Fee Waiver-Financial Hardship

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Fee Waiver-Financial Hardship

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96 views72 pages

Fee Waiver-Financial Hardship

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parsequality

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Fee Waiver-Financial Hardship

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Request for Fee Waiver uscis Form 1-912 OMB No. 16150116 Expires 0937020 Application Receipted At (Select only one box) Tluseis Fieia Oftiee Fee Waiver Approved [1] Fee Waiver Denied Date Date [uscis Service Center jer Approved [_] Fee Walver Denied Date > START HERE - Type or print in black ink. iceineoailele ai euuiiek shiseniyelsb ise Solect at nev lagt nreene Th He teeese ‘one basis or more for which you may qualify and provide supporting documentation for any bass you select. Yeu only ‘eed to qualify and provide documentatlon for one basis for U.S, Citizenship and Immigration Services (USCIS) to arant yout fee waiver. Ifyou choose, you may select more than one basis, you must provide supporting documentation for each basis you went considered, 1. C) tem, my spouse i, or the head of household living in my household is currently receiving & means-tested benefit (Complete Parts 2-4, and Pets 7-10.) 2. 1] My househod income is at or below 150 percent ofthe Pe §, and 7, 10,) 3, [X] Ihave fiancil hardship. (Complete Parts 2, 3, end Parts 6, 10.) Provide information about yourself if you ae the person requesting a fee waiver for «petition or application you wre filing. Ifyou ate the parent or lege! guardian filing on bebal€ ot a enild ot person wi ‘ederal Poverty Guidelines, (Complete Parts 2.-3, Part ith a physial disablty or developmental or mental impairment, feito cies arm. pists 5. DateofBirth(mmiddlyyyy) «6. *U, Sacial Securlty Number (i'any) ce eS) Fomisi2 oa/ane Page Dot TT 7. Mati Stats (Single, Never Merred [) Marcied [) Divorced [} Widowed [] Marriage Annulled C) Sepaiaed C1 Other Expain Full Name Date of Birth | Relationship to You |Forms Being Filed hear a Total Number of Forms (ineluding self) I you selected Item Number 1 Part 1., complete this section, 41. you, your spouse, or the head of houschol (including parent if he child is under 21 years of ege) living with you is recelving say mets ested benefits, list the information in the table below and attach supporting documentation. you are the parent ot {egal guardian fling on behalf ofa child or person with « physical dissbility or developmental or menial impairment, provide information about the child or person for whom you ae fling the fort if he o she i eoeiving & means-tested boned, MTU nen i i Full Name of Person [ Relationship | Name of Agency ‘Type ot | Date Benefit | Date Benet Expires Receiving the Benent_| to You | Awarding Benefit Benesit | was Awarded | (or must be renewed) 4. Employment Stas © Employed cllsime, partine, C) Unemployed or [] Reticed C} Other (xp seasonal sele-enployed) Not Biployed ae and ey wer ent, Formisi2 os/anie age 2 oF 2, Ifyou are curently unemployed, ae you currently receiving tinemployment benefits? De: [No A. Date you became unemployed (oamibdyyy) LT 3. Ifyou are married or separated, does your spouse lve in your household? Dyes [Ne ‘A, Ifyou answered "No" to Item Number 3, does your spouse provide any financial support to your Des (Ne household? 4. Abe you the person providing the primary fsa: support for your household? Oves TNo {If you answered "Yes" to Ttem Number 4, type or print your name onthe lin mated "se( in the table below, Ifyou answered "No! to Item Number 4, type or print your name onthe line marked "sel In the table below and add the heed of household's name on th line Below yous, samy income earned by this Person counted towards the household income? Full Dateot | Relationship Name Birth to You FulkTime Married btn seis [C1 Ye BiNo | yes Lyne] Clyes CINo C¥es (Ne |C)¥e CiNe[ Elva LIne Cl¥es No [Ci ves Nol Lives No Dives Cio [C1 ¥es Dino] Dives Lyne ‘Total Household Size (including self) a Te ea asm i erat Provide information about your income and the incame ofall family members counted as pat of your household, You must liste amounts in US, dollar, 5. Your Annual tncome 8 6. Aniual Income of All Family Members Provide the annual income of al family members counted as part of your household as listed in Ltem Number 4, (Oo nc include the amount provided in Item Number 5.) 3 7, ‘Total Additional Income or Finsnclal Support 8 Provide te total annual amount you receive in additonal income ot financial support from a source outside of your household (De not inclads the amount provided jn Item Numbers 5, or 6.) You must ad all ofthe additional income and financial support ‘mounts and pu the total amount inthe space provided, Type or prin "0 in the ftal bax if here are none. Selet the type of ‘addtional income or financial support that you receive and provide documentatlon, CoParena Support C)Bescaional sipencs C) Unemployment Benefits C] Financial Support From Adult Children, | Ci spousal Support (Alimony) (Royalties Ceci securiy Benests pendent, Other People Living inthe (Cletiteé support CPensions Dveeer sBenefits [Other ae Fomroi2 o/iae Page 3of11 8. Total Household Income (add the amounts from Item Numbers 5, 6, and 7.) s 9. Has anything changed since the date you filed your Federal tax returns? (For example, your marital status, [] Yes C) No income, or number of dependents.) If you answered "Yes" to Hem Number 9, provide an explanation below. Provide documentation ifavailable, You may also tse this space to provide any additional information about your crcumstances thet you would like USCIS to consider. I you selected Item Number 3. in Part 1, complete this setion, 1, Ifyou or any femily members have a situation that has caused you to incur expenses, debs, or loss of Income, describe the situation in the box below. Speciythe amounts ofthe expenses, debs, and income lsses in as much etal as possible. Exainples may include medical expense, job loss, eviction, and homelessness, ee EE ET a aT ge TS Sa eee SS LE STE, NE SED LTS FS LL A TT I RT TE) ‘SE 2, Ifyou have cash or assets that you ean quickly convert to cash it those in the table below, For example, bank aecounts, stocks, orbonds, (Do not include retirement accounts) ‘Value (US, Dollars) Total Vas of Axe Form ola owianis Page oft ‘otal Monthly Expenses and Liabilities Provide the total monthly amount of your expenses and labities. You must ad all ofthe expense end libiliy aouns end pe ¢ print th total amount in the space provided. Type or print “0 inthe total box if thee are none. Seleat the types of expensee oF liabilities you bave each month and provide evidenee of monthly payments, where posible. [Xl Rentandior Mortgage —(Z] Loans andlor Credit Cards Other Hl Food CO currayment BH vuties [Commuting Coxs C child andlor Bier Coro OH] Medical Expenses Hl insurance {R].School Expenses NOTE: Read the Penalties section of the Form 1-912 Instictions before completing this par, Each person applying fora fee waiver request must complete, sign, end date Forts 1-912 and provide the required documentation. ‘This inludes family members identified in Part 3. Signature fields for faaily members are atthe end of this par, Iranindivideal s under 14 years of age, parector legal guardian may sgn the request on ther behalf. USCIS zjecs any Form 1-512 the is nt signed by all Individuals requesting a fee waiver and may deny a request that does not provide required dacumentetion, Select the box for cither Item A. or B. in Item Number 1. Ifapplicable, select te box for Item Number 2. 1, Requestor’s Statement Regarding the Interpreter ‘A. (i Lean read and understand English, and Ihave read and understnd every question and instruction on this request and my answer to every question. “ “B.C The interpreter nomad in Part 9. read to me every question ard instruction on this request and my answer to every 4 + question in ,# language in which am Aueae, end | understood everything. "Requestor's Statement Regarding the Proparer (i applicable) {B] Atmy request, the preparer named in Part 10, , repered tis request for me besed only upon nfrrvalon T provTUeU OF WOH, . ~~ 5. Requesters Email Address (If ee ids witty documents Ihave submitted aro exact photocopies of unelcrd, original documents, and {understand that USCIS may ‘require that {submit original documents to USCIS ata later date, Furthermore, | authorize the release of try information fom any of ‘my revords thet USCIS may need to determine my elighbllity forthe immigration beneftf seek | further authorize release of information contained in ths request, n supporting documents, and in my USCIS records to other enies tnd persons where necessary for the administration and enforcement of US. immigration laws, 1 cenit under penalty of perjury, that I provided or authorized all ofthe information in my request, understand all ofthe {information contained i, and submitted with, my request, and that ll ofthis information is comple, true, and correc. Forl9i2 OBG/I8 Page Soft WARNING: Ifyou knowingly and wilfully falsity or conccal material fact or submit false document with yor Fog 1912, USCIS wil deny your fe waver request and may deny any oer immigration bereft. In wddon, you may fae severe peal provided by Ie and maybe subject to erimina prosetton 6 Re 5 Date of Signature (mm 03 /07( S015 NOTE TO ALL REQUESTORS: Ifyou do not completely Sill out this requestor fll o aubmit required documents listed In the Instructions, USCIS may deny your request. NOTE: Each family member must type o print their fll name and sign inthe spaces below. You can find additional family members signature spaces in Item Numbers 7-1. below. All family members identified in Part 3. must sign and date Form I-912, 1 certfy tha the information provided ty the requestor in Part 7. applies to me, 7. Family Member 1 anally Member's Name amily Member's Sanat ate of Sighatte (rmittlyyyy 8, Family Member 2 Family Member's Name Famlly Member's Signature Date of Signature (mmddyy) 9. Farnlly Member 3 Family Member's Name Fay Members Signature ‘ats of Senator (ml) et 10, Family Member 4 “ring Mbivers Name ‘arly Mernber's Signature Date of Sint mildly) 11, Family Member $ Bamily Members Name arly Member Signature ‘Date of Signatre ude Fomiai2 canaie Page Sarit NOTE: Read the Peialties section ofthe Form 1-912 Instructions before completing ths part, Ifthe information provided by the requestorin Part 7 snot applicable to family member identified in Part 3, for example, the {amily member used an oterprter or speaks a diferent language) ta individual should complete Part 8, USCIS reject any Form 1-912 thai at signed by all individuals requesting a fee waiver. Select the box for either Item A. or B, in Item Number 1. [fepplicable, select the box for Item Number 2, 1 Fay Members 8 Regarding the Interpreter for A; Ly Loan read and understand English, and { heve read and understand every question and instruction on ths request and my answer fo every question, B. (1) The interpreter named in Part 9, read to me eve an and instrution on this request and my atiswer to every question In «language in which fam fluent, and 1 understood overt: 2. Fanily Members Statement Regarding the Prepare for CZ Atmy roques the preparer named in Part 10, repaved tis request for me based only upon inforavalon prOvIa6d oF aun 3. Family Member's Daytime Telephone Number 4. Family Members Mobile Telephone Number (If any) ‘5. Family Members Small Address (iPany) Copies of any documents I have submited are exact photocopies of unaltered, origin documents and | undersand that USCIS may ‘quire that {submit original documents to USCIS at a later date, Purtheemore, Lsuthorie the release of any information from any Of my records that USCIS may need to determine my eligibility forthe immigration benefit 1 seek. 1 further authorize elease of information contained inthis request, in supporting documents, and in my USCIS records to other entities and persons wiere nesessary forthe administration end enforcement of U-S, immigration las, 1 certify under penalty of perjury, that | provided or authorized all ofthe Information in my request, {understand ll ofthe information Contained’ and submited with, my request, and that al of tis infomation is complet, ia, and corec. Family Member's Signature 1 of Signature tumiddlyyyy) NOTE TO ALL FAMILY MEMBERS: If you do not completely fill out this request ofall to submit required documents lsted in the structions, USCIS may deny your request, Fomisi2 ovianie Page Toft 1. Didany person fing this request use an interpreter? G Yes, (complete this section) [X] No (kip to Part 10;) 2. Wasthe same interpreter used for al individual eguesting a fee waiver (a lited in Pat 3.7 Oye 2 wo [NOTE for Family Members: Ifyou used a cffern interpreter than the one used by tho requester, make additonal copies of Part 9, providethe following information, indicate the family member for whom he or she interpreted, and include the pages with your completed Form 1-912, Provide the following information bout the interpreter for 3. Intarpretrs aml Name (Last Name) Interprters Given Name (Pirst Name) 4. Interpreters Business or Ongpnzation Name (Fan) 5. Steet Number and Name Apt. Ste. Fle, Number ooa Cy or Town Sute__ ZIP Code Province Postal Code. ey 6. Interpreters Deytine Telephone Numbor 7, Interpreters Mobile Telephone Numba (Pani) 8, Imerprte's Bal Address (fang) 1 certify, under penalty of perjury, th 1am fluent In English and |, whichis the same language specified in Part 7, Item B. in tem Number 1, aad have ead to Ws requcsior Th the WEnTMed Tanguge every question and instsction on ‘his request and his or her answer to every question. The fequestor informed me that he oF she understands every instruction, question, ‘and answer onthe request, including the Applicant's Certification, and has verified the accuracy of every answer. 's Signature Date of Signature (mmyyyy) Fomrste oanane Page oft 1 2, ‘Dic any person prepare this request on your behalf? NOTE for Family Members: Ifyou used a different ‘Was the same preperer used forall individuals requesting a fee walver (es listed in Part 3.)2 TH Ye (empl tissecon) C) No kp @ Yes ) No reparer than the one used by the requestor, provide the following information, ‘and include the pages with your completed Form 1-912. Provie the following intrmaionshou he pcp + i eres Pr 3 family Name (Last Name) Preparers Given Name (First Name) 4: Prepaie’s Business or Organization Name (if any) [Pars Equality Center San Jose Ne Street Number nd Name Apt Ste. Plt. Nurber 1635 The Alameda 00 we iy or Town State Z1P Code [San ose [ca] size ravines Postal Code ted States a Preparers Daytime Telephone Number 7. Preparers Mobile Telephone Number (agp) [tos 261 640s 8. Prepaters Ball Address ee 6 9. As [1 Lam not en aorey or credited representative but have prepared tls request on behalf of he equestor and with the requestor consent, B.D Laman atomey or acoredited representative nd my represenlaton ofthe requestor in this case Clestends &) does notextend beyond the preparation ofthis request. NOTE: Ifyou are an attomey or accredited represenative, you may be obliged to sub completed Form 0-28, Notice of Entry of Appearance es Attorney ot Accredited Representative, oF G-281, Notice of Enty of Appearance as Atiomé CConfines of the United States, with tis request, Fomi-9i2 ong ey In Maters Ousidethe Geographical Page DFT By my sinatre,| certify under penlly of petjry, tht | propaed thls request a the request ofthe requestor. The requestor then reviewed this completed request and informed me tet he or she understands al ofthe iortion contained in and submited his or her cequest, including the Applinnt's Certieston, and that al ofthis information is complete true, and correst.Teompeled this request based only on information thatthe requestor provided to me o authorized me o obtsin or we, 10. Dat of Signature (mm ES 9 3)0% 4 Bel 8 we For 1912 owiarie Poge (0fT1 yout name and A-Number (if any) atthe top of each sheet; ‘Your answer refers, {fyouneed ext space to provide any additional informetion within this request, Use he space below. Ifyou need more apace than what s provided, you may make copies of tis page to complete and file with this equest or atch e separate sheet of pape, Include indicate the Page Number, Part Number, and Item Number to which 1 iu a 3 i” Given Name (Pitt Name) Middle Name 2 A, Page Nugbet pm. opan Nitec. em Number 4a ia Number Parktumber__C, tom Number D. S.A, Page Number B, Part Number __C._Nesn Number D. 6 A, Page Number __B, Part Numbor__ Chem Number D. Form i912 ogame Page Hof (1040 s"istvidial income Tax Retuin |2OAB|oyoreruiione| vawson na gn Sagas Se] Mert wy CL mares gee] Hater Cou Year aire ott aires Tera ey ae Tee oT sr rade] Soman co an ara eel [Tor wb ny Wed] Yorn “ Tren ri lin vate Seid aa a RT pi aes ena Samar ct Ca yo Tae ts Cpe ALT Spot va Dm oa eV TaST— Bj Fr pom acon D)spevsn bind 2 spose noms on’ prt retro yl wore dusts lan ‘ec ovaral ee int) Feeds iia gy te ig Ta | Pell eaten oon i = . [fot "Ch veu Conine i ioe San ete dE Se Fyne le nas TBST Tare an depart nonnene eE pants ae a @ Seca | aaa 18 esa a (eon tatsee cuesrendteadctrohe mbes = —a : or | = Sign creepa Stseatonc ope Ste Sus ungayg baie avaton teas coe ta moe em oT Here ‘Your eigratuee Oe Your ceaupation {Uma sent you an Idenity Protection Sele oz/issa9 eer Roneaptt PSpancexpaaie Walon bam rawr | Bxle— SnoT RTOT Tess en ern Eee Paid ar ae Tapaaro pate Tar Trinisen | Gok Preparer = hese pode Use Only Atstane + EARS EQUALITY CONTR Piensnn 108261 =BA00| C) esters vaty Ket, and Papervort Redon Act Nee, Fo 10409019 Fexphecion GAR’ Foor wang t Page 1 Wages aes no AtacnFEoM@WE Ta anne 24 Tenorat te c 2 eset 5 (ei Momen 38 uals idence ae Ordnaryaldanse ‘2% TERTESSS 40 ittsprsonentomite ae 2 Taxes ® sitet seal smny ete se teatieamoun Altach to Form 1040 oF Form 1040NR, 2” G0 to wnwits.gov/Formess0 tor the latest informatio, oma No. 645-074 2018 seo es Ya Rol wou mbar 1) Tatitional and Roth IRA contributions, and ABLE accoint gontibullons by the designated beneficiary for 2018, Bo not Include’ rollover contributions... ets 2 Elective detotrals to a 401(W or other qualfiod ama! employee contibutions, {00 inatucions) 3 Addines tand2 . 4 Certain clotributlons receWved after 2018 and bofora the due date =) of your 2018 tax return [see Instructions). if ‘marod fling [oity, elude both spouses! amounts In both columns, (nciuding extension Seeinsiructions for anexcepticn sss pla, vlutay he SGHaKS) pan contours for 2018 You cannot taka tis reel althar of tre ToloWhg apples + The amount on Form 1049, ba 7 Fer ‘marieg a lony, +The parson) who mace th ‘Sependent on someane else's i) vour spouse tt TO40NR, line 36 Is more than $31,500 ($47,250 I head of household; $69,000 .QUallied contribution or lective deter fa) Was bor ater January 1, 2004; (bs claimed as 0 2078 tax return; or (o) was @ student see Instuctons). 5 Subtract line 4 from line 3, I zero 0 lose, entor-0- ‘ @ Ineach cokumn, enter the smaller of ne § or $2,000 | | 7 Add the amounts on ine 6, if 2aY0, stops you can't take this credit 8 Enter the amount from Form 1049, lin 7* or Form JOACNR, line 38 | 8 Entor the applicable decimal amount shown below. Tine ae: ‘Apayour flag stats Maried Head of ‘Siege, Marr ling over flingetngy ouseralé pacatiy, of Enter on tne = ‘aualivng widowle) oF cr os $19,000 08: 0s 02 $20,500 os 0s oa $28,800 | $30,750 0s 02 oa, $20,760 | $31,800 0s: a4 of 881,500 | $39,000, os ay 0.0 $28,000 | $43,000 02 a1 00 sa1io00 | $47,250 oa on 0.0 47280 | $69,000 on 00 00 $63,000, _ 00 i) 09 41 Umbation based on tex abilty, & Instructions. 12 Creait or qualified retirement aavin land on Schedule 3 (Form 1040), * S00 Pubs 590-4 forthe amount For Paperwork Reduction Aot Notte, aN Note: Fine 8 1s zoro, atop; you cant take ths red 40. Multiply tne 7 by tine 8 ‘tori you ola any exluslen or deduct Puerto Flo o for bona fs resisonts of Asican Samoe Your fax rolurn inevrdetions, F the amount from the Crecit Limit Worksheet in'the ontributions, Enterthe smaller of line 10 or ine 11 here line 5; or Form TO40NR, tne 48, - 7 en or foreign 10 it 1381 2 10 ye income, forelgn housing of Income from Fam BBBO RG SCHEDULE A Itemized Deductions ‘vane saeco (orm 1040) > Go to worn. gov/Schedule forinstuctons and the lta intermation. [20148 case say Altec a Form for, ere ene] Coton: Ny ae clint. uated case asen Fo 488s the inturton ori 18, | SMEAR, op Fan eewt a Form 00 : [Fourie ac rer marr | Tneaiear ‘GatonsDo al nade expo aes ralnburaod GPA by OO and 1. Medical and dental exnenses (S00 Instructions) Dental 2 Enter amount from Ferm 1040, tne 7 [2 Expenses 9 ‘Muliplyiine 2by 7.5% (0.075)... 4 Subtract line 3 from line 1, fin $i nore than ine enter =. Taxes You 6 Statoand local texes. i ‘State and local Income taxes or general sales taxes, You may Include elther income taxes or general sales taxes on ine 6a, ‘but not both, If you elect to Include general sales taxes instead ‘of income taxes, chack ths box - > O [se 256 bb State and local roa! eatato taxas (800 instructions) - {State and local personal property taxes I) Be Add lines 6a through 6¢ . aj Entr the smaler of line Seer $10,000 (5,000 I mariad fing ‘soparataly) oe 256 © Other taxes, List type and amount . 7 Kediines Se and6 __ 17 256 interest You 8 Home mortgage terest and pont. Ifyou dn’ use al of your Pala home mavtgage fans) o buy, Bld, o improve your home, can tay, seolstutiors and chock tl box ved BEBREN™ atame mengage ret en pon topo Yo you on Fam ‘008 : es b Home mongage Interest not rapt to yeu on Form 1088. bald to the ptaon fom whem You bought the hem, #08 fratuctore anc show hat peor hare ntyig na an sarees > oe few Bi lvoe yuan Pao G68" Sa wants ar facies fe aPesered fea Addlines Sathvougn8o | | a @ Inasnere es. tac Form 052 raze, Sen Instustors 3 10 Aad thos Bemis Sie Ne TH ey cash or ene Hauge ay GH of SD or am feolestuctons i 12 Other han by cash oF chock. any git of $260 or mor, 80 Inatuctins. You must sta For 8209 fever $00 2 18 Caryowrtomproyerr se ne ss ss 34 Adéinos 1 hrug'S rn Grau and 16 Casuay and tht lssas) om a fedora decared dlastr (lhe than vet qalied That Losses" alsastorassee) tach Form 4684 snd entr fo amount fom ine 78 af that frm, See Inststion ae dd her Te Otome ninotians: Unt po and amount Homizog es Dductions Total 17 Aah anourte nthe far ight cour foros 4 rough 16 Ae, wvlar Wis amaurt on Itemized Form 1040, line 8 256 Deduotions 10 if you vic o emize deductons even though thay ae ios than your standard deduction, chook here or Paperwork Reduation Act Notle,s08 the inetrctions Tor Form 1000. ‘Sehaaula 8 Farm 10602018 QnA ster ousomy scr naun sence Boerimmecn eonnsien IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM NOTICE TO APPLICANT OF HEALTH CARE CERTIFICATION REQUIREMENT SREB (Wotare and Institutions Code section 12309.) requires that each person applying for IHSS Res ie @ health care certification from a licensed health care professional (auciamaeor they can get , physician assistant, physical therapist, psychiatrist, jpervisor, occupational therap! psychologist, optometrist, ophthalmologist, public hecith nurse, ete The certification must state that you are not able to-do some activities of dally living your own and that without help to do these activities you would be at risk of placement in out care. Basic ADLs are: eating, bathing, dressing, using the toilet, walking, and getting out-of bed or a chair, Other ADLs ate: housekeeping, preparing meals, shopping for food or other necessities, taking medication, etc. Attached is-@ blank copy of the Health Care Certification Form SERRE you can give to your LHCP to complete. if you want, the county can send itto the LHCP for you Buh you will have to give the county the LHGP’s name_and address. The county may accept alternative documentation in place of the SOC'873 as long as it meets all of the following requirements: 1. Indicates that you are not able'to do one or more ADLs on your own and without services you are at risk of placement in out-of-home care, 2. Describes the medical or other condition that makes you unable to do ADLs on your own and causes you to need IHSS, and 3. Has been signed by a LHCP within the last 60 days, Whether. you sends it for you, you are responsible for gffrom the date the Under certain limited circumstances, such as when services are requested because you are boing discharged from a hospital or nursing {golly and you need services to ratutn safely to your home, or the county determines that you are at risk placement in out-of-home care, the county may grant an exception that would allow you to get IHSS.on a temporary basis before the county receivas the fompleted SOC 873 or alternative documentation. However, even If an exception is granted, you will stil be required to provide one of these documents for the county within the 45-day timeframe to determine ttyeu can continue atin IMSS. If you have been granted an exception but you are not able to get the SOG 878 from your LHCP within 45 days, call yer aocla) worker before the due date to tell him/her why you are not able to meet the due date and ask if the county can grant you more time. |f you have questions about the health care certification requirement, ask the social worker who has béen assigned to your case. cee Las Vontanae LOW INCOME HOUSING TAX CREDIT LEASE RIDER (to be attached to resident lease) Property Name: nite Household Name: esr Resident or Applcant: The owner(s) of this properly rents residential units under the federal Low-income Housing Tax Credit Program (the *program*) adminletered by the California Tex Credit Allocation Committee (TCAG). Under the program, the ovner hes agreed to rent some of all of the units in the property to low-income households and restrict the rems for those unite, Another protection provided by federal law is that Low Income Tenants may not be evicted without good cause. The folowing Lease Rida le an Important pat of ensuring your rights to good cause for eviction. ‘The Lease or Rental Agreement dated April 3, 2048s horaby amended by adding the folowing grovislon: Lease Rider: Good Cause for Eviction ‘Owner may not terminate the tenancy the Lease or rental agreement ofa Low income Tenant excep for good caus, Including 8 gerious ar repeated vclatin of he material tarmis and conatons ofthe Lease, or @ olatlon-ofappleahie Federal, State, or local law. To terminate tha tenancy the Leese, Owner must provide writen notce to tha tenant ofthe grounds with sulitent specify to enable the tenant to prepare a defense. The notlca must te served et leest three days before the termination of tenancy, and must comoly with all requirements of Califoria law and other applicable programs. Tenant has the right to enforce tis requirement In state court, including prasenting a dafense to ny evielion action brought by Owner To tha extent that any terms contained Inthe Lege or rental agreament, or any other agreementbetween the owner and the tenant, contradic the terms ofthis Rider, the provislons of this Rider shall corte, “ a By signing below, | Indleate my ednsent to this Lea = \ \S ‘ Fropery Repreveriatve Name (oat ‘amet owe By algning below, | ndleato my content to this Lease Rider, Ie have been given a Gopy ofthis Lease Ridr, Las Ventanas LEASE AGREEMENT (LIHTC:Projects) ‘This Residential Lease Agreement (hereinafter "Agreement" or “Lease") Is entered into between, ‘reinator Lenora’ atthe fatima i "ny and severaly (hereinafter collectively "Residents): ', Together Residents) and Landlord are referred to hereln as the *Partiog" ELECTRONIC SIGNATURES: Both partes agroo:tha, to the exent permite by epplcable Program regulations, they may enter Io tis lease tanenaton by electronic means, ethough vactonel hard coples wih wet slgnaturos may oo used nated atthe option of Landlore, Resides) agrebs and acknowledges that Reser) ie entering Ino ths fase transaction wth Lanclord by electronic means, doing 80 Is not condtioned on Resider(a)’ agreement to condvc! te leasing transaction electronical LEASED PREMISES: Landlord rents to Resident(e) the premises located at Apartment & Santa Clara Caunty, CA (noreinater "the Prefnises’, whlch Is located wihla the’ Apartment Communlty, commonly known 28 (hereinafter the "Apartment Communty® of “Property of "Project for use as a resklenee and for no other purpose, PROGRAM: | The Premises may be operated in accordance wit one or more affordable housing programs Includhg, but ot limited t, the Housing Choice Program andor the State andlor Federal Low Income Housing Tex Crest ITC) Program Che Program’. The Premises and ths Lease are subject to the lawa and regulations governing the Program Including, but net limited to Section 42 of the Faderal Internal Revenus Coda, Section 60792.4 et seq, of the Callfomla Health end Safely Coda, Sections 12208, 17068 and 23810.5 of the California Revenue and Taxation Code, and related Fegulations 8 promulgated by the Tex Crectt allocation Committee (‘TCAG") 28 wall as the lawe end regulations governing ary other subsidy applesbie tothe Property, If Reldent nas a Housing Cnolce voucner, tren the HUD Tenancy ‘Adgenduit | Incorporated by reference Into this Lease. Reskdent(s) understand and agree that ‘hls Loses, may be ‘amended at any tne upon thy (80) days! noice as necessary to ensure compliance vith al laws, ules and reguittons Governing any subsidy program In effect at the Prem TERM: Original Term. This Lease shall befor @ period of month, commencing cn AnilLS, 2018 ("Commencement Date), {and ending on Octobe 2.2018, unless sooner terminatod as provided in ths Lease or alowed by apolicabie lew, ‘Delay of Possession. Resident(s) understand that, for reasons beyond the control of Landlord, Landlord may not be able fo provide occupancy to Residents) on the commencement date I, for exampla, a former tenant of the Premisos \who has given notice to leave cancels the nctles or fals to leave by the scheduled date. I or any reason, Landlord Ie uled commencement date, Residents)’ remedy inthis event shal bo limited to termination of this Agreement and Residents) shal be ented to a prompt rau af any monies ion other than promptly to refund any ‘monios pal, '& Holding Over, Any holding over by Tenant() at the expiration of the’ Lease term with the consent of Landlord shall {teate a tenancy from month to month on the same terms and conditions set forth in this Lease, subect to amendment by Landlord as set forth in Civil Code section €27 and terminabla by elther perty on thy daye vitton notice In ‘Secardance vith the prouilons of Celforia Civ Code section 1948, ures a longer notice period le required by applicable law, RENT: ‘a Resldent(e) shell pay to Lanciord, as ret forthe Premises, the eum of $1,392.09 each month, 'b. The name telephone umber arid actrees of the person. or entity to whom rent payments shall bo mado le © Except as otherwise provided In ths Lea: ee, sad sum shall be pad in fl n advance, oh or Before the frsiday of each month ithe form of 8 check of money order, In ay month the rents paid efter the fite day Frans arth, payrent must be in the form of eather check or money ordr I Landlord serves Resident) lt fieticey noe to pay rent ot auander pessanslen which Lancord may don any dais afar ho eet dey ot he Tappan payret fendered folowing sore of sald notice must be nha form of a cashiers oheck or money oxioe UA Sk gvon by @ Resaen(} efor any reason whatsoever, returned unpald by te bark upon whieh ie arom, 4, de caldera)’ responsibilty to ba'cartan thet each paymoht le ectially received by Lanclord-on cr betere ts due cE Les ot real oaymont crop box efor Reside corvoniance = Ne tek of ace of unis ty a nea oe ‘sueh boxe used ie Resident) ek, and not Landlord's, sk Te usual daya and novre when tak oie ae oe ‘ is Las Ventanas ‘made personally are Monday to Friday 9:00 a.m, 6:00 p.m, 6, UTILITY ALLOWANCE: | The Rent Kdentfdin the preceding paragraph Includes a deduction forthe uly aowance for the Premises a8 established bythe Program where utes, other than telephone end cable or Satata TV, are peld ‘ect by tne Resident. 7, LATE GHARGE'AND NSF CHARGE: — Landlord an Raaldent(s) agree that when Resident) falls topay rent on time, or when'Resdert() pay rent by a check whith Is subsequent dishonored by the bank, the ectual cost to Landlord is clfcuo+Imponsilo ta ascertain, tut the parties agres that Landlore dees nthe event of late payment Inthe event of 8 dishonored check, Incur certain cose, euch as additional Bockkeeping and administative charges, bark charges, lost pportuily costs ofthe Inte payment, ete. Aer making a reasonable enceavor lo eslimets avctretaly the aporntnate costs aaaodlated vith such a roach, which both parties aroe la ecu or Imposable fo eecertal, the rales agree thet Bry tme the rent fer any glven month is pald after the ith day af auen ment, Resdeni(s) wi Im dat month pay anor ate charge in the en of $80.00 and frthoragros tht Inthe event ofa lshonere check, Rasen) wil pay te Landird, along wih the payment raquited to replace the ishonored check, a NSF foe In the sum of $25.00, The paris. . Its understood thatthe securty depost is appieabe to all Resident) Joint, and Landlord does not eecount for It nil the passing of tho permissible statutory paried ater all Residents hava vacated the Premises. Any rotund due may be made payable jointly to all Resident) and it shall be the respensblliy of all Residents) to work out between {hemeevestho manner of dividing sald securly depos. If Lanclord choceas to make the refund to any of tha Residents) indlvdually (which nea not be done untl the statutory ime has elapsed after al Residents have vaceted ‘he Premises, In lege conterplalon the neynent shall be deemed to have been made to al Residents ane andlord shal have no lity to any one or group of Residents) fr felure of any Residents) equitably to dds sun refund. ©. the securly depost ie later ncroased by agreement of the parties for any reason (auch ae tho inaction of @ sttalito cith, a waterbed or relating to pel), the addilonal sccurly. deposit will be dlaburaed by Landlord in ‘accordance vith thls peragraph atthe end ofthe statutory perod folowing the end of Residents} tenancy, Removal of the et, satelite dish or waterbed, or whetever ceused the Increase in the deposi, will not be grounds for early dlsbursement of the secur depos. 10.MOVE.IN PAYMENT: Rsideni(s) shall pey to Lendiorg, at the time of move-in, the sum of $3,907.00, This:emount le composed ofthe folowing sums: 8 the fst ments rent, $1.382.00 as secutty deposi, Landord mey recule {hat this entre-sum bs pald In the fom. of cashier's cheok or money erder, If Lardierd accepte a personal or etter 1norartied shack and the chet, for ary feasan whatsoever, ceurmed unpald by the bank Upon which Xf dawn, the enlce amount shel immediatly become due and payable and shell be considered rent eo that Landlord may earve a ttrae-day notes t0 pay rent or aut forthe entre amount and, IF Reldent() dose not comply with sald netics Larclord ‘ay utiles uniewulcetalnerprocaduree to evlet Residents) tr the Premises, ‘Y.CHEGK CONVERSION: If Residents) makes any payment by check, It may be converted Infoan elecfene funds Atanater (EFT), This meana Lendord il copy the check and usa the account Information oni {0 eectencly debit : is Lae Vontanas Resident account for tho amount ofthe check. The debt tom Restore) accourt wt usualy occur win 24 hour, rel may coc a8 ea a he sae dey at Land raatos parent. The dab ull shown on casera regular pant sateen Restarts) vl ol receve the eal check tock. Landlord Vl destoy Your ote ae rebate om compliance wih apoicetle laws, I the EFT cannot be orocessed for lecnla! eaters: Redec wey Aushoraet Landlord to procass te copy In place ofthe argnal check. I tho EFT cannot be comploted fone oy Inaifilent funds, Landlord may require payment in certfted funde ae required by tho Rent provision above TA RENT INCREASES: Lanclord wil sdust the rent desabed above as allowed by TCAC RegUaton, Including, but not ered fo micease farm adjustment of rent. We wil provide you wth atleast thity (20) dye writen notice pis tothe Efeative date of any rent Increase, o the minimum amount of notice required by applicable law Any euch Increase grew Se computed n accordance with appicable laws and regulations and shal not exseed the amount allowable by TORS. 18. OCCUPANGY: The Premises shall be occupied only bythe fllowing persone: a {0 occupy the Premises. Should any person not nemed above maka any clalm to right of po any aunt arson shall be deemed to be the questo: Inuteo ofthe named Resiseri(s) and thelr calm to ght of oaraseion shell be denies. Any person named above in thls Paragraph who le not also named above 20.0 Reselaet andlor wno Is not a signatory to thie Lease shall be deemed to be invitees of the named Recife Signatories to tis Lease, Accordingly, if any such Inalidual is not named In any uniawul deta Possession ofthe Premises, and if any such Individual thereafter mi ‘hat clam shail bo denied on the basis that sald inclu I the, ‘an Independent claim to right of possession ofthe Premises. Residents) {wo persons per bedroom plus one addons! peraan occupy the Pre {hat the number of acoupants exceeds this occupancy standard, Residents) agrees thet such over-ullzation erat ‘r0unds for Lendlora to terminate this Agreemant,eolly at Lanclord's option ‘4 GHANGE IN OCCUPANTS: Retident(s} understands and. agrees: that adonel oocipehs wil be alowed endiar asllowed In ecosrdance vith income guidelines par tne Program reguatons, Landlord eccupancy. savers nod Spplcable laws, Before ary change in oocupancy occurs, Resldari(s) must recalve writen permission fem the Larges Descent) understand ta! no event shall mere tian io persons per beétoom pus ne adaltonl person coup) tae ABPROGRAM ELIGIBILITY: Bated upon the information provided by Rebldeni(a), Landtord has determined thet esica) are lll fo Losse the Promises oubjet fo the raguramenis ofthe Prgram, Incudng, but ot lmted os ‘nplcebie Income requirements, age requirements (only it and as epploable to the Property), end tlkame’stedect Srentons, It applcabe: If at any time Resideri(e) are no longer algible under the Program, the ineligibility a's nalera! Pree ths leas and wil be goed caus for arming the Lease, Rslioi(] must vcate the Premisgs str recelvng Notice from the Lanird of thelr naligity, % ‘Natteaton Resuemenis: Reedon(s) shal noty Landlord immediately In wilt any of he ftoing avert occu, ‘even though () and (I) may make Resident) ineligible fer tenancy 1). There re any changes in Reskdent(s)’ household size, 1), Any adut resident becomes a fulime student, or 1M Resierls) begin fo recsive HUD assstance (Landlord wl not refuse to rant to someone slay betause. they Teoelve HUD assistance, however, tne nfermation is required for rent aleatons an income oan, Falize anally Lendord ot te cccurence of any of hese evens Isa mate reach ofthe Lead and may result in {Refeminaton of tre tenancy even ithe occurrence of heaven would not have made Realdent)ineige srees res Program, b 'h Residents) undertond,eckriowledge end agree for eny reason Resideri() ate ot become Insite forthe Frearam, or cterwise equally the Promises orth Propary under the Pogram, Landon mat worieee esee upon ety (80) day’ ratios, of a8 much notes as required by appleabe law. The uly tovacelo cases ‘matter when or how Landlord learns of tha ined, ‘ fie Las Vontanae 0. Resident(e) must vacate the Premises Ifthe orginal teriaiy 1s granted based upon incorrect information oe Inacourate calculations of Income during the original cartieaton process, whether such errors ara based Upon the mistake, inadvertence or neglect of Lancloré, Resicet() or anyone proving information on Resident) behalt The duty 19 vacate exists no matter when or how Lanidordlaame of ine incorrect ktermation, 16, MISSTATEMENTS ON APPLICATION OR CERTIFICATION FORMS: Resldeni(s)/have completed an application and income ceification and household composition forms in éonnecton with securing tris Leas, Landlord hs relied upon the Statements set forth In thase-doounents-n deciing torent the Premios to Resieri(a) and in determining Residon(o) slighty forthe Program. 1 le agreed that should Lanclord subeequonty dlacover any misatémonts of fact In the Resigeri(s) appleaion or on any cartfction forms, any auch misstatements shal be deemed a material and Incurable breach ofthis Lease and shal enttla Lanclord to sorve Rasider(s) witha three-dey nti terminating the tenancy ‘T-ANNUAL RECERTIFICATION: Your elgbilty for housing under ihe Program rust be ceed each year, Residents) ‘agree to fully cboperete In the reeertifeation process Including tmaly providing all necessary information rogarding household income, heusehold composition and ful-time student statue aa well es slgning necessary verifeations, ‘authorizations and all otnor fers relating to the recetiicetion process. Further, Resident(s) understand tne Project may bbe operated by & tax-exempt entty and the Landord may need sttitioel Income Information for tax-exemation or other purposes. Failure to provide accurate and timely Information requires for eatifeaion will constitute a materlal breach of this eate, Resident(s) also understend Information provided by Residents) fo Landlord is subject to inspection by TCA. ‘and Residents) hereby euthorize the release cf all information supplied by Residents) t0 Landlord to representatives of ToAC, ‘18. EXPIRATION OF LOW INCOME PERIOD: At the explation of the Low Income Period, Lanclore may change ‘Resdants) the maximum rent allowed under state and loca law upon the explrtion of the lease In offect at that ime enc ‘all subsequent lease renewale, For the purpose ofthis paragreph, the Low Inaome Period begins on the fst day of te {et taxable year of the crest period for the Project and ends atthe conclon of the compliance period designated by the Program. 19, UTILITIES: Payment of al utes charges shall be the responsiblity of Resldent(s), wlth the exception of Water, Hot a8, which shall be paid by Landlord. With respect to the utllies charges listed above to be ald by Landlord, Residents) shall not make excessive or unreasonable use of such utils. I Residents) do make ‘9x0888V6 oF unreasonable use of such uti, Lanciord may bl Resident() for such excessive or unreasonable use and ‘sald bllng ehell bacome dus anc! payable, In ful, togother with the regular monthly ental payment on the ist day of tne ‘month next following the'date of such bling, in the event of a dispute es to any such charges, Reslderi(s) shall pay the ‘lsputed amount ae required, but may fle @ Small Claims Court action fer & refund and, f such Court determines thatthe ‘amount charged by Landlord is excessive, Lendord shall promptly refund any euch overcharge. 1 Residect(a) fall to pay ‘any uti charges that aro to be pald by Realdents), Landlord may, ati option, pay such eharges to retain continuing tities service. If Landlord does 20, any euch charges may bo biled to Residents) by Landlord end seld billng shall ‘become dio and payable in ful, together with the regular monthly rental payment on the fst day of the month naxt fallowing the date of such bing, 20, APPLIANCES: Landlord will provide Dryer. Appliances should only be ullized for thelr Intended purposes and no other. Mieusing appliances can cause ‘damage to them, whlch wil be the responsibly of Resldents, You will be alled for any damages caused by you misusing appliances, 21.RECYCLING: Lenclord shall arange for recyding services conelstent with applicable lav. Resident(s) agrees to ‘cooperate in all recycling efforts anc comply with applicable laws and Rules regarding recycina. 22, JOINT AND SEVERAL LIABILITY AND AUTHORITY: All persons signing this Agreement as Resident(s) shall ramaln Joltly and severally table for all ablations arising under i, whether or not they remain in actual possession of the Premises. The glving by any inaividual Resident of @ notca of termination of tenancy shall not terminate the Loace as to that Resident unless al Resicents vacate the Ptemiees by the agraod date, Lanalord may, however, treat ery euch notice ‘as a nallce binding against a Resldent(s) of tha Promises, and may Insttute unlawful detainer proseedings against all Resident) if they do not restore possession of the Premises to Landlord on or before tha end of the notice period, Conversely, Landlord may, at Its solo onton, if ona of more Resident(s) lve notice but al Residents do not roturn Possession of te Promiees to Landlord within the nofie period, continua the tenancy In effect and, if Landlord does so, all Resident(), including tha Resldert(s) giving notice, shal remain full llable for all obigatons arsing hereunder whether of not they remain in occupancy ofthe Premises, 23. NOTIGES: Any nctce that Landlord gWes to Resident(s) shall be deemed properly served (whether or ot tually Tecalved by Residents) if sarved inthe manner prescribed In Code of Civ Procedure Section 1162. Except as prohlblted ‘by law If Lanctord falls to serve the notes in acoordance with tho provisions of Cade of Civil Procedure saclion 1182, but Residnt(e) actually ecelve the notice, the actual recelpt shall be deemed to cure any defectsin the mariner of saree and ‘ fils Las Ventana the notice shall be deemed properly and personally served, Service upon any ofthe Residents) ofthe Premises shal be ‘deemed velld service upon sll Residents) - Is not necessary ndvidualy to serve each Resident uniese etharvice required by law. 24, DISCLOSURE REGARDING OWNERIMANAGEMENT: Pursuant to Ol Cade Section 1862(e)() the current or-lto property manager so long @8 ha or the Is employed by Is authorized to manage the Premises, The telephone rumber and steal ecdress at which porsonel sevice may be elfected on the poraon le ‘The person designated above, so lang as he/she Ia employed at tha property, Is also the person authorized by the Ovmer ofthe Premises to act for and on behalf of the Over for the purpose of service of process end for the purpose of receiving and glving receipts tor all notices and demands, 25. AGCESS TO PREMISES: ‘The parlles agree that uoon advance reasonable wien notice to Resldent(s), unlose ‘thenvise agreed to by Resident(s), Landlord shall have the right to enter the Premises during normal Business hours tor {he purpose of (a) making desired, necessary or agreed repars, decorations, alterations, improvements, or renovallans 10 {the Premless; to an acjacent unit or fore benef of the Bulg in which the Premises ls located; () supplying necessery oF agreed services (c) showing the unit t prospective or actual purchasere, mortgagees, tenants, workrnen or contactors, or (d) for any othat purposes permitted by Callfomia Civil Code §1064 (and any other applicable statutes or amendments, ‘nich might be enacisd subsequant tothe execution of this Lease). The parts hereby agree thet wentyfour f24) hours! etic Is presumed ressonable, although botn acknowisdge thet a chorter time period may elso be reasonable under the

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