2019 zero or very low-income worksheet - the arc of north ...€¦ · questionnaire for...

QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME

of 8 Revised 5/29/18

2019 Zero or Very Low-Income Worksheet

Applicant/Resident Name

Head-of-Household Name (if different)

Current Address

Address Line 2

City, State, Zip

Home Phone

Cell Phone

Email address

Work Phone

May we contact you at work? Yes No

During your eligibility/certification interview, you indicated that your household has no income or very sporadic income. It is this company’s policy to ensure that you can pay your rent in accordance with the lease, that you can maintain the unit in accordance with the lease and that you are fully disclosing all income as required so that you are provided the correct housing assistance amount. In order to receive assistance, you are required to supply the following information every 90 days so that we can ensure that no income is overlooked. All responses are subject to verification. Incomplete forms will not be processed which means that assistance and/or tenancy may be denied or terminated as appropriate.

Have you been employed in the last 12 months?

Yes No If yes, please provide the following employer information Name:______________________________

Address: ____________________________

Address: ____________________________

Phone Number: _______________________

Income earned in the last 12 months:$_________________________

Do you expect to be employed at all in the next 12 months?

Yes No If yes, please provide the following employer information

Name:______________________________

Address: ____________________________

Address: ____________________________

Phone Number: _______________________

Income expected to be earned in the next 12 months: $____________________________

How do you plan to pay rent for the next 12 months?

_______________________________________________________

_______________________________________________________



Do you ever perform odd jobs such as construction jobs, field work, babysitting, seamstress work, preparation of meals, etc.?

Yes No Income expected to be earned in the next 12 months: $____________

Do you have money deposited in any bank?

Yes No

Do you have any outstanding loans?

Yes No If so, how do you pay the monthly balance? ________________ __________________________________________________________

Do you have any outstanding medical expenses?

Yes No If so, how do you pay the monthly balance? ___________ __________________________________________________________

Do you have recurring monthly or quarterly medical expenses such as prescriptions, routine medical care, etc.?

Yes No If so, how do you pay the monthly balance? _____________________________ _________________________________________________________________

Do you have credit cards?

Yes No If so, how do you pay the monthly balance? _____________________________ ________________________________________________________________

Does any person provide you with money, on a regular basis, to pay for rent, meals, child care, utilities, automobiles or any other regular expense?

Yes No If so, what kind of help? __________________________________ How often? __________________________________ Total financial assistance to be provided in next 12 months: $_______________

It is required that you maintain all required utilities when occupying the unit. In the past months when you say you have had minimal, or no money, how did you, or do you, pay for the following: (Please note that the owner/agent may ask for verification of these expenses while you live in the unit)

Rent? _______________________________________________________ Electricity? ___________________________________________________ How much was your electricity bill last month? $_____________________ Gas? ___________________________________________________ How much was your gas bill last month? $_____________________



If you have a car, the registration and insurance must be maintained. Do you have a car?

Yes No What is the monthly care payment? $_______________________________

How do you pay the car payment?______________________________

How much was your automobile registration last year?$_________________

How will you pay for annual registration? ________________________

How much is your annual automobile insurance?$ ________________________

How will you pay for automobile insurance?____________________________

How do you pay for gas and maintenance?______________________________

If you do not own/lease a car, how do you get from place to place?

_______________________________________________________

_______________________________________________________

It is required that you maintain the unit in a decent, safe and sanitary manner. How do you plan to purchase supplies necessary to maintain the unit? (i.e. dishwashing liquid, cleaning supplies, etc.)

_______________________________________________________

_______________________________________________________

_______________________________________________________

How do you purchase food?

_______________________________________________________ _______________________________________________________ _______________________________________________________

Do you have a washer and dryer?

Yes No

If yes, how do you buy laundry supplies.

If no, how do you pay for the laundry expenses? ________________________

Do you have a pet or an assistance animal or pet? (All animals must be current on all shots at all times.)

Yes No

If so, how do you pay for food, veterinary expenses and supplies?

______________________________________________________________

Do you have a cell phone?

Yes No

If so, how do you pay for the phone? __________________________________



Do you have internet service?

Yes No

If so, how do you pay for the internet service? ___________________________

Do you have cable/satellite TV?

Yes No

If so, how do you pay for the cable/satellite service? _____________________

Do you smoke? If so, how many packs per day/week/month?

Yes No ___________________ day week month

If so, how do you pay for the items you smoke? _____________________

How do you buy items such as toilet paper, paper towels, bath soap, laundry soap.?

If you have children who are in diapers, how do you pay for the diapers?



Additional Comments

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________.

12 MONTH INCOME REPORT FOR APPLICANTS/RESIDENTS CLAIMING

ZERO OR VERY LOW INCOME

Expense Your average monthly expenses for the last 12 months

Apparel & Services

Food and Expenses

Housekeeping Supplies – the average monthly cost of household goods and cleaning supplies such as paper napkins, toilet paper, paper towels, trash bags, laundry detergent, etc.

Miscellaneous – Average monthly cost of all other living expenses that do not fall within the categories of food, housekeeping, personal care, transportation and utilities.

Personal Care Products and Services – personal grooming products such as soap, deodorant, shampoo, toothbrushes, toothpaste, barber shop visits, etc.



Please provide income information for the past 12 months starting with the current month and working backward.

Month

Source of Income

(i.g. Employer, ADC, DFCS)

Amount of Income (Gross Amount)

Self Emp., Family, Etc.)

If Stopped, Why?

I Did Did Not File A Federal Income Tax Report Last Year. If you did file a federal tax return last year,

please provide the owner/agent with a copy.

In an effort to ensure the right assistance is provided to the right people, The Department of Housing and Urban Development (HUD) has provided property managers with access to a new verification database called the Enterprise Income Verification System (EIV). EIV provides information about project-based and tenant-based HUD assistance recipients. This database is also used to verify certain types of reported income with records maintained in the Social Security Administration databases and the Department of Health and Human Service (HHS) National Database of New Hires. HHS provides information about current and past employment and unemployment insurance information. At your move-in or at your annual certification, all adult household members give consent to the release of this information by signing HUD Forms 9887 and 9887A. If HUD indicates that there is a discrepancy discovered by the EIV database, we will contact you so that we continue to ensure that you are receiving assistance for which you are eligible. If it is discovered that any member of the household failed to disclose income as required, it will be considered a material lease violation. The household will be required to return any assistance paid in error and additional penalties may apply including eviction and pursuit of fraud.



You should have already received a pamphlet entitled EIV and You. Please review the information provided in the pamphlet so that you understand how the EIV system works.

PENALTIES FOR MISUSING THIS VERIFICATION FORM Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. 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. 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 PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

By my signature I certify that the information I have provided above is true and complete. I understand that if I furnish false or incomplete information I can be fined up to $10,000 or imprisoned up to five years, and/or lose the subsidy HUD pays and/or have my rent increased. Any assistance paid in error must be returned to HUD. ________________________________________ _______________________________ Signature of Applicant/Resident Date cc: Applicant/Resident File

Enter the Project Name

Address

City, State Zip



See attached 2019 NC Allowable Living Expense Housing Standards.

This worksheet shows how much income a person must have to be able to live. This does not include food stamps or WIC. Since these are not counted as income.

2019 Allowable Living Expenses Housing Standards

County

State Name

2019

Published

Housing and

Utilities for a

Family of 1

2019

Published

Housing and

Utilities for a

Family of 2

2019

Published

Housing and

Utilities for a

Family of 3

2019

Published

Housing and

Utilities for a

Family of 4

2019

Published

Housing and

Utilities for a

Family of 5

Alamance County North Carolina 1,231 1,445 1,523 1,698 1,726

SB/SE - Research - Team #1 Page 61 of 104 March 25, 2019


County

State Name

2019

Published

Housing and

Utilities for a

Family of 1

2019

Published

Housing and

Utilities for a

Family of 2

2019

Published

Housing and

Utilities for a

Family of 3

2019

Published

Housing and

Utilities for a

Family of 4

2019

Published

Housing and

Utilities for a

Family of 5

Alexander County North Carolina 1,090 1,280 1,349 1,504 1,528

Alleghany County North Carolina 1,107 1,300 1,370 1,528 1,552

Anson County North Carolina 1,067 1,254 1,321 1,473 1,497

Ashe County North Carolina 1,156 1,358 1,431 1,596 1,621

Avery County North Carolina 1,119 1,314 1,385 1,544 1,569

Beaufort County North Carolina 1,282 1,506 1,587 1,770 1,798

Bertie County North Carolina 1,135 1,333 1,405 1,567 1,592

Bladen County North Carolina 1,108 1,301 1,371 1,529 1,553

Brunswick County North Carolina 1,382 1,624 1,711 1,908 1,939

Buncombe County North Carolina 1,343 1,577 1,662 1,853 1,883

Burke County North Carolina 1,101 1,293 1,363 1,520 1,544

Cabarrus County North Carolina 1,399 1,644 1,732 1,931 1,962

Caldwell County North Carolina 1,052 1,236 1,302 1,452 1,475

Camden County North Carolina 1,689 1,983 2,090 2,330 2,368

Carteret County North Carolina 1,408 1,653 1,742 1,942 1,974

Caswell County North Carolina 1,121 1,316 1,387 1,547 1,571

Catawba County North Carolina 1,153 1,354 1,427 1,591 1,617

Chatham County North Carolina 1,534 1,802 1,899 2,117 2,152

Cherokee County North Carolina 1,061 1,246 1,313 1,464 1,488

Chowan County North Carolina 1,256 1,476 1,555 1,734 1,762

Clay County North Carolina 1,167 1,370 1,444 1,610 1,636

Cleveland County North Carolina 1,100 1,292 1,361 1,518 1,542

Columbus County North Carolina 1,125 1,321 1,392 1,552 1,577

Craven County North Carolina 1,319 1,549 1,632 1,820 1,849

Cumberland County North Carolina 1,265 1,485 1,565 1,745 1,773

Currituck County North Carolina 1,577 1,852 1,952 2,176 2,212

Dare County North Carolina 1,681 1,974 2,080 2,319 2,357

Davidson County North Carolina 1,164 1,367 1,440 1,606 1,632

Davie County North Carolina 1,242 1,459 1,537 1,714 1,741

Duplin County North Carolina 1,166 1,369 1,443 1,609 1,635

Durham County North Carolina 1,446 1,699 1,790 1,996 2,028



County

State Name

2019

Published

Housing and

Utilities for a

Family of 1

2019

Published

Housing and

Utilities for a

Family of 2

2019

Published

Housing and

Utilities for a

Family of 3

2019

Published

Housing and

Utilities for a

Family of 4

2019

Published

Housing and

Utilities for a

Family of 5

Edgecombe County North Carolina 1,119 1,314 1,385 1,544 1,569

Forsyth County North Carolina 1,253 1,472 1,551 1,729 1,757

Franklin County North Carolina 1,244 1,461 1,540 1,717 1,745

Gaston County North Carolina 1,223 1,436 1,513 1,687 1,714

Gates County North Carolina 1,353 1,589 1,674 1,867 1,897

Graham County North Carolina 972 1,142 1,203 1,341 1,363

Granville County North Carolina 1,306 1,534 1,616 1,802 1,831

Greene County North Carolina 1,142 1,341 1,413 1,575 1,601

Guilford County North Carolina 1,311 1,539 1,622 1,809 1,838

Halifax County North Carolina 1,131 1,329 1,400 1,561 1,586

Harnett County North Carolina 1,269 1,490 1,570 1,751 1,779

Haywood County North Carolina 1,235 1,450 1,528 1,704 1,731

Henderson County North Carolina 1,281 1,504 1,585 1,767 1,796

Hertford County North Carolina 1,084 1,274 1,342 1,496 1,520

Hoke County North Carolina 1,212 1,424 1,500 1,673 1,700

Hyde County North Carolina 1,150 1,350 1,423 1,587 1,612

Iredell County North Carolina 1,333 1,566 1,650 1,840 1,869

Jackson County North Carolina 1,231 1,446 1,524 1,699 1,727

Johnston County North Carolina 1,293 1,518 1,600 1,784 1,813

Jones County North Carolina 1,154 1,355 1,428 1,592 1,618

Lee County North Carolina 1,214 1,426 1,503 1,676 1,703

Lenoir County North Carolina 1,179 1,385 1,459 1,627 1,653

Lincoln County North Carolina 1,255 1,474 1,553 1,732 1,760

McDowell County North Carolina 1,048 1,231 1,297 1,446 1,470

Macon County North Carolina 1,106 1,299 1,369 1,526 1,551

Madison County North Carolina 1,252 1,471 1,550 1,728 1,756

Martin County North Carolina 1,099 1,291 1,360 1,516 1,541

Mecklenburg County North Carolina 1,461 1,716 1,808 2,016 2,048

Mitchell County North Carolina 1,126 1,322 1,393 1,553 1,578

Montgomery County North Carolina 1,118 1,313 1,384 1,543 1,568

Moore County North Carolina 1,387 1,628 1,716 1,913 1,944



County

State Name

2019

Published

Housing and

Utilities for a

Family of 1

2019

Published

Housing and

Utilities for a

Family of 2

2019

Published

Housing and

Utilities for a

Family of 3

2019

Published

Housing and

Utilities for a

Family of 4

2019

Published

Housing and

Utilities for a

Family of 5

Nash County North Carolina 1,248 1,466 1,545 1,723 1,750

New Hanover County North Carolina 1,517 1,782 1,878 2,094 2,128

Northampton County North Carolina 1,097 1,289 1,358 1,514 1,539

Onslow County North Carolina 1,313 1,542 1,625 1,812 1,841

Orange County North Carolina 1,756 2,062 2,173 2,423 2,462

Pamlico County North Carolina 1,237 1,453 1,531 1,707 1,735

Pasquotank County North Carolina 1,386 1,628 1,715 1,912 1,943

Pender County North Carolina 1,364 1,602 1,688 1,882 1,913

Perquimans County North Carolina 1,299 1,526 1,608 1,793 1,822

Person County North Carolina 1,174 1,379 1,453 1,620 1,646

Pitt County North Carolina 1,338 1,572 1,656 1,846 1,876

Polk County North Carolina 1,281 1,504 1,585 1,767 1,796

Randolph County North Carolina 1,126 1,323 1,394 1,554 1,579

Richmond County North Carolina 1,019 1,197 1,261 1,406 1,429

Robeson County North Carolina 1,067 1,254 1,321 1,473 1,497

Rockingham County North Carolina 1,092 1,282 1,351 1,506 1,531

Rowan County North Carolina 1,163 1,366 1,439 1,604 1,630

Rutherford County North Carolina 1,075 1,263 1,331 1,484 1,508

Sampson County North Carolina 1,144 1,344 1,416 1,579 1,604

Scotland County North Carolina 1,096 1,287 1,356 1,512 1,536

Stanly County North Carolina 1,208 1,419 1,495 1,667 1,694

Stokes County North Carolina 1,143 1,343 1,415 1,578 1,603

Surry County North Carolina 1,113 1,308 1,378 1,536 1,561

Swain County North Carolina 1,134 1,331 1,403 1,564 1,590

Transylvania County North Carolina 1,239 1,455 1,533 1,709 1,737

Tyrrell County North Carolina 1,127 1,324 1,395 1,555 1,581

Union County North Carolina 1,506 1,769 1,864 2,078 2,112

Vance County North Carolina 1,134 1,332 1,404 1,565 1,591

Wake County North Carolina 1,576 1,851 1,951 2,175 2,210

Warren County North Carolina 1,147 1,347 1,419 1,582 1,608

Washington County North Carolina 1,151 1,352 1,425 1,589 1,615



County

State Name

2019

Published

Housing and

Utilities for a

Family of 1

2019

Published

Housing and

Utilities for a

Family of 2

2019

Published

Housing and

Utilities for a

Family of 3

2019

Published

Housing and

Utilities for a

Family of 4

2019

Published

Housing and

Utilities for a

Family of 5

Watauga County North Carolina 1,407 1,652 1,741 1,941 1,973

Wayne County North Carolina 1,185 1,391 1,466 1,635 1,661

Wilkes County North Carolina 1,106 1,299 1,369 1,526 1,551

Wilson County North Carolina 1,244 1,461 1,539 1,716 1,744

Yadkin County North Carolina 1,115 1,310 1,380 1,539 1,564


2019 zero or very low-income worksheet - the arc of north ...€¦ · questionnaire for...

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