Macclenny Housing Authority

APPLICATION PACKET

 Macclenny Housing Authority

 Baker County Housing Assistance Program

Application Process:

Before you begin completing your application, please be aware that both the Public Housing (MHA) and Section 8 (BCHAP) programs extend a local preference to existing Baker County residents.  This may ultimately effect your position on the waiting lists as a newly completed and approved application from a Baker County resident will be placed ahead of a non-resident regardless of the date of the application.

After your application is completed and submitted, we will contact you to set an appointment.  At the interview we will sign documents, ask and answer questions, make copies of the items listed below and begin to verify income and other information you have provided.  Once your information is verified and the application approved you will be placed on the waiting list for either or both programs as you may specify.

Following is a list of documentation that you will need to provide at the time of your interview.  Please be sure that you have all of the documentation that applies to you.

bullet Verification of all income with the exception of employment.  (In that case, this Office will send proper forms to your employer for completion.)
bullet Verification may consist of:
  1. A print out of child support from Domestic Relations Department of the courthouse where the child support is paid.
  2. A letter from Social Security stating correct year amounts or a current bank statement if your check is directly deposited.
  3. A letter from HRS Office stating your monthly cash assistance.
  4. A letter indicating amount of pension/retirement.
  5. Copy of divorce papers indicating alimony and/or child support.
bullet Declaration of U.S. Citizenship Form for each member of the household
bullet Copies of Social Security Cards on all household members.
bullet Copy of Marriage Certificate, if applicable.
bullet Copy of Driver’s License or Picture I.D. for all household members 18 years of age or older.
bullet Notarized statement from an individual who pays you any amount directly such as the father who pays you child support, a parent gives you money on a regular basis or if a separated spouse gives you alimony prior to divorce, etc.
bullet Any household member 18 years of age or older must come into the office to sign additional forms required to process your application. 
bullet Birth Certificates
bullet Proof of pregnancy (if applicable).

**Any delay in turning the requested items in to the office, will delay the processing of your paperwork.

 

Warning: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful, false statements or misrepresentation of any material fact involving the use of or obtaining federal funds.

 

 

PRELIMINARY APPLICATION

 

IF YOU HAVE A HANDICAP OR DISABILITY (A PHYSICAL OR MENTAL IMPAIRMENT THAT LIMITS A MAJOR LIFE ACTIVITY), OR HAVE DIFFICULTY COMPLETING THIS APPLICATION, PLEASE ADVISE US OF YOUR NEEDS WHEN YOU RECEIVE THE APPLICATION OR CALL US TO SCHEDULE ASSISTANCE.  OUR PHONE NUMBER IS (904) 259-3287.  CALL BETWEEN THE HOURS OF 9:00 A.M. AND 5:00 P.M.  (OFFICE IS CLOSED BETWEEN 12:00 NOON AND 1:00 P.M. FOR LUNCH.)  If you have a hearing impairment, all calls are directed to the TDD number at the Baker County Board of Commissions Office.  That number is (904) 259-1443.  That Office will relay any necessary information to our Office.  Appropriate assistance will be provided in a confidential manner and setting.

 Please answer all questions truthfully.  We will verify your answers.  Any misrepresentation of information related to eligibility, preference for admission, allowances, rent, family composition, or prior rental history is grounds for rejection.

Answers to questions concerning handicap or disability status are optional.  However, without this information we may not be able to: (1) determine your eligibility or need for special housing features; or (2) calculate your rent correctly.  Families with members who have a handicap or disability may be entitled to certain deductions from income that affects rent.

If you answer these questions, we will need to verify that you or a family member has a handicap or disability.  We do not need to know the nature, extent, or current conditions of the handicap or disability.  We will need to know that you meet the federal definitions that apply to these terms and that you can abide by the terms of our lease.

Information you provide on handicap or disability status will be treated as confidential by Management.  In accordance with program regulations, information may be released to appropriate federal, state, or local agencies.

Please complete the special needs questionnaire attached to the application form.  The information is needed so that we may help you locate a unit appropriate to any needs that exist for your family.  Your answers will be verified.  Please note that completing this questionnaire is completely voluntary.  We are asking you to complete it solely to meet your housing needs, and that any information obtained will be used solely for this purpose and will be kept completely confidential.

Application for Rental Housing:  Baker County Housing Assistance Program  (BCHAP) & Macclenny Housing Authority (MHA).

 

INSTRUCTIONS FOR HEAD OF HOUSEHOLD 

  1. Print all sections in ink.  Do not leave any sections blank.  If they do not apply, indicate N/A.
  2. As head of household, you will complete this application form.  Each adult who will live in your unit must sign the application.
  3. All information on this form must be complete and correct.   False, incomplete or misleading information will cause your household’s application to be rejected.
  4. As long as your application is on file with us, you must contact us if your address, telephone number, income status or family size changes.
  5. After we accept your application, we will make a preliminary determination of eligibility.  If eligible, you will be placed on a Waiting List; if rejected, we will follow standard procedures and notify you in writing.
  6. All areas marked with * are required fields and must be entered.  If the area does not apply, please enter N/A

 Warning:  Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful, false statements or misrepresentation of any material fact involving the use of or obtaining federal funds.

 

Head of Household and Spouse:

 * Please enter a username for your application:  
   This username will be used to access your application in the event you are unable to finish.

   Head of Household     Spouse  
 * Last Name:     Last Name:
 * First Name:     First Name:
 * Address:     Address:
 * City:     City:
 * St:     St:
 * Zip:     Zip:
 * Phone: ()     Phone: ()

 * Have you or your spouse ever used different names other than indicated above, such as maiden names?                             

 **If yes, indicate person and name used:

 

 * Have you or your spouse or ever received rental assistance from a HUD Program?  

**If yes, indicate program(s):

 

Household Composition: (Including those indicated above) PLEASE PRINT

 

 

Full Name

Relation

Sex

Age

Birth Date

Occupation

SS#

Race
* 1.  
2.
3.
4.
5.
6.

 

Income from Employment

 

  Member # Employer Mailing Address Telephone# Gross Wkly Income
* 1.  () $
2.  () $
3.  () $

 

Income from Other Sources: (SS, SSI, Pensions, Public Asst., Unemployment, Alimony, Child Support, etc.)

 

  Member # Type of Income Address for Verification Gross Wkly Amt
* 1. $
2. $
3. $

 

Assets:

 

  Member # Description Est. Current Value Gross Monthly Amt
1. $ $
2. $ $
3. $ $

 

Race and Ethnicity of Head of Household:

HUD requires us to report the race and ethnicity of the Head of Household for all applicants.  This response is optional and your entry will have no bearing on your eligibility for housing.

Race of Household Head:
Ethnicity of Household Head:

 

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 *HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD EVER BEEN ARRESTED OR CONVICTED OF ANY CRIMINAL ACTIVITY?   

 **IF YES, PLEASE EXPLAIN:

 

Allowances

 

Dependent Deductions:  Enter the names, separated by commas, of all household members other than head or spouse who are:

Under age 18 

18 or older and full time student

18 or older and disabled or handicapped

Each family member verified above = $480 deduction from Annual Income for computing rent.

 

Childcare Expenses:  List amounts your pay for the care of children or foster children in the household under the age of 13 to permit an adult family member(s) to work or go to school:
   $

List names of children for who care is provided:

List the name of any adult member of the family able to work or go to school because of the childcare paid indicated above:

Indicate the name of your childcare provider:

Indicate the address of your childcare provider:

 

Handicapped Care/Expenses:

List amounts you pay for care of a handicapped/disabled family member to permit an adult family member to work: $

Names of members who amounts are claimed for:

Names of care provider:  

Address of care provider:

 

Elderly Household Allowances: An elderly household is one in which the head, spouse, or sole member is 62 or older, disabled or handicapped. 

Such households qualify for a $400 deduction in computing rent.  Select to claim the deduction:

 

Special Needs Questionnaire

 

Do you, or does any member of your family need any of the following as a direct result of a disability?

A separate bedroom        A barrier-free unit                 One Level unit
 Unit for Vision-Impaired     Unit for Hearing –Impaired   BR/Bath on 1st Floor

Other:

 

If you checked any of the previous listed categories of units, please explain exactly what you need to accommodate your disability:
 

 What is the name of the family member who need the features or live-in- aide?

Who should be contacted to verify that the individual in your family who you have indicated as needing the feature(s) identified or live-in-aide has a disability and needs the reasonable accommodation requested as a direct result of his/her disability?  Indicate name, address & phone number:
  

 

EMERGENCY CONTACT INFORMATION

* Nearest Relative:
*Name:  
*Address:  
*Relationship:   
*Phone Number: ()
 
*Person to notify in case of an Emergency:
*Name:  
*Address:  
*Relationship:  
*Phone Number ()
 
*Other Relatives or Friends:
 

*Name:  
*Address:  
*Relationship:  
*Phone Number ()
 
*Name:  
*Address:  
*Relationship:   
*Phone Number ()
 

LANDLORD HISTORY FROM PRESENT TO PAST THREE YEARS 
 
*Present Landlord:
*Landlord Name:             
*Years                              *Months                     *Monthly Rent $             
*Address    
*Phone Number ()  
 
*Previous Landlord:
*Landlord Name:                
*Years                              *Months                     *Monthly Rent $             
*Address   

*Phone Number ()  

 
Previous Landlord:
Landlord Name:  
Years                     Months           Monthly Rent $
Address

Phone Number ()

 
Previous Landlord:
Landlord Name:    
Years                    Months            Monthly Rent $
Address   
Phone Number ()

 

 

 

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Copyright © 2005 Macclenny Housing Authority
Last modified: 04/09/05
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