Nia

Nia Association, Inc
Community Housing Development Organization
(CHDO)
APPLICATION FOR RENTAL ASSISTANCE

A $25 Application Fee must be submitted with signed Rental Assistance Application
Please Print


Applicant’s Name:

______________________________________________________________________________


Current Address:

______________________________________________________________________________

City:

_____________________________

State:

__________________

Zip Code:

_________________________

Home Phone:

___________________________

Alternate Phone:

_____________________________________

 

HOUSEHOLD COMPOSITION

(List the Head of Household and all other members who will be living in the unit.  Give the relationship of each family member to the head of household.)

Full Name

Relationship

Birth Date

Sex

Social Security Number

 

Head of Household

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


                           FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SPACE


Date Received:  ________________________________ 		 

More Information requested:
Yes No
Date letter Sent: ________________________

Date Application Completed: 		___________________ Date of Home Visit: ________________________

Accepted Denied
Date Letter Sent: ________________________

 



INCOME INFORMATION

What is the total annual income of all household members?  (Include wages, salaries and tips; other income such as alimony, child support; and Social Security, AFDC or other benefits) $ ____________

Full Name Source of Income Annual Amount Payment Basis
(weekly, monthly, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSET INFORMATION

List the type and source of any family assets.  Provide both the current cash value and the estimated annual income from the asset.

Full Name Type and Source of Asset
(e.g.bank accounts, investments) 		Cash Value of Asset Annual Income
from Asset

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXPENSE INFORMATION

Yes No
Does your household have un-reimbursed medical expenses in excess of 3 percent of annual income?
Yes No
Does your household pay child care expenses for children under the age of 13 that enable a family member to work or go to school?
Yes No
Does your household pay care expenses for the care of a family member with disabilities that enable a family member to work?

 

APPLICATION CERTIFICATION:  I/we understand that the above information is being collected to determine if I/we are eligible to receive rental assistance.  I/we authorize the Nia Association, Inc to verify all information provided on this application.

_____________________________________________   _______________________________________________
Head of Household's Signature                  Date Co-Applicant's Signature                               Date

 

 

 

Applicant's Name: ____________________________________________________________________________

This information is being collected to assure compliance with fair housing and equal opportunity guidelines.  If you do not wish to furnish the information below, please check the box below.

I do not wish to furnish this information

Race of Head of Household:

White
Asian/Pacific Islander
Native American/Alaskan Native
Hispanic
Black
Other (specify) ________________

 

Preference Information:

You may qualify for a preference for housing assistance if any of the following circumstances can be verified for your family.  Please check any that apply to you.

Yes No
Are you currently homeless or living in substandard housing?
If yes, please explain:
  _____________________________________________________________________________
  _____________________________________________________________________________
  _____________________________________________________________________________
  _____________________________________________________________________________

 

 

Yes No

Have you been (or are you about to be) displaced from your housing?
If yes, please explain
  _____________________________________________________________________________
  _____________________________________________________________________________
  _____________________________________________________________________________
  _____________________________________________________________________________

 

 

 

 

 

 

 

EHO

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