Application For Housing

    HOUSING AUTHORITY OF THE CITY OF MIDLAND

    HILLCREST MANOR

    700 W. SCHARBAUER DRIVE

    PHONE: 432-682-0011

    FAX: 432-685-1976

    Dear Applicant:

    You will find enclosed an application for admission to the City of Midland Housing Authority as you requested.

    Please fill out completely, as it will delay or stop the processing of your application. If you have any questions regarding any part of the application, please don't hesitate to call.

    Also, after your application has been processed and if you are found to be eligible for a unit, you will be notified and asked to provide the following documents for calculating your monthly rent.

    • Two forms of identification
    • Social Security or SSI benefits statement or printout
    • Paperwork showing any other income you might have
    • If you have a bank account, the last three statements
    • If you pay out-of-pocket medical expenses
    • Prescriptions printout from your pharmacy
    • Doctor's printout of payments
    • Health Insurance premium
    • Tax documentation showing tax value of any property you might own

    If you have any questions, please contact this office.

    HOUSING AUTHORITY OF THE CITY OF MIDLAND

    Hereinafter referred to as "PHA"

    HILLCREST MANOR

    700 W. SCHARBAUER DRIVE

    PHONE: 432-682-0011

    FAX: 432-685-1976

    Hillcrest Manor is an apartment facility and regulated under a program of the U.S. Department of Housing and Urban Development (HUD). Providing low income housing for senior citizens and disabled/handicapped person with limited incomes. Property is within walking distance of many retail outlets and services establishments.

    Occupants may include: Single person who is 62 years of age or over, disabled/handicapped person who is 18 years of age or older, a family of two persons, the head of which (or his/her spouse) is 62 years of age or over, or is disabled/handicapped person I8 years of age or over.

    To qualify as disabled/handicapped, applicants must have a physical or mental impairment that is expected to be a long continued and indefinite duration: substantially impeding the person's ability to earn living wage.

    All residents must be able to take care of all their living needs without reliance on neighbors or staff of the PHA.

    Income limits are established by HUD annually. Rent is based on 30% of the adjusted income (Gross income minus a S400 standard deduction S480 for dependent and any applicable medical deduction) Residents at Hillcrest Manor pays his/her own electric bill, and usage is determined by individual meters. A Utility allowance for electric is deducted from the gross amount of the rent.

    Each apartment includes the following: Carpeting or tile flooring, window drapes or blinds, electric range, refrigerator, individual controlled heating and air conditioning units, and smoke detectors.

    Applicants may be filled out in person from 8:30 a.m.to 5:00 p.m. Monday thru Friday.

    SERVICES AND ACTIVITIES

    Coin operated laundry facilities and community room in which various activities take place;
    A Beauty Shop is operated at the Hillcrest Manor location (one or two days a week). All activities are provided for the resident's pleasure.

    This Section for Office Only

    APPLICATION FOR ADMISSION

    HOUSING AUTHORITY OF THE CITY OF MIDLAND

    HILLCREST MANOR

    700 W. SCHARBAUER DRIVE

    MIDLAND, TEXAS 79705

    PHONE: 432-682-0011

    FAX: 432-685-1976

    I am Interested In :

    Bedroom Size :

    I have read and understand the "Applying for HUD Housing Assistance" form HUD-1141

    Applicant must contact the Authority in person every six (6) months to indicate continued interest and update information on the application. Failure to notify the Authority every six months from date of application, the application will be removed from active files

    Initials()

    We will provide assistance to individuals with a handicap or disability to insure equal access to this document. If you require assistance or help in understanding this document or help with completing the application, we will provide assistance. You must notify this office to arrange for assistance.

    THIS FORM MUST BE COMPLETED IN FULL AND SIGNED BY ALL PERSONS AGE 18 AND OVER. Failure of the
    applicant or participant to sign this application constitutes grounds for denial of eligibility or termination of assistance or tenancy.

    Use the correct legal name for each person who will reside in the apartment as it appears on the Social Security card or other legal forms of identification. All persons age 18 and over must sign this application certifying the information pertaining to them is correct. Do not leave blank any section of the application. If that section does not apply to you, write NIA.

    I. APPLICANT INFORMATION:

    II. HOUSEHOLD COMPOSITION:

    Race of Head of Household

    Ethnicity

    Adults (age 18 & over)
    First Mid Last
    		Relation To Head Sex (M/F) Decline To Disclose Social Security # Elderly/Disabled Date of Birth Place of Birth
    Children (under age 18)
    First Mid Last
    		Sex (M/F) Decline To Disclose Social Security # Date of Birth Place of Birth Name & Address of Absent Parent
    (not living with child)

    Which of the following do you claim? (check one)

    In case of emergency contact:

    Does anyone in your household require special accommodation due to a disability?

    Ill. TOTAL HOUSEHOLD INCOME:

    List all money earned or received by everyone living in the household. This includes but is not limited to gross wages, self­ employment, child support, Social Security, SSI, Worker's Compensation, Unemployment benefits, retirement benefits, TANF, Veteran's benefits, alimony, babysitting, rental property income. Income from banks such as interest on savings bonds, checking accounts, and CDs. Also include any regular contributions to the household from any person outside the household.

    Name of Household Member Who Receives Income Source or Type of Income

    (Name of Employer, Company, Absent Parent, TANF, SS, SSI, VA, Bank, Individual, etc.)

    		 How Often?

    (Monthly, Weekly, Bi-weekly)

    		 Gross Income

    (Cash or Check before deductions)

    		 List any changes anticipated

    IV. ASSETS

    Do any household members have or receive income from assets: (check all that apply)?

    V. CHILDCARE AND MEDICAL INFORMATION

    If the Head of Household or Spouse are age 62 or older OR disabled regardless of age, list all medical expenses anticipated for the next 12 months that will not be reimbursed by insurance or other outside source. (This includes but is not limited to: prescriptions, physicians' bills, hospital bills, insurance premiums, and over-the-counter medications) Back-up info required.

    Medical Expense Yearly Total Medical Expense Yearly Total

    VI. GENERAL INFORMATION

    PHA will be contacting all current and former landlords for the period three years from the date of application

    PRESONAL REFERENCES: Three (3) Must be Non- Family Members

    Name Relationship
    Address
    State City Zip
    		Telephone

    PHA will conduct a criminal record check on all adult applicants or those for whom adult records are available.

    Driver’s License or State ID#

    APPLICANT/TENANT CERTIFICATION

    All family members age 18 and over should review the information listed on this application and MUST sign below.

    I/We do hereby attest that all the information* given to the Housing Authority of the City of Midland on household composition, income, net family assets, and allowances and deductions are accurate and complete to the best of my/our knowledge and belief. I/We understand that I/We must report any changes in income, assets, family composition, or address to the Housing Authority with 14 days of such change. I/We further understand that false statements or information are punishable under Federal Law and are grounds for denial of this application and subsequent housing

    l/We understand that this application is valid for six (6) months unless renewed or updated by the applicant.

    This application is made with the understanding that it is to be processed for both credit and character references. I have no objection to inquiries for the purpose of verification of the above statement. This includes criminal Background Check. It is understood that the information provided in this application will be held in strict confidence except as provided in the Authorization to Release information form attached to this application. I also understand this This application is made with the understanding that it is to be processed for both credit and character references. Application is good for only six months from date of application. If l desire, my application to remain active, I must renew this application each six months thereafter in person or by letter stating my desire to remain on the waiting list and providing any updated information necessary to keep my application current

    I do hereby authorize the Housing Authority to obtain a consumer report as defined in the Fair Credit Reporting Act 15 U.S.C Sec 1681a(d). Seeking information on the credit worthiness, credit standing credit capacity, general reputation or mode of living of applicants

    COMMUNITY SERVICE/SELF SUFFICIENCY ACTIVITY REQUIREMENT

    The Quality Housing and Work Responsibility Act of 1998 requires, as a condition of lease renewal, that all non-exempt Public Housing adult residents (18 or older) contribute eight (8) hours per month of community service (volunteer work) or participate in eight (8) hours of training counseling. classes and other activities which help an individual toward self-sufficiency and economic independence. Failure to comply with the Authority's Community Service /Self - Sufficiency Policy incorporated herein by reference may The Quality Housing and Work Responsibility Act of 1998 requires. as a condition of lease renewal, that all non-exempt Public Housing adult residents (18 or older) contribute eight (8) hours per month of community service (volunteer work) or participate in eight {8) hours of training. counseling classes and other activities which help an individual toward self-sufficiency and economic independence result in non-renewal of the Lease.

    If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll free hotline at 1-800-669-9777

    Warning· 18 U.S,C. 1001 provides, among other things that whoever knowingly and willfully makes or uses a document or writing containing false, fictitious or fraudulent statement or entry in any matter within the jurisdiction of an department or agency of the United States shall be fined not more than $10,000 or imprisoned for not more than five years or both.

    I DO HEREBY CERTIFY THAT I HAVE REVIEWED ALL ANSWERS AND CERTIFICATIONS, INCLUDING PREFERENCES AND CITIZENSHIP WITH APPLICANT PRIOR TO SIGNATURES

    I understand that this is not a contract and does not bind wither party. The above information is full true and complete to the best on my knowledge. I have no objections to inquires being made for purpose of verifying statements made herein.

    l have also read, or have had read to me, and understand the eight-page Notice of Section 214 Requirements and have completed a Declaration of Citizenship/Non-citizenship document for each member of my household that will be living in assisted housing

    Possible credit and/or character reference checks Credit Bureau, Apt Assoc, Police Dept, Court, Prev. Landlords, Credit Ref., Personal Ref, Other

    DO NOT write below this line (For PHA use only)

    Record of Offers:





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