67248_DM&B MSHDA 1890_Section 1_Front_Sheet.pdf

HOUSING CHOICE VOUCHER PROGRAM

Household, Income, Asset and Expense

Declaration

Page 1 of 8 MSHDA-1890_Household, Income, Asset, and Expense Declaration (12/14/20) Previous Version Obsolete Distribution: MSHDA File

NOTE: Use of correction fluids/tapes will void this document.

Section A – MSHDA USE ONLY

New Admission Date Eligibility Determined: Date Mailed by MSHDA:

Annual Re-Examination Next Annual Re-Examination Date:

Return By:

Interim Re-Examination

Section B – Head of Household Name of Head of Household:

Last 4 SSN:

Phone: Email Address:

Living Address: Mailing Address (If different than Living Address):

Section C – Household Members/Household Composition – All line Items must be completed.

HOUSEHOLD COMPOSITION: List yourself and all other persons who will live in the unit, including Live-In Aides. You must also list every dependent child that is in your physical custody and they must also be listed on your lease agreement.

All new household members must provide a copy of a Birth Certificate, Social Security Card, and complete either a MSHDA-214 or MSHDA-213 to declare Proof of Citizenship. If a MSHDA-214 or MSHDA-213 is needed or you need a list of other acceptable documentation for proof of birth or social security number, please contact your Housing Agent.

Name

Social Security Number

(if no SSN use Alien Registration

Number)

Relationship to Head Birth Date Age Sex

M/F

Ve te ra n?

Ye s/ N o

D is ab le d?

N o

H is pa ni c or

La tin o?

Y es

/N o

U S

C iti ze n?

N o

*R ac e C od e s

1. Head of Household

2.

3.

4.

5.

6.

7.

8.

9.

10.

*Race Code #’s (enter one or more above):

1 – White 2 – Black/African American 3 – American Indian or Native Alaskan 4 – Asian 5 – Native Hawaiian/Other Pacific Islander

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Respond Yes or No to every question in Sections D, E, F, and G with information for all household members. You must provide ORIGINAL verification (not photocopies) as indicated for items checked YES. Provide address, phone number, fax number, and additional information for items checked YES as requested. Income must be reported for all household members regardless of age or source. All household members age 18 and older must sign this form on Page 8.

Failure to comply could result in the denial/termination of assistance.

NOTE: HUD and MSHDA have entered into cooperative agreements with other agencies to obtain information on wages, unemployment compensation and other income information through a computer matching operation.

Section D – Income

D1 YES

NO

Is any member of the household reporting a decrease in income? This includes a decrease in pay, hours worked, loss of employment, Social Security, Unemployment, VA Benefit, Welfare, Child Support, Disability, or any other source of income. If yes, attach documentation that supports the decrease in income or loss of employment and complete the information below.

Household Member Source Address, City, State, Zip Phone Fax New Weekly

Amount

1. $

2. $

3. $

D2

YES

Is any member of the household employed? List all jobs below and gross amount earned weekly, before deductions, including tips. If yes, attach at least two (2) most recent and consecutive ORIGINAL pay stubs for each job and/or a signed statement declaring weekly tip amount.

Household Member Employer Address, City, State, Zip Phone Fax Weekly Amount

(including tips)

1. $

2. $

3. $

4. $

5. $

D3

Is any of the income listed above earned from Title V or economic/self-sufficiency job training programs?

Household Member Employer

1.

D4

Is any of the income listed above new income or a wage increase for a household member with a disability?

Household Member Employer

1.

D5

Is any member of the household self-employed (hairstylist, barber, daycare, construction worker, independent sales, etc.)? If yes, attach the prior year income tax return and/or a statement of income and expenses.

If yes, describe: How much per week? $

D6

Does any member of the household receive unemployment benefits? If yes, attach the most recent ORIGINAL award letters or payment stubs.

If yes, household member: How much per week? $

Last day worked: Date benefits began: Date benefits will end:

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D7

Does any member of the household receive payments from retirement funds or pensions? If yes, attach at least two (2) most recent and consecutive ORIGINAL check stubs and/or award letter. If it is not dated within the last 60 days or if you don’t have one, you must call the office of the company that you receive your retirement funds or pension from and request a currently dated proof of benefits letter.

Household Member Source Address, City, State, Zip Phone Fax Monthly Amount

1. $

D8

Does any member of the household receive monthly federal Social Security (SS), Supplemental Security Income (SSI), or State Disability Allowance (SDA)? List state and federal separately. If yes, attach the most recent ORIGINAL award letter. If it is not dated within the last 60 days or if you don’t have one, you must call Social Security Office (1-800-772-1213) or go on-line at www.socialsecurity.gov and request a currently dated proof of income letter.

Household Member Type (SS, SSI, State SSI, SDA) Monthly Amount

1. $

2. $

3. $

4. $

5. $

6. $

7. $

8. $

D9

Does any member of the household receive workman’s compensation, disability or death benefits other than Social Security? If yes, attach at least two (2) most recent and consecutive ORIGINAL check stubs and/or award letter. If it is not dated within the last 60 days or if you don’t have one, you must call the insurance company that you receive your benefits from and request a currently dated proof of benefits letter.

Household Member Source Address, City, State, Zip Phone Fax Monthly Amount

D10

Does the household receive any type of public assistance from DHHS such as: grants, cash payments, food assistance, or daycare? If yes, attach at least two (2) most recent and consecutive ORIGINAL check stubs and/or award letter. If it is not dated within the last 60 days or if you don’t have one, you must call DHHS and request a currently dated proof of assistance letter.

Program/Type of Assistance Monthly Amount

1. $

2. $

3. $

4. $

DHHS Caseworker Name: DHHS Case Number:

E-mail address: Phone:

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D11

Does any member of the household receive military active duty allotments or Veterans Administration benefits? If yes, attach at least two (2) most recent and consecutive ORIGINAL check stubs and/or award letter. If it is not dated within the last 60 days or if you don’t have one, you must call your local Veterans Administration Office and request a currently dated proof of benefits letter.

If yes, household member: Monthly Amount: $

D12

Does any member of the household receive Adoption assistance or Foster payments? If yes, attach at least two (2) most recent and consecutive ORIGINAL check stubs and/or award letter. If it is not dated within the last 60 days or if you don’t have one, you must call and request a currently dated proof of assistance letter.

Household Member Source Address, City, State, Zip Phone Fax Monthly Amount

1. $

2. $

D13

Does any member of the household receive child support and/or alimony? If yes, attach the ORIGINAL payment disbursements, printout, or receipts for the past 12 months.

Household Member Child Source Monthly Amount

1. $

2. $

3. $

4. $

6. $

D14

Does any member of the household receive periodic payments from a trust, lottery, annuity, inheritance or insurance policies? If yes, attach at least two (2) most recent and consecutive ORIGINAL check stubs and/or award letter. If it is not dated within the last 60 days or if you don’t have one, you must call and request a currently dated proof of award letter.

Household Member Source Address, City, State, Zip Phone Fax Monthly Amount

1. $

D15

Does any member of the household receive income from Indian Trust Land?

Describe: Monthly Amount: $

D16

Is any adult member of the household (age 18 or older) a student? If yes, attach the most recent ORIGINAL enrollment or schedule from the educational institution.

Household Member School Address, City, State, Zip Phone Fax Credit hrs.

1.

3.

Page 5 of 8 MSHDA-1890_Household, Income, Asset, and Expense Declaration (12/14/20)

D17

Does any member of the household receive income for educational assistance (Pell grants, scholarships, federal work study program, and private sources)? This includes payments that others make on your behalf for tuition, books, or other schooling expenses. If yes, attach the most recent ORIGINAL financial aid award letter for any grants, scholarships, loans, etc. and most recent tuition statement from the institution.

Household Member School Address, City, State, Zip Phone Fax Monthly Amount

1. $

D18

Does any member of the household receive cash contributions or gifts or have bills paid on their behalf (includes rent, groceries, car payments, utility payments, phone, internet, TV expenses, etc.) on an ongoing basis from person(s) not living in the household? If yes, attach the most recent ORIGINAL receipt or other documentation.

Contributor’s Name Address, City, State, Zip Phone Monthly Amount

1. $

2. $

3. $

4. $

D19

Does any member of the household have miscellaneous income (earned or unearned) not previously listed such as donating plasma, collecting cans/bottles for refunds, scrapping metals, etc.? If yes, certify the monthly amount below.

Household Member Describe Monthly Amount

1. $

2. $

Section E – Assets

E1

Does any member of the household have assets such as savings, checking, stocks, bonds, IRA’s, etc.? If yes, attach the most recent ORIGINAL bank statements for each account.

Household Member Account Type Bank/Institution Address, City, State, Zip Phone Fax Balance

1. $

2. $

E2

Does any member of the household own real estate, mobile home, or land contract? If yes, attach the most recent mortgage statement along with a copy of the summer and winter tax statements.

Describe:

E3

Does any member of the household receive income from rental of real estate or personal property? If yes, attach a copy of the Tenant/Landlord lease.

Describe: Monthly Amount: $

E4

Does any member of the household have personal property held for investment purposes (jewelry, coin or stamp collections, etc.)?

Describe:

Page 6 of 8 MSHDA-1890_Household, Income, Asset, and Expense Declaration (12/14/20)

E5

Does any member of the household have a life insurance policy with a cash surrender value? If yes, attach the most recent ORIGINAL statement(s). Do not include burial policies.

Household Member Insurance Company Address, City, State, Zip Phone Policy # Amount

E6

Has any member of the household sold, given away, or otherwise transferred ownership of assets valued over $1,000 within the last two (2) years? Do not include personal vehicles.

List items: Sale amount $

E7

Does any member of the household have assets from sources other than those listed above? If yes, attach the ORIGINAL most recent statement(s).

Household Member Source Address, City, State, Zip Phone Fax Amount

1. $

2. $ Section F – Medical/Disability Expenses – Questions F1 Through F3 Apply Only To Families Whose Head Of Household, Co-Head, Or Spouse Are Elderly Or Disabled F1

Does any member of the household have monthly Social Security payments reduced to pay for Medicare insurance premiums?

Household Member Amount Deducted Per Month

1. $

F2

Does any member of the household pay out of pocket for Medicare or any other medical insurance premiums? If yes, attach the ORIGINAL most recent premium statement(s) showing amount and frequency of payment.

Household Member Insurance Company Address, City, State, Zip Phone Fax Monthly Amount

1. $

F3

Does any member of the household pay for ongoing and anticipated medical expenses or services, or medical equipment that are not reimbursed by insurance or DHHS/other Agency? (List separately each pharmacy, licensed health care, and special care provider who you pay directly to meet your medical/health/disability needs.

Estimate the monthly amount). If yes, attach the ORIGINAL listing of annual expenses or statement from the provider.

Household Member Provider Address, City, State, Zip Phone Fax Monthly Amount

1. $

2. $

3. $

4. $

6. $

Page 7 of 8 MSHDA-1890_Household, Income, Asset, and Expense Declaration (12/14/20)

F4

Does any member of the household under the age of 62 have a disability and does not receive SSI or SSDI? If yes, please list the Health Care Professional who is authorized to verify the disability.

Household Member Health Care Professional Address, City, State, Zip Phone Fax

F5

Is attendant care, for a person with disability, or childcare expenses being paid for a member of the household to allow another member of the household to be gainfully employed or to further their education? NOTE: Expense is not deductible if provider is a member of the household. If yes, attach the most recent ORIGINAL receipts for the day-care or child care provider payments.

Household Member Care Provider Address, City, State, Zip Phone Fax Monthly Amount

1. $

2. $

Section G – Other

G1

Have you or any member of your household been arrested for, or charged with, a drug related or violent criminal activity, or listed as a lifetime registered sex offender?

(Please note that a criminal history will not necessarily exclude you from participation with the HCV Program.

MSHDA conducts a criminal screening on all applicants to ensure all HUD Program requirements are met.)

Household Member Date of Offense Describe Offense

G2

Is any member of the household pregnant?

(This information is necessary to determine your household’s voucher/unit size in accordance with 24 CFR 982.402(b)(5) and for inspection requirements for units built prior to 1978 in accordance with 24 CFR Part 35.)

List their names:

G3

Does any member of the household, under the age of 6, have an identified Elevated Blood Lead Level (EBLL)?

If yes, attach documentation indicating EBLL.

List their names:

G4

Use this space to provide any additional general information to MSHDA or to complete questions above. To complete questions indicate the question number and the information that was requested.

Question # Response

OVER → (FOR SIGNATURE PAGE)

Page 8 of 8 MSHDA-1890_Household, Income, Asset, and Expense Declaration (12/14/20)

Section H – Certification and Authorization to Release Information The undersigned authorize the Michigan State Housing Development Authority (MSHDA) and/or its contracted agent to contact any agencies, offices, groups, organization, or employers for the purpose of obtaining information that is pertinent to eligibility, level of benefits, or continued participation in the Housing Choice Voucher (Section 8) Programs (“Requested Information”) and authorize the release of the Requested Information to MSHDA. This authorization for Requested Information includes but is not limited to requests to the Social Security Administration (SSA), Immigration and Naturalization Service (INS), and the Office of Child Support (OCS). The undersigned will be given an opportunity to contest the immigration status determination with the INS or MSHDA. The undersigned acknowledge that MSHDA has cooperative agreements with agencies to obtain information on wages, unemployment compensation, child support, and other income information through a computer matching operation. MSHDA may use this authorization and the information obtained with it, to administer and enforce its program rules and policies. MSHDA is authorized to release any Requested Information it obtains to the Head of Household.

The undersigned consent to release of criminal conviction records including sexual offenses and alcohol abuse pursuant to 24 CFR 982.307 and allow MSHDA to receive records from law enforcement agencies and use them in accordance with the U.S. Department of Housing and Urban Development regulations and MSHDA policy. MSHDA will check all adult household member’s criminal conviction records including sexual offenses, drug and alcohol abuse. Certain offenses will result in denial of assistance.

The undersigned certify that the information given to MSHDA on household members, income, net family assets, allowances, and deductions is accurate.

The undersigned understand that false statements or information are punishable by imprisonment for up to 10 years or by a fine of up to $5,000 and grounds for termination of housing assistance under State and Federal Law.

Certification for Head of Household:

In addition to the above certification and authorization of release of information, I certify that only the people listed in Section C, on page one of this form will occupy the unit. I hereby attest that I have reviewed this entire form and that all of my household information, income, assets and expenses have been accurately reported. I understand that providing false information will result in denial or termination of benefits.

As the Head of Household, I certify that only the people listed on my Lease Agreement will occupy the unit. I certify that the house or apartment will be my principal residence and that I will not obtain duplicate federal housing assistance while I am receiving assistance from MSHDA. I will not live anywhere else without notifying MSHDA immediately in writing. I will not sublease my assisted residence.

I understand I must report income, household size, and/or student status changes within 10 business days to my MSHDA assigned Housing Agent.

Certification for Co-Head of Household if applicable:

In addition to the above certification and authorization of release of information, I certify that only the people listed in Section C, on page one of this form will occupy the unit. I hereby attest that I have reviewed this entire form and that all of my household information, income, assets and expenses have been accurately reported. I understand that providing false information will result in denial or termination of benefits. I understand I must report income, household size, and/or student status changes within 10 business days to my MSHDA assigned Housing Agent.

(Print name of head of household above)

X Phone Number

(Print name of co-head of household above)

(Signature of head of household above) Date (Signature of co-head of household above) Date

MSHDA Use Only MSHDA Use Only OTIS I-CHAT SOR DRU Debt/Term. OTIS I-CHAT SOR DRU Debt/Term.

Date P P P P P Date P P P P P

Initials F F F F F Initials F F F F F

Certification for Adult Signatures below:

In addition to the above certification and authorization of release of information, I hereby attest that I have reviewed this entire form and that all of my information, income, assets and expenses have been included and accurately reported. I understand that providing false information will result in denial or termination of benefits. I understand I must report income, household size, and/or student status changes within 10 business days to my MSHDA assigned Housing Agent.

Certification for Adult Signatures below:

In addition to the above certification and authorization of release of information, I hereby attest that I have reviewed this entire form and that all of my information, income, assets and expenses have been included and accurately reported. I understand that providing false information will result in denial or termination of benefits. I understand I must report income, household size, and/or student status changes within 10 business days to my MSHDA assigned Housing Agent.

(Print additional adult’s name)

(Print additional adult’s name)

Phone Number

(Signature of adult printed above) Date (Signature of adult printed above) Date

MSHDA Use Only MSHDA Use Only OTIS I-CHAT SOR DRU Debt/Term. OTIS I-CHAT SOR DRU Debt/Term.

Date P P P P P Date P P P P P

Initials F F F F F Initials F F F F F

Please return to:

If you or a member of your household is a person with a disability and require a reasonable accommodation in order to participate in MSHDA's affordable housing program(s) or services, please submit your request in writing to your Housing Agent.