Pre application form_english
- 1. Our mission is to enhance the Seattle community by creating and sustaining decent, safe and affordable living environments that foster stability and increase self-sufficiency for people with low incomes. Our materials and services are available in alternate formats. We are committed to making our materials, services and programs accessible to people with disabilities. If you have a disability and need help to complete the application process or lease a unit, please request an accommodation. We will try to help you in any way we can. Pre-application for housing assistance PO Box 19028 190 Queen Anne Ave N Seattle wa 98109–1028 Phone 206-239-1737 Fax 206-239-1780 tdd 7-1-1 SHA-1204 (Rev. 02/16)_English www.seattlehousing.org
- 2. Area Code Telephone Number ( ) – Birth date (mm / dd / yy) 14. Certification of applicant: I hereby certify that the information I have provided in this pre-application is true and accurate. I understand that if I do not provide all of the information request, or if I make inappropriate property selections, my name may not be added to the waiting list. I understand that providing false information may result in my application being cancelled or denied or in the termination of my housing assistance. I understand that at the time I rise to the top of a waiting list, I will be required to verify the information I have provided here. I accept responsibility for keeping the Seattle Housing Authority informed of my current address, and I understand that my application may be cancelled if I fail to do so. I understand that I must check-in once a month to stay on the waiting list. Pre-application for housing assistance 13. Disability It is not necessary to give us details about your disability unless you are requesting an accommodation. 13c. Do you need an accommodation in housing features as a result of your disability? Do you need an accommodation to help you complete the application process? 7. List others who will live with you Include unborn children and live-in aides. Relation# Birthdate (mm / dd / yy)Social Security numberLast name First name 1 2 3 8. Total number of people expectedto live in the unit: ____. Please list additional household members on a separate sheet of paper. 4 5 Last name First name Middle initial Mailing address Apartment number City State Zip Address where you are currently living (if different from mailing address above) City State Zip 2. Name and address of head of household1. Personal information Please complete and return to Seattle Housing Authority PO Box 19028 190 Queen Anne Ave N Seattle WA 98109–1028 Date stamp (SHA office use only) Donotwriteinthisspace.SHAofficeuseonly. 6b. Seattle Senior Housing Program (SSHP) Property #1: Property #2: 6c. Impact Property Management (IPM) Property #1: Property #2: 6. Property Choice(s) See the Application Guide for more information about choosing a property where you would like to live This form must be filled out in English. Print neatly in ink. All fields are required. Read the instructions on the facing page before completing each item. My household is extremely low-income. My household is homeless. 4. Current living situation The Application Guide explains how your living situation determines your waiting list preference. My household is NOT extremely low-income NOW, but has been in the last 12 months. My household is NOT homeless NOW, but has been in the last 12 months. 5a. Total monthly income Include income from all family members. You may estimate. 5. Income Provide gross (not net) amounts for all questions $ Enter your Social Security Number Check all that apply. See instructions on the opposite page for definitions. 5b. Income source(s) Check all that apply. Yes No Yes No 13b. Email Address Wages Interest/annuity income Worker’s Compensation Someone pays my bills/gives me money: $ (list how much) SSA SSI Pension L & I TANF Child support Other assistance: Do you claim a disability? 13a. Yes No Optional Demographic Information 10. Ethnicity Hispanic Non-Hispanic 3a. Primary language White Asian Other: Black Alaskan Native 3b. Do you need an interpreter? Yes No 9. Sex Male Femaile 11. Race Native American Pacific Islander 12. U.S Veteran status Veteran Not a veteran 13d. If “yes” to 13b or 13c, what accommodation do you request? (See instructions on facing page for more information. You may attach additional sheets to explain.) ____________________________________________________________________________________________________________________________________ Signature of head of household Date Signature, spouse or co-head of household Date X ________________________________ _________________ X ________________________________ _________________ Bedroomsiae 6a. Low Income Public Housing (LIPH) Property #1: Property #2:
- 3. 9. Sex (head of household) - Indicate the head of household’s sex. 10. Ethnicity (head of household) - The housing authority collects statistical data on ethnicity and race in accordance with federal regulations. People of various races may also be of Hispanic ethnicity. Please indicate if you are Hispanic. 11. Race (head of household) - For statistical purposes only. The choices listed are the same as the federal government’s statistical categories. 12. U.S. Veteran Status - Indicate the head of household’s Veteran Status. 13. Disability (head of household) 13a. Are you disabled? Check Yes or No. (You are not obligated to provide information about your disability unless you want an accommodation.) 13b. Tellus if you need an accommodation as a result of your disability, to help you complete your application or to help you conduct business with us before you are housed. 13c. Tell us if you need any features in your housing unit to accommodate your disability. 13d. Describe the assistance you need. - The Admissions Office has more information available to help you request a reasonable accommodation, including copies of our Reasonable Accommodation Policy and our Request for Reasonable Accommodation form (SHA-968), which you can submit along with your Pre-application for housing assistance. You can obtain these documents at our office or we will mail them to you. For more information about SHA’s Reasonable Accommodation Policy, contact SHA’s Section 504/ADA Coordinator at (206) 615- 3550, or (TDD/TTY) 7-1-1. 14. Certification of applicant. - Please read this statement very carefully. By signing it, you agree to its terms. You must sign the form and date it where indicated. E X T R E M E L Y L O W - I N C O M E L I M I T S (HUD, 3/09/2015) Number in 30% of median 30% of median household income (annual) income (monthly) 1 $ 18,850 $ 1,571 2 21,550 1,796 3 24,250 2,021 4 26,900 2,242 5 29,100 2,425 6 32,570 2,714 7 36,730 3,061 8 40,890 3,408 Pre-application instructions Follow these instructions while completing the pre-application form on the left facing page. Each number below refers to the section on the form with the same number. The form must be filled out in English. Please print neatly in ink. TearalongthecreasetoremovethePre-applicationforhousingassistanceform.Submittheformonly(plusanyextrasheetlistingfamilymembers;seeNo.11).Keeptherestofthepacketforreference. 1. Definition of extremely low income A household that (1) earns 30 percent of Seattle-area median income or less, or (2) earned 30 percent of Seattle-area median income or less during the 12 months prior to an eligibility determination. See the table above for income limits according to family size. 2. Definition of homelessness A household that (1) is living on the street, in an emergency shelter, or in a transitional facility, or is a client of a case-management program serving the homeless; or (2) has met one of these conditions during the 12 months prior to an eligibility determination. *Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et.seq.),TileVI of the Civil Right Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601- 19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and localagencies,whenrelevant,andtocivil,criminal,orregulatoryinvestigatorsandprosecutors. However,theinformationwillnotbeotherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA(HousingAuthority),includingallSocialSecurityNumbersyou,andallothermembersagesixyearsandolder,haveanduse. GivingtheSocial SecurityNumbersofallhouseholdmemberssixyearsofageandolderismandatory,andnotprovidingtheSocialSecurityNumberswillaffectyour eligibility. Failure to provide and of the requested information may result in a delay or rejection of your eligibility approval. 1. Personal information (head of household) - Applicants must identify a single head of household for each application. Provide the Social Security Number of the head of household for your family. Enter your birth date and telephone number. *(See Privacy Act Notice below.) 2. Name and Address (head of household) - We must have a current mailing address to contact you at all times. If we are unable to contact you by mail, you will be removed from the waiting list. 3. Primary language (head of household) 3a. Write in the name of the language you speak at home. 3b. Indicate if you will need an interpreter to conduct business with us. 4. Current living situation (waiting list preference) - If you are either extremely low income or homeless according to definitions 1 and 2 on the chart (right), you may receive preference. See the Application Guide for more information. Check all that apply. 5. Income. Include all sources for all family members. 5a. Write in the approximate amount of the family’s gross (not net) monthly income. 5b. Check all boxes that correspond to income types available to your family. 6. Property Choice(s) 6a. Low Income Public Housing. - Choose one or two properties from the Low Income Public Housing property table on p.2 of the Application Guide. You can ask Admissions staff which waiting lists are the shortest. 6b. Seattle Senior Housing Program. - SSHP has mostly one- bedroom units, with a few two-bedrooms. You must be at least 62 or disabled (18+) to live in these properties. See the Application Guide for more information. 6c. Impact Property Management. - Choose properties from the IPM section of the Low Income Public Housing property table on p.2 of the Application Guide. You can ask Admissions staff which waiting lists are the shortest. 7. List others who will live with you - List everyone who will be living with you, including aides and unborn children. Do not include yourself. If you have more than five people in your family, list the additional members on a separate sheet of paper. 8. Total number of people expected to live in the unit. - In the blank line, write the total number of people who will be occupying the unit.
- 4. After you receive confirmation that your name has been added to the waiting list, you must check in once every month or your application will be canceled. These phone numbers are programmed in English, Amharic, Cambodian, Cantonese, Mandarin, Russian, Somali, Spanish, Tigrinya, and Vietnamese. Or check in on the Internet at www.SaveMySpot.org, where instructions are provided in 17 different languages. OTHER HOUSING RESOURCES IN THE SEATTLE AREA All housing programs operated by the Seattle Housing Authority have long waiting lists and we cannot serve you immediately. Fortunately there are other organizations in the area that operate shelters, emergency housing, transitional housing programs, traditional federally subsidized housing programs, and other types of affordable, permanent housing. Bellingham Housing Authority 360-676-6887 Bremerton Housing Authority 360-479-3694 Everett Housing Authority 425-258-9222 Island County Housing Authority 360-678-4181 King County Housing Authority 206-574-1100 Kitsap County Housing Authority 1-800-693-7070 Pierce County Housing Authority 253-620-5400 Renton Housing Authority 425-226-1850 Snohomish County Housing Authority 425-290-8499 Tacoma Housing Authority 253-207-4400 Thurston County Housing Authority 360-753-8292 HUD-subsidized apartments (listing) 206-220-5140 Archdiocesan Housing Authority 206-448-3360 Capitol Hill Housing Improvement Program (CHHIP), 206-329-7303 Central Area Development Association 206-328-2240 Housing Resources Group (HRG) 206-622-2893 Low Income Housing Institute (LIHI) 206-443-9935 Lutheran Alliance to Create Housing (LATCH) 206-789-1536 Plymouth Housing Group 206-652-8325 Southeast Effective Development (SEED) 206-760-4265 St. Andrews Housing (King County) 425-957-4742 LOW INCOME HOUSING PROVIDERS EMERGENCY HOUSING, TRANSITIONAL HOUSING, AND SHELTERS Community Information Line 2-1-1 or 206-461-3200 or 1-800-621-4636 Senior Information & Assistance 206-448-3110 or 1-888-435-3377 24-Hour Crisis Line 206-461-3222 or 1-866-427-4747 Provides a wide range of information about community resources from a database of more than 9,000 service providers. Provides a wide range of information for people over the age of 60 using a database of more than 4,000 service providers. Also provides advocacy and follow-up for callers who have difficulty accessing services. Provides immediate help to people in emotional crisis, and referrals to agencies that provide additional help. 206-256-7000 From pay phones or outside Seattle, call toll-free 1-866-623-5111 www.SaveMySpot.org 24 hours a day, 7 days a week Check in every month! Save MySpot! You must check in once a month to stay on the waiting list PO Box 19028 Phone 206-239-1737 190 Queen Anne Ave N Fax 206-239-1770 Seattle wa 98109-1028 Seattle Housing Authority