state agency responsible for

keeping that information; (3) HUD to request certain tax return

information from the U.S. Social Security Administration and

the

U.S. Internal Revenue Service. The law also requires

independent

verification of income information. Therefore, HUD or the

may request information from financial institutions to verify your

eligibility and level of

benefits.

Purpose: In signing this consent form, you are authorizing

HUD

and the above-named HA to request income information from

the

sources listed on the form. HUD and the HA need this

information

to verify your household’s income, in order to ensure that you are

eligible for assisted housing benefits and that these benefits are

set

at the correct level. HUD and the HA may participate in

computer

matching programs with these sources in order to verify your

eligibility and level of

benefits.

Uses of Information to be Obtained: HUD is required to protect

the income information it obtains in accordance with the

Privacy

Act of 1974, 5 U.S.C. 552a. HUD may disclose

information

(other than tax return information) for certain routine uses, such

to other government agencies for law enforcement purposes,

Federal agencies for employment suitability purposes and to

HAs

for the purpose of determining housing assistance. The HA is

also

required to protect the income information it obtains in accordance

with any applicable State privacy law. HUD and HA

employees

may be subject to penalties for unauthorized disclosures or im-

proper uses of the income information that is obtained based on

the

consent form. Private owners may not request or

receive

information authorized by this

form.

Who Must Sign the Consent Form: Each member of your

household who is 18 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 18 years of age.

Persons who apply for or receive assistance under the

following

programs are required to sign this consent form:

PHA-owned rental public

housing

Turnkey III Homeownership

Opportunities

Mutual Help Homeownership

Opportunity

Section 23 and 19(c) leased

housing

Section 23 Housing Assistance

Payments

HA-owned rental Indian

housing

Section 8 Rental

Certificate

Section 8 Rental Voucher

Section 8 Moderate

Rehabilitation

Failure to Sign Consent Form: Your failure to sign the

consent

form may result in the denial of eligibility or termination of assisted

housing benefits, or both. Denial of eligibility or termi- nation of

benefits is subject to the HA’s grievance procedures

and

Section 8

informal hearing procedures.

Sources of Information To Be

Obtained

State Wage Information Collection Agencies. (This consent

limited to wages and unemployment compensation I have re-

ceived during period(s) within the last 5 years when I

have

received

assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent

limited to the wage and self employment information and pay-

ments of retirement income as referenced at Section 6103(l)(7)(A)

of the Internal Revenue

Code.)

U.S. Internal Revenue Service (HUD only) (This consent

limited

to unearned income [i.e., interest and

dividends].)

Information may also be obtained directly from: (a) current

and

former employers concerning salary and wages and (b) financial

institutions concerning unearned income (i.e., interest and

divi-

dends). I understand that income information obtained from

these

sources will be used to verify information that I provide

determining eligibility for assisted housing programs and the

level

of benefits. Therefore, this consent form only authorizes release

directly from employers and financial institutions of

information

regarding any period(s) within the last 5 years when I

have

received

assisted housing

benefits.

LOUISIANA HOUSING AUTHORITY

Project Based Voucher Program

1690 North Blvd

Baton Rouge, LA 70802

ref.

Handbooks

7420.7, 7420.8, & 7465.1

form HUD-9886 (7/94)

Original is retained by the requesting organization.

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form

for

the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs

that

receive income information under this consent form cannot use it to deny, reduce or terminate assistance without

first

independently verifying what the amount was, whether I actually had access to the funds and when the funds were received.

addition, I must be given an opportunity to contest those

determinations.

This consent form expires 15 months after

signed.

Signatures:

Head of Household Date

Social Security Number (if any) of Head of Household

Other Family Member over age 18 Date

Spouse Date

Other Family Member over age 18 Date

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 Government’s 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

six years of age and older 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, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper

uses

information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. 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.

ref.

Handbooks

7420.7, 7420.8, & 7465.1

form HUD-9886 (7/94)

Original is retained by the requesting organization.

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, the HA or the owner responsible for the unauthorized disclosure or improper use.

Louisiana Permanent Supportive Housing

Project Based Voucher Program Family

Obligations

Under the terms of the Project Based Voucher Program the family shall:

1. Supply all documentation as Louisiana Housing Authority determines to

be necessary in the administration of the program;

2. Allow Louisiana Housing Authority (LHA) or its contractors to inspect the unit

at reasonable times and after reasonable notice. The family must allow the

Owner / landlord access to make repairs;

3. Notify Louisiana Housing Authority, in writing, at least sixty (60) days

before vacating the dwelling unit as well as providing Louisiana Housing

Authority with a copy of the notice to vacate the unit submitted to the

owner;

4. Use the unit only for residence by the family and the unit must serve as the

family's principal place of residence. The family shall not assign the lease or

transfer the unit;

5. Shall not receive PBV housing assistance while residing in a unit owned by a

parent, grandchild, sister, brother, or any member of the family, unless

Louisiana Housing Authority has determined that approving the unit would

provide a reasonable accommodation for a family member who is a person

with a disability;

6. Avoid creating a violation of Housing Quality Standards (HQS) by:

a. Paying for utility bills for which the head of household is responsible

b. Allowing the owner / landlord access to the unit to make repairs

c. Providing and maintaining any appliances the owner is not required to

provide

d. Not damaging or allowing any family member or guest to damage the

unit or common areas

7. The family must also correct, within 24 hours, any life-threatening breach of

Housing Quality Standards (HQS) it has caused, and any other violations

within the time frame specified by Louisiana Housing Authority.

8. The family and their guest(s) shall not:

a. Commit serious or repeated violations of the lease

b. Own or have any legal interest in the dwelling unit

c. Commit any fraud, bribery, or any other corrupt criminal act in

connection with the Project Based Voucher Program

d. Receive assistance under the Project Based Voucher Program while

occupying, or receiving assistance for occupancy of, any other unit

assisted under any Federal housing assistance program including any

subsidy program

e. Engage in any drug-related criminal activity, violent criminal activity or

illegally possess weapons

f. Engage in the use of illegal drugs or abuse of alcohol that threatens the

health, safety or right to peaceful enjoyment of other residents and

persons residing in the immediate vicinity of the premises

g. Engage in or threaten abuse or violent behavior toward Louisiana Housing

Authority or Local Lead Agency personnel

h. Damage the unit or premises (other than damages from ordinary wear

and tear) or permit any guest to damage the unit or premises

9. The family shall report to Louisiana Housing Authority any absence of the

entire household (all family members) of more than thirty (30) days. In no case

may a participant be absent from a unit for more than 180 days. If the family

leaves the household for more than 180 days for a reason other than medical

need, the unit will not be considered the family's principal place of residence

and the family's assistance shall be terminated.

Signature of Family Representative:

Date

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