Salem & Keizer's Largest Affordable Housing Provider 503-588-6368 TDD Users: Dial 711 Fax: 503.588.6465 360 Church Street SE Salem, Oregon 97301 [email protected] www.cityofsalem.net/sha WAITING LIST REQUEST (PRE-APPLICATION) SECTION 8 VOUCHER PROGRAM MODERATE REHABILITATION PROGRAM Return application to: Salem Housing Authority Section 8 Voucher and Mod Rehab Program 360 Church Street SE Salem, Oregon 97301-3707 IMPORTANT – PLEASE READ All pages of the pre-application packet must be completed to be accepted. Please be advised that it is your obligation to ensure that SHA has a current mailing address on record, at all times, in order to contact you as needed. Changes to your mailing address can be made by completing and submitting a Waiting List Update Form which can be found in SHA’s lobby at 360 Church St SE; Salem OR 97301 or maybe printed from SHA’s website at www.cityofsalem.net/sha . Failure to keep your mailing address current will result in removal from the waiting list(s). Last Name Voucher Mod Rehab First Name Mod Rehab Single Residency Occupancy (SRO) for women MI *Ethnicity Relation to Sex and Race Head M/F Directions Birth Date Age SS# 000-00-0000 below 1 Head 2 3 4 5 6 7 Use a separate sheet for additional household members if necessary. * OPTIONAL - Information is not used to determine eligibility. Information is used for informational purposes only. For Ethnicity (Write one letter only): A) Hispanic or Latino B) Not Hispanic or Latino D) Decline to disclose For Race (Write all numbers that apply): 1) White 4) Asian 2) Black/African American 3) American Indian/Alaska Native 5) Native Hawaiian/Pacific Islander 6) Other 7) Decline to disclose Examples: Ethnicity (Hispanic) Race (Native Hawaiian and Other) = A 5 6 Former Last Names Used (include all household members): Additional Comments: Page 1 of 3 Ethnicity (Decline), Race (Decline) = D 7 Disability Y/N Select all that apply: Mailing Address: Contact: Home Phone: Apt #: Address: City: State: Message Phone: Zip: Email: Cell Phone: Is the Head of Household a Veteran? Household Income $: Is an accessible unit needed? Yes If yes, specify all types that apply: Income Source: What is your primary language? English Spanish Yes Yes No Hearing Mobility Vision Other Is a household member pregnant? Yes No If English is not your primary language, can you speak or read English fluently? Check all that apply SRO Program only: Are you homeless? No If HEARING impaired, do you need a SL interpreter or hearing access equipment? Yes No Other Specify: Do you need an interpreter? Yes Speak Read No If yes, provide the pregnant Household members name: No Expected delivery date: The U.S. Department of Housing & Urban Development (HUD) requires criminal background checks on all applicants prior to providing housing assistance. HUD and Salem Housing Authority policies require lifetime denial of assistance under the following circumstances: 1) A lifetime registration as a sex offender, or 2) Conviction for manufacture of methamphetamine. One or more members of the household have a lifetime registration as a sex offender: One or more members of the household have a conviction for manufacturing methamphetamine: Yes Yes No No I hereby authorize representatives of Salem Housing Authority (SHA) to contact any agency offices, groups, organizations, and/or individuals necessary to obtain information needed to determine my household’s eligibility to be placed on a SHA program waiting list. I/we understand that this is a request for placement on a waiting list and that eligibility for any SHA program may not be determined until my name comes to the top of the list. I also understand that my signature on this form certifies that: 1) No member of the household has a lifetime registration in the U.S. as a sex offender, and 2) No member of the household has a conviction for manufacture of methamphetamine. Signature: Date: If you need assistance interpreting this notice, please call 503-588-6470 Si necesita ayuda en traducir esta notificación favor de llamar al telefonó 503-588-6470 Note: Screening criteria for all programs is available for review at the following locations: SHA Main Office - 360 Church St. SE, Salem, Oregon, Phone: 503-373-3803; Parkway Village Property Management Office - 3143 7th Place NE, Salem, Oregon, Phone: 503-390-8008 Robert Lindsey Tower-SHA Homes Property Management Office - 370 Church St. Suite #100, Salem, Oregon, Phone: 503-588-6458 Website: www.cityofsalem.net/sha/pps For Office Use Only: Application screened by: Date: Application input by: Date: Imaged/Scanned by: Date: ATTENTION: The SUPPLEMENTAL AND OPTIONAL CONTACT INFORMATION FORM on the next page must be completed with this Waiting List Request. Page 2 of 3 IMPORTANT NOTICES Salem Housing Authority REASONABLE ACCOMMODATION If you or anyone in your family is a person with disabilities and you require a specific accommodation in order to fully utilize SHA programs and services, please contact SHA to obtain a Reasonable Accommodation Request form at 503-588-6368. PENALTIES FOR MAKING FALSE OR FRAUDULENT STATEMENTS 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 willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor or 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 numbers are contained in the Social Security Act at 42 U.S.C. 408 (f) (g) and (h). Violations of these provisions are cited as violations of 42 U.S.C. 408 (f) (g) and (h). SALEM HOUSING AUTHORITY STATEMENT OF NONDISCRIMINATION The Housing Authority of the City of Salem does not discriminate against any person because of disability, race, color, religion, sex, marital status, familial status, national origin, sexual orientation, gender identity, source of income, and/or domestic partnership in accessing, applying for or receiving assistance, or in treatment or employment in any of its programs and activities. All public meetings are held in accessible locations. Appropriate aids (e.g., assistive listening system, interpreters, readers, assistance filling out forms) will be provided upon request. Complaints regarding accessibility of the Authority's programs for individuals with disabilities can be submitted in writing to Terry Frazier, Salem Housing Authority, 360 Church St SE, Salem OR 97301-3707. Requests for aid, questions, or comments may also be directed to 503-588-6368, [email protected], TDD Users Dial 711. The Fair Housing Act prohibits discrimination in the sale, rental or financing of housing on the basis of race, color, religion, sex, disability, familial status, national origin, lesbian, gay, bi-sexual and transgender individuals. Federal law also prohibits discrimination on the basis of age. Complaints of discrimination may be forwarded to the Administrator, Office of Fair Housing and Equal Opportunity, U.S. Department of HUD, Washington, D.C. 20410. 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.), Title VI of the Civil Rights 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 local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise 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, including all Social Security Numbers you, and all other household members age six years and older, have and use. Providing the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or denial of eligibility. Revised March 2014 IB Page 3 of 3