maine state housing authority stability … › 2015 › 02 › all-step...4. rental income from...
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MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
NAME: INSTITUTION:
SSN: ADDRESS:
RE: ASSET VERIFICATION
Federal Law and regulations require us to verify the sources and amounts of income of all applicants for
admission as tenants to our federally assisted housing program and to re-examine periodically the incomes of
existing tenant families. All information is confidential and will be used only in determining eligibility for
rental assistance.
*****************************************************************************************
SAVINGS ACCOUNT(S) Current Balance Interest Rate Date
$________________ ____________% _________________
$________________ ____________% _________________
$________________ ____________% _________________
CHECKING ACCOUNT(S): Current Balance Interest Rate Date
$________________ ____________% _________________
$________________ ____________% _________________
Average balance for the past (six) months: $__________________ PLEASE LIST ANY OTHER ASSET ACCTS (CD’S, MONEY MARKETS, IRA’S, TRUSTS, ETC.)
Type Interest Rate Balance Cash Value
____________________ _______________% $________________ $________________
____________________ _______________% $________________ $________________ **NOTE: THE CASH VALUE IS THE CURRENT VALUE MINUS PENALTIES FOR EARLY WITHDRAWAL
__________________________________________________ _____________________________
Signature/Title Date
Phone ____________________________________
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 624-5768
7-1-1 (Maine Relay)
Name: Institution:
SS#: Address:
SUBJECT: Assets: Stocks/Bonds/Securities
Federal law and regulations require us to verify the sources and amounts of income of all applicants for
admission as tenants to our federally assisted housing program and to re-examine periodically the incomes of
existing tenant families. All information is confidential and will be used only in determining eligibility for
rental assistance.
Number of Current Market Current Dividends Earned
Type Shares Owned Value per Share Dividend Rate Past 12 months
____________ __________ _____________ ____________ _______________
____________ __________ _____________ ____________ _______________
____________ __________ _____________ ____________ _______________
____________ __________ _____________ ____________ _______________
____________ __________ _____________ ____________ _______________
____________ __________ _____________ ____________ _______________
__________________________________________ ________________________
Signature/Title Date
__________________________________
Phone
Penalties for misusing this consent: Title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties fur 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 willingly requests, obtains, or discloses any information under false pretenses concerning any applicant or participant may be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and see 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.
CERTIFICATION OF ZERO INCOME
MaineHousing STEP Program
Household Name: SSN:
Address: City:
I hereby certify that I do not individually receive income from any of the following sources: 1. Employment wages including: overtime, commissions, tips, bonuses, fees etc.
2. Unemployment compensation. 3. Income from operation of a business: sales from self-employment resources.
4. Rental income from real or personal property. 5. Interest/dividends from Assets: savings/checking accounts, annuities, insurance policies,
retirement funds, pensions or death benefits.
6. Social Security (SS) and/or Supplemental Security Income (SSI) benefits. 7. Public assistance payments including: General Assistance, TANF and/or Food Stamps.
8. Regular contributions/gifts received from person not living in the household. 9. Alimony and/or Child Support payments.
Please list the payment sources for the following expenses. If you need additional space, please use back side of this form: Monthly Expenses: Source of Funds: Address of Source:
Food. Grocery bill X 4 wks
Communications. Telephone
/cell phone, internet connection.
Transportation. Bus fares. Taxi
fares. Personal car expenses: gas, insurance, maintenance, or tires.
Medical. Unreimburseable .
Living. Clothing. Cleaning
supplies, personal grooming and paper products.
Entertainment. magazines,
memberships, etc.
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. I understand that providing false, misleading or incomplete information may result in the termination of my housing assistance. ________________________ ________________________ _________________ Tenant/Applicant Signature Printed Name Date
Penalties for misusing this consent: Title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties fur 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 willingly requests, obtains, or discloses any information under false pretenses concerning any applicant or participant may be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and see 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.
For additional space, please enter below: Monthly Expenses: Source of Funds: Address of Source:
Food. Grocery bill X 4 wks
Communications. Telephone
/cell phone, internet connection.
Transportation. Bus fares. Taxi
fares. Personal car expenses: gas, insurance, maintenance, or tires.
Medical. Unreimburseable .
Living. Clothing. Cleaning
supplies, personal grooming and paper products.
Entertainment. Cable or Dish
TV, magazines, club memberships, liquor/beer/wine, lottery tickets, cigarettes.
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768 7-1-1 (Maine Relay)
CHILD CARE VERIFICATION
NAME PROVIDER
SSN ADDRESS
NAME(S) OF CHILD(REN) BEING CARED FOR:
_________________________________ ________________________________
__________________________________ ________________________________
__________________________________ ________________________________
HOW MANY DAYS PER WEEK? _______________ HOURS PER DAY ________________
CHARGE PER DAY _____________ PER WEEK _______________ PER HOUR__________
DO CHARGES VARY FOR ANY REASON? (example: child in school) IF YES, PLEASE
EXPLAIN. ____________________________________________________________________
______________________________________________________________________________
DO YOU RECEIVE MONEY FROM ANY OTHER PERSON OR AGENCY TOWARD THE
AMOUNT YOU CHARGE FOR THE ABOVE NAMED CHILD(REN)? IF YES, WHO?
_____________________________________________________________________________
TOTAL AMOUNT YOU RECEIVED FOR THE LAST 12 MONTHS: ____________________
_______________________________________ _________________________
Signature Date
____________________________________
Telephone
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
CHILD SUPPORT PAYMENTS BY INDIVIDUAL
__________________________________
__________________________________
__________________________________
Date: Re:
Please provide the amounts of child support you paid for the months that have X’s in front of
them.
A signed Release of Information is enclosed authorizing you to provide the requested
information.
2010 2011
_____ January ____________ _____ January _____________
_____ February ___________ _____ February ____________
_____ March ____________ _____ March _____________
_____ April ____________ _____ April _____________
_____ May ____________ _____ May _____________
_____ June ____________ _____ June _____________
_____ July ____________ _____ July _____________
_____ August _____________ _____ August ______________
_____ September __________ _____ September ___________
_____ October ____________ _____ October _____________
_____ November __________ _____ November ____________
_____ December __________ _____ December ____________
Please return this form by the date requested on the cover letter.
Authorized Signature: ___________________________________ DATE: ________________
TEL. __________________________
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768 7-1-1 (Maine Relay)
Name: _______________________________ Agency: ____________________________
SS#: _______________________________ Address: ____________________________
____________________________________
SUBJECT: Disability Benefits
Federal law and regulations require us to verify the sources and amounts of income and expenses for all
applicants for admission as tenants to our federally assisted housing programs and to re-examine periodically
the incomes/expenses of existing tenant families. All information is confidential and will be used only in
determining eligibility for rental assistance.
Gross amount of Disability payment: $ _______________ per ______________(week/month)
Initial date received: ________________ Amount $ _________________
Have benefits been continuous since initial start? _________ If not, dates not received ___________________
_________________________________________________________________________________________
If benefits are expected to terminate, what is the expected date? ____________________
Will there be a settlement, how much? _________________________ Date of settlement ________________
___________________________________________ __________________________
Signature/Title Date
_____________________________
Phone
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
EMPLOYMENT VERIFICATION
NAME : EMPLOYER:
SS#:
Date of Employment: ___________________ Occupation: ____________________________
Full or Part Time: ___________________ Effective Date: __________________________
Day Week Month
Average Hours Worked Per: _________ _________ _________
Average Hours of Overtime Per: _________ _________ _________
Average Anticipated Tips Per: _________ _________ _________
*PLEASE DO NOT INCLUDE WAGES FROM ADVANCED EARNED INCOME CREDIT PAYMENT
PLAN. It is not considered income for Housing Authority purposes.
Hourly Rate: $ ___________ Overtime Rate $ ______________ Salary $ ______________ Per ________
Effective Date of Present Pay: ______________________
Any other compensation not included above (commissions, bonuses, incentive allowance, etc.)
Type: _____________________ Amount $_______________per _____________wk/mo/yr
Total pay received over the last 12 months: $_____________________
Medical deductions: $________________ Per _____________wk/mo/yr
_________________________________________________ __________________________
Signature/Title Date
________________________________
Telephone Number
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
AUGUSTA, ME 04330 (207) 626-4600 or Fax: (207) 624-5768
7-1-1 (Maine Relay)
MEDICAL/DENTAL EXPENSE VERIFICATION
NAME: PROVIDER
SSN:
Federal law and regulations require us to verify the sources and amounts of certain types of expenses of all
applicants for admission as tenants to our federally assisted housing program and to re-examine periodically the
expenses of existing tenant families. All information is confidential and will be used only in determining
eligibility for rental assistance.
**NOTE: Please provide your best estimate of medical/dental expected over the next 12 months, based on
experience/costs over the last 12 months and/or anticipated costs for applicant/family’s current
medical/dental condition. To the extent that you are aware that medical/dental insurance covers
some/all of the charges, please answer accordingly.
Your assistance and prompt response will be greatly appreciated.
Maine State Housing Authority
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Total medical/dental expense for the above named individual for the coming 12 month period: $___________
Amount individual is expected to pay out-of-pocket (amount not covered by insurance): $___________
If the individual does not pay in full for all services at the time rendered, is there a current balance? _________
If yes, what is the balance? $___________
If applicant/tenant is making regular payments on an outstanding balance, what is the amount and frequency
regularly paid. $ ___________per ___________
Amount How often
________________________________________ ________________________
Signature/Title Date
_____________________________
Phone
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, Maine 04330
(207) 626-4600 or Fax: (207) 624-5768 7-1-1 (Maine Relay)
NAME: ADDRESS:
SS #:
SUBJECT: Medical/Dental Insurance Premiums
Federal law and regulations require us to verify the sources and amounts of certain types of expenses of
all applicants for admission as tenants to our federally assisted housing program and to re-examine
periodically the expenses of existing tenant families. All information is confidential and will be used only
in determining eligibility for rental assistance.
A signed Release of Information is enclosed.
Please provide the following information. Your assistance and prompt response will be most appreciated.
Amount of premium: __________
How often premium is paid: _________________
Amount of deductible, if any: _____________ Annually? __________
Is this a primary or secondary insurance? ________________________
Date: ___________________ Signature: __________________________
Tel #: ___________________ Title: ______________________________
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, ME 04330
Tel. 207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
OTHER UNEARNED INCOME
I / We (name of person/s giving money)____________________________________ give
(person receiving that money)______________________________ $_________________
per (day, week, month, etc) ___________________. This money is given for __________
_________________________________________________________________________.
Additional comments, if any: _________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________ ______________________
Signature Date
_________________________________________ ______________________ Relationship to Recipient Phone
OTHER UNEARNED INCOME
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
PENSION/ANNUITY BENEFITS VERIFICATION
NAME: ADDRESS:
SS#:
File #
A signed Release of Information is included.
Type of retirement benefit: ___________________________________________________________
Date Benefits started : ______________________
Gross monthly amount: $________________
Effective date of current amount: ______________________
Medical Insurance Deduction per month: $_______________
Comments:_____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________ ________________________
Signature Date
__________________________________________ ________________________
Title Phone
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768 7-1-1 (Maine Relay)
PRESCRIPTION DRUGS
NAME PHARMACY:
SSN ADDRESS:
DOB:
Federal law and regulations require us to verify the sources and amounts of income and allowable expenses of
all applicants for admission as tenants to our federal assisted housing program and to reexamine periodically the
incomes and allowable expenses of existing tenant families. All information is confidential and will be used
only in determining eligibility for rental assistance.
Your assistance and prompt response will be appreciated.
MaineHousing
*****************************************************************************************
What is the anticipated amount paid by the customer for prescription drugs for an ongoing basis.
$ __________________ per month or $ _______________per year? Of the amount/s entered, is there a
balance owed that the customer is responsible for? _______ If yes, how much is owed ______________?
Signature: _________________________________ Date: _____________________
Tel # ____________________________________
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, ME 04330
626-4600 or Fax: 624-5768
7-1-1 (Maine Relay)
SELF–CERTIFICATION OF EMPLOYMENT For use when paid by cash or taxes are not deducted
Name: ____________________________ SSN _________________________
Address: ____________________________ Phone: _________________________
____________________________
Mailing Address: ______________________________________________________________
I receive $___________ Hrly _____ Daily _____ Wkly _____ Bi-monthly _____ Mthly _____
I receive my pay by: Check _________ Cash ________ Money Order _________
Person paying: Name _____________________________________
Address _____________________________________
_____________________________________
Phone _____________________________________
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make
willful false statements of misrepresentation to any Department or Agency of the U.S. as to any
matter within it’s jurisdiction.
I certify that the above information is true and complete to the best of my knowledge and
understand that my subsidy may be terminated if I do not report all income coming into my
household.
__________________________________ _________________________
Signature Date
SELF-CERTIFICATION OF EMPLOYMENT For use when paid by cash or taxes are not deducted
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
SOCIAL SECURITY VERIFICATION
FEDERAL
NAME: ADDRESS: Social Security Administration
SS#: PO Box 1075
Claim # Augusta, ME 04332
A signed Release of Information is attached.
SOCIAL SECURITY
Gross Monthly amount:
$_____________
Deduction for Medicare Premiums: $_____________
SUPPLEMENTAL SECURITY INCOME (Federal Amount only)
Gross Monthly amount: $____________
_______________________________________________________________________________
__________________________________________ _____________________
Signature/Title Date
____________________________
Telephone #
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, ME 04330
207-626-4600 or 207-624-5768
7-1-1 (Maine Relay)
SOCIAL SECURITY VERIFICATION
STATE
NAME ADDRESS: Dept. of Human Services
BFI
SS#: 11 SHS Whitten Rd.
Augusta, ME 04333
A signed Release of Information is attached.
SUPPLEMENTAL SECURITY INCOME (State amount only)
Gross Monthly amount: $____________
Food Stamp (monthly amount) $__________ ______________________________________________________________________________________________________
__________________________________________ _____________________
Signature/Title Date
____________________________
Telephone #
THANK YOU
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP) 353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
UNEMPLOYMENT BENEFITS
NAME: ADDRESS: 45 Commerce Drive
Augusta ME 04330
ATTN: UC Director’s Office
SS#: Fax: 287-2305
Federal law and regulations require us to verify the sources and amounts of income of all applicants for
admission as tenants to our federally assisted housing program and to reexamine periodically the incomes of
existing tenant families. All information is confidential and will be used only in determining eligibility for
rental assistance.
Your assistance and prompt response will be appreciated.
MaineHousing
__________________________________________________________________________________
Gross weekly payment: $________________ Date of Initial Payment:___________________________
Ending Date if known:____________________________
Is the client entitled to an extension of benefits: Yes ___________ No __________
If yes, for how long? ____________________________________________________________
If no, what is termination date of benefits: ___________________________________________
REMARKS:
___________________________________________________________________________________
___________________________________________________________________________________
Date: __________________________ Signature/title: _______________________________________
Tel.#: __________________________
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768
7-1-1 (Maine Relay)
VA BENEFITS VERIFICATION
NAME: ADDRESS: Dept of Veterans Affairs
SSN: 402/21
VA Claim # Togus, ME 04330
A signed Release of Information is included.
Gross amount of VA Disability per month: $______________ Date Started: _______________________
Gross amount of VA Pension per month: $______________ Date Started: _______________________
Gross amount of Survivor Benefits per month: $ _____________ Date Started: _______________________
Do Survivor Benefits include amounts for child/ren? ____________ If yes, gross per month $ ____________
Gross amount of Education Stipend per month $_____________ Date Started: _______________________
Comments:__________________________________________________________________________________________
_________________________________________________________________________________________
______________________________________________ ___________________________________
Signature Date
______________________________________________ ____________________________________
Title Phone
MAINE STATE HOUSING AUTHORITY
Stability Through Engagement Program (STEP)
353 Water Street
Augusta, ME 04330
207-626-4600 or Fax 207-624-5768 7-1-1 (Maine Relay)
Name: _______________________________ Agency: ____________________________
SS#: _______________________________ Address: ____________________________
____________________________________
SUBJECT: Worker’s Compensation
Federal law and regulations require us to verify the sources and amounts of income and expenses for all
applicants for admission as tenants to our federally assisted housing programs and to re-examine periodically
the incomes/expenses of existing tenant families. All information is confidential and will be used only in
determining eligibility for rental assistance.
Gross amount of Worker’s compensation: $ _______________ per ______________(week/month)
Initial date received: ________________ Amount $ _________________
Have benefits been continuous since initial start? _________ If not, dates not received ___________________
_________________________________________________________________________________________
If benefits are expected to terminate, what is the expected date? ____________________
Will there be a settlement, how much? _________________________ Date of settlement ________________
___________________________________________ __________________________
Signature/Title Date
_____________________________
Phone