MID‐ COLUMBIA HOUSING AUTHORITY

APPLICAT10N FOR SECTION 8 HOUSING ASSISTANCE

Phonc(541)296‐ 5462
Complete and Return to: Toll Frec岸 1‐ 888-356‐ 8919
Fax(541)296‐ 8570
500 East 2nd street DeafCommunity Relay OR l‐ 800‐ 735-1232
The Dalles,Oregon 97058 WAl-800-833‐ 6384

Ilead of llousehold APPlicant:

(Last Name) (First Namo
Current Mailing Address: Apt.#or P。 0。 Box#
City County State Zip Day Phone:

in the assisted unit: with Hcad of

Part I. Ilousehold Me4bgIq.littu[ Mcln検 が that will be

RACE" - HisPanic, 2 - Non- HisPanic

ETHNICITY: I -White,2-Black,3-Americanlndian/AlaskanNative,4-Pacificlslander/Asian

Part Ⅱ.Ⅱ OusehOld lncome. .

′grθ ss income for persons liStcd above. hcOme includes but is not limited to Wages,Welfare,Social Security,
List α′
sSI,VA,Pensions,Child Support,Unemployment,ctc.

PLEASE CHECK AI\Y OF TIIE FOLLOWING THAT

MAY APPLY TO YOU:
PATt III: veteran El Displaced by Government Action E Pregnant or E In the
E Elderly (age 62or older) E Disable.d or Handicapped tr Disabledthe age of 18.
not attained
;.";;;, ;i;;ring tegal "*tooy of any individual who has
■ ▼。し しユ
ラー …
Part Ⅳ .Cirde Y for "…N^L面
V二 Yes and for No.
"rι
Have
“
naVO)υyou or anyone l■ yollr
V巫 V`“
い V八 ιμ り .houSchold [jふ
hous requred coⅣ ded
tO regls ofmanufac光uring methAmphetnmine?Yノ N
■ 4__^_1_`^_^^^‐ anЛ ハr9 Vノ T可
′
・ ● ●● ・ oν
ter as a sex offender?
^幹 Y/N
Have yOu or anyone ln yolu
liy」 markedjestoeitherquesiOn,what Sttte?
PART v'
rArsrV. contacted for housing
vou are contacted
Do you wish a *,::i*l^Y::i""
irrrJr"""i-"*_" *" . If yes, give us the name of caseworker or other person

Date:
Signature:
励′
競絡M、∬脇:勝 ち ″
J″ 留躍 紺■
鰤&詰が幌鰍 驚 驚絲
%鰐謡

P_lMCHA,Rev.10-06
 U.S. Department of Housing
and Urban Development

呻
office of Public and lndian Housing
:寵 鴇∞
驚億:朧‖ J"帥 d urban D"d∞ m酬 但 ofiB coNlRot NUMEER 2501-0014

and the Housing Agency/Authottty(HA)

requestrng ielease of intomation: (ctoss out space
name of conlact Person, and date)
(Full address,name of contacl pe「 son and date)
MID COLUMBlA HOuSING AUTHORITY
500E2ND ST
THE DALLES,OR 97058
PHi541‐ 296-5462
FAX:541‐ 296‐ 8570

Authority: Section 904 ofthe Stewart B. McKinney Homeless
Assistance Amendnlents Act of 1988, as amended by Section 903
ofthe Housing and Community Development Act of 1992 and
Section lO03 of the Omnibus Budget Reconciliation Actof I 993'
This law is found at 42 U.S.C.3544.
This law requires that you sign a consent form authorizing: ( l)
HU D and the Housing Agency/Authority (HA) to request verifi-
cation ofsalary and wages from current or previous employers; (2)
HUD and the HA to request wage and unemployment conrpensa-
tion claim information from the state agency responsible for
keeping that information; (l) HUD to request certain tax r€turn
information fronr the U.S. Social Security Administration and the
U.S. lnternal Re ven ue Serv ice. The law also requ ires independent
verification of income information. Therefore, HUD or the HA
may request ioformation from financial institulions to verify your
eligibility and level of benefits.
Purposel ln signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HU D and the HA need this information
to verify your household's income, in order to ensute that you are
eligible for assisted housing benefits and that these benefits are set
at the correct level. H U D and the H A may participate in computer
matching progranrs with these sources in order to verify your
eligibility and level of benefits.
Uses oflnformationto be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of 1974. 5 U.S.C.552a. HUD may disclose information
(other than tax return information ) for certain routine uses' such as
to other government agencies for law enforcement purposes, to
Federal agencies for employment suitability purposes and to HAs
for the purpose ofdeterm ining housing assistance. The H A is also
required to protect the income information itobtains in accordance
with any applicable State privacy law. HUD and HA employees
may be subject to penalties for unauthorized disclosures or im-
proper uses ofthe income information that is obtained based on the
consent form. Private owners may not request or receive
information suthorized by this form.
Who Must Sign thc Conscnt Form: Each member of your
household who is t 8 y€ars of age or older rnust sign the consent
forrn. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household become I 8 Years of age
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PH A-owned rental public housing
Turnkey lll Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and l9(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental lndian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure tosign Consent Form: Yourfailure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial ofeligibility or termi-
nation ofbenefits is subject to the HA's grievance procedures and
Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage lnformation Collection Agencies. (This consent is
limited to wages and unemploynrent compensation I have re-
I
ceived during period(s) within the last 5 years when have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited to the wage and self employment information and pay-
ments ofretiremenl income as referenced at Section 6l 03(l)(7XA )
ofthe lnternal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is
limited to unearned income Ii.e., interest and dividendsl.)
lnformation may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and divi-
dends). I understand that income information obtained from these
sources will be used to veriry information thal I provide in
determining eligibility forassisted housing programs and the level
ofbenefits. Therefore, this consent form only authorizes release
directly from employers and financial inslitutions of information
regarding any period(s) within the last 5 years when I have
received assisted housing benefits.

ref Handbooks 7420 7 7420 8 8 7465 1 rOm Huo● 886(7′ 94)

Original is retained by the requesting organizalion.
 Consent: I consent to sllow HUD or the HA to request and obtrin income ilformation from th€ sourc€s listed on this form for
the pu rpose o f verifying my eligibility a nd level of benefits u nder H U D's assisted housing program s. I undcrstand that HAs that
receive inconre information under this consent form cannot use it to deny, reduce or terminale assistance without first
independently verifying whal the amount was, whelher I actually had rccess to the funds and when the funds were received. In
additior, I must be given an opportunity to contest those determinations.
This consent form expires l5 months after signed.

Stnatures

Hend“ HOusehold Date

sO● a seallty Nunber(r any)ご Head OI HOusehdd Olher Family Membe, over aqe 1E oae

Dare Othe, Family Memb€r over age 18 Dae

olher Family luember ove. age 18 Date Olh€. Family Member over a9. 18 Dare

Other Family Memberover ege l6 Dale Other Family Memb.r over age t8 Dde

Privacy Act Notice. Authority: The Departnrent o f Housing and Urban Development (H U D) is authorized locollectthis information
bythe U.S. HousingActofl93T(42 U.S.C. l417et.seq.),TitlevloftheCivil RightsActofl964(42U.S.C.2000d).andbytheFair
Housing Act (42 U.S.C. 3601- 19). The Housing and Community Dev€lopment Act of 1987 (42 U.S.C- 354i) requires applicants and
panicipants lo submit the Social Security Number ofeach household memberwho issixyearsold orolder. Purpose: Yourincomeand
other information are being collected by HUD io determine your eligibility, the appropriate bedroom size, and the amount you. family
willpay toward rent and utilities. Other Uses: H U D uses your fam ily income and other information to assist in managing and mon iloring
H U D-ass isted hous ing programs, to protect the Covernment's financ ial interest, and to verify the accuracy ofthe in form ation you prov ide.
This information may be released (o appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory
investigators and prosecutors. However, the infornration will not be otherwise disclosed or released outsidc of H UD, excepl as permitted
or required by law. Penalty: You must provide all ofthe information requested bytheHA, includingall Social Security Numbers you,
and all other househo ld mem bers age six years and older, have and use. GivingtheSocial Security Num bers o f all household mem bers
six years ofage and older is mandatory, and not providing the Soaial Security Numbers will affect your eligibility. Failure to provide
any of the requested information nray result in a delay or rejection ofyour eligibility approval.

Penrlties for llrlsusing thls Con3ent:

HUO. the HA and any owner (or any employee of HUD, the HA or the owne.) may be subiecl to penallies ,or unaulhoaized disclosures or improper uses of
informalion collecled based on the consent fom.

Use of lhe informalion collecled based on lhe fonn HUD 9886 is restricled lo the purposes cited on the form HUD 9886- Any person who knowingly or willfully
requests, obtains or discloses any informelion under false pretenses concerning an applicanl or participant may be subiecl lo e misdemeanor and fned not more
lhan $5.000.

Ahy applicanl or participant affecled by negligent disclosure of infomation may bring civil aclion lor damages, and seek olher rclief, as may be appropriate. againsl
lhe officer or employee of HUO. the HA or the owner responsible for lhe unaulhodzed disclosure or imprcpea use.

Original is retained by the requestrrE orgenization rei HandboOks 7420 7,74203 &74651 fom HUD・ 9886(7194)
 OUSINC AUTHORITY

REASONABLE ACCOMMODATION VERIFICATION

Clientele Who Can Qualifu for a Reasonable Accommodation

It is the MCHA/CGHA policy to provide a reasonable accommodation in housing for Housing Choice
Voucher (Section 8) clients with a disability who are otherwise qualified for MCHA/CGHA services.
This policy is furtherance of MC}IA/CGHA's goal to provide and develop quality affordable housing
opportunities for people regardless of disability and remain in comptiance with applicable federal, state
and local law.

A person with a disability is one who:

' Has a physical or mental impairment that substantially limits one or more major life
activities such as caring for one's self, doing manual task, watking, seeing, hearing,
breathing, learning and working;
o Has a record for such an impairment; or
. ls regarded of having such impairment.

To be completed by a Qualified Professional to fill out (8.G.., Counselor, social worker, doctor
rehabilitations center, service agencies, or other entity identified by the person requesting
a
reasonable accommodation.

A Reasonable Accommodation has been requested by.

name of
client) in order for MCHA/GGHA to provide the following accommodarion:

Please list what accommodation you are requesting MCHA/GGHA provide:

Please explain why you are requesting this accommodation and how it will provide your Client an
equal opportunity to participate in and use our housing program.

Page I ofT

500 East 2nd Street, The Dalles, OR. 9705g

Deaf Community Relay - (OR) 1-800-735-1232 (WAl 1-800-833_0384
( Phone) l-547-296-5462
(Fax) 1-541-296-8570
(1〕 し
MCHA/CCHA is required by law to provide reasonable accommodations to disabled participants

thatwill provide them with equal opportunity to participate in the use of our housing progranrs.
MCHA/CGHA rvill not provide reasonable accommodations rvhen the request is a rnatter of
convenience or Dreference onlv.

Please verify that the above requested accommodation:

l) ls related to the participants disability; and 2) would provide tlre participant with equal
opportunity in and use our housing program in their unit.

l, do do not _(pleasecheck one)

Bclieve that the above reqL:CSted accoinmodatio:l is rclated to the participallts disability and
would providc equal opportunity to palt:cipate in thc hoLiSing program.

I HEARBY CERITY THAT I HAVE READ PAGEI FOR COMPLETING THE

QUALIFIED PROFESS10NAL VERIFICAT10N OF NEED FOR AN
ACCOMMODAT10N IN HOUSING BECAUSE OF A DISABILITY AND I
UNDERSTAND ITS CONTENTS.IFURTHER CERTIFY THAT ALLINOFRMAT10N I
HAVE PROVIDEDIN THE FOM IS ACCURATE,COMPLETE,AND CURRENT.
FINALLY,lUNDERSTAND THATI CAN BESUBPOENDAED TO TESTIFYIN ANY
TRIALS OR HEARINCS RELATED TO THE PARTICIANTS REQUEST.

Signature Date

Printed Name Phone#

Professional title

Please return this form to: ATTN Housing Certifler ll

Page 2 of 2

500 East 2nd Street, The Dalles, OR.97058

Deaf Community Relay - (OR) 1-800-735-1232 (WA) 1-800-833-6384

{PhOne1 1-541-296-5462 1To::Free)1-888-356-8919

(Fax)1-541‐ 296-8570