2019 Zero or Very Low-Income Worksheet - The Arc of North ...€¦ · QUESTIONNAIRE FOR...
Transcript of 2019 Zero or Very Low-Income Worksheet - The Arc of North ...€¦ · QUESTIONNAIRE FOR...
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 1 of 8 Revised 5/29/18
2019 Zero or Very Low-Income Worksheet
Applicant/Resident Name
Head-of-Household Name (if different)
Current Address
Address Line 2
City, State, Zip
Home Phone
Cell Phone
Email address
Work Phone
May we contact you at work? Yes No
During your eligibility/certification interview, you indicated that your household has no income or very sporadic income. It is this company’s policy to ensure that you can pay your rent in accordance with the lease, that you can maintain the unit in accordance with the lease and that you are fully disclosing all income as required so that you are provided the correct housing assistance amount. In order to receive assistance, you are required to supply the following information every 90 days so that we can ensure that no income is overlooked. All responses are subject to verification. Incomplete forms will not be processed which means that assistance and/or tenancy may be denied or terminated as appropriate.
Have you been employed in the last 12 months?
Yes No If yes, please provide the following employer information Name:______________________________
Address: ____________________________
Address: ____________________________
Phone Number: _______________________
Income earned in the last 12 months:$_________________________
Do you expect to be employed at all in the next 12 months?
Yes No If yes, please provide the following employer information
Name:______________________________
Address: ____________________________
Address: ____________________________
Phone Number: _______________________
Income expected to be earned in the next 12 months: $____________________________
How do you plan to pay rent for the next 12 months?
_______________________________________________________
_______________________________________________________
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 2 of 8 Revised 5/29/18
Do you ever perform odd jobs such as construction jobs, field work, babysitting, seamstress work, preparation of meals, etc.?
Yes No Income expected to be earned in the next 12 months: $____________
Do you have money deposited in any bank?
Yes No
Do you have any outstanding loans?
Yes No If so, how do you pay the monthly balance? ________________ __________________________________________________________
Do you have any outstanding medical expenses?
Yes No If so, how do you pay the monthly balance? ___________ __________________________________________________________
Do you have recurring monthly or quarterly medical expenses such as prescriptions, routine medical care, etc.?
Yes No If so, how do you pay the monthly balance? _____________________________ _________________________________________________________________
Do you have credit cards?
Yes No If so, how do you pay the monthly balance? _____________________________ ________________________________________________________________
Does any person provide you with money, on a regular basis, to pay for rent, meals, child care, utilities, automobiles or any other regular expense?
Yes No If so, what kind of help? __________________________________ How often? __________________________________ Total financial assistance to be provided in next 12 months: $_______________
It is required that you maintain all required utilities when occupying the unit. In the past months when you say you have had minimal, or no money, how did you, or do you, pay for the following: (Please note that the owner/agent may ask for verification of these expenses while you live in the unit)
Rent? _______________________________________________________ Electricity? ___________________________________________________ How much was your electricity bill last month? $_____________________ Gas? ___________________________________________________ How much was your gas bill last month? $_____________________
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 3 of 8 Revised 5/29/18
If you have a car, the registration and insurance must be maintained. Do you have a car?
Yes No What is the monthly care payment? $_______________________________
How do you pay the car payment?______________________________
How much was your automobile registration last year?$_________________
How will you pay for annual registration? ________________________
How much is your annual automobile insurance?$ ________________________
How will you pay for automobile insurance?____________________________
How do you pay for gas and maintenance?______________________________
If you do not own/lease a car, how do you get from place to place?
_______________________________________________________
_______________________________________________________
It is required that you maintain the unit in a decent, safe and sanitary manner. How do you plan to purchase supplies necessary to maintain the unit? (i.e. dishwashing liquid, cleaning supplies, etc.)
_______________________________________________________
_______________________________________________________
_______________________________________________________
How do you purchase food?
_______________________________________________________ _______________________________________________________ _______________________________________________________
Do you have a washer and dryer?
Yes No
If yes, how do you buy laundry supplies.
If no, how do you pay for the laundry expenses? ________________________
Do you have a pet or an assistance animal or pet? (All animals must be current on all shots at all times.)
Yes No
If so, how do you pay for food, veterinary expenses and supplies?
______________________________________________________________
Do you have a cell phone?
Yes No
If so, how do you pay for the phone? __________________________________
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 4 of 8 Revised 5/29/18
Do you have internet service?
Yes No
If so, how do you pay for the internet service? ___________________________
Do you have cable/satellite TV?
Yes No
If so, how do you pay for the cable/satellite service? _____________________
Do you smoke? If so, how many packs per day/week/month?
Yes No ___________________ day week month
If so, how do you pay for the items you smoke? _____________________
How do you buy items such as toilet paper, paper towels, bath soap, laundry soap.?
If you have children who are in diapers, how do you pay for the diapers?
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 5 of 8 Revised 5/29/18
Additional Comments
_______________________________________________________________________________________________________
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_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________.
12 MONTH INCOME REPORT FOR APPLICANTS/RESIDENTS CLAIMING
ZERO OR VERY LOW INCOME
Expense Your average monthly expenses for the last 12 months
Apparel & Services
Food and Expenses
Housekeeping Supplies – the average monthly cost of household goods and cleaning supplies such as paper napkins, toilet paper, paper towels, trash bags, laundry detergent, etc.
Miscellaneous – Average monthly cost of all other living expenses that do not fall within the categories of food, housekeeping, personal care, transportation and utilities.
Personal Care Products and Services – personal grooming products such as soap, deodorant, shampoo, toothbrushes, toothpaste, barber shop visits, etc.
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 6 of 8 Revised 5/29/18
Please provide income information for the past 12 months starting with the current month and working backward.
Month
Source of Income
(i.g. Employer, ADC, DFCS)
Amount of Income (Gross Amount)
Self Emp., Family, Etc.)
If Stopped, Why?
I Did Did Not File A Federal Income Tax Report Last Year. If you did file a federal tax return last year,
please provide the owner/agent with a copy.
In an effort to ensure the right assistance is provided to the right people, The Department of Housing and Urban Development (HUD) has provided property managers with access to a new verification database called the Enterprise Income Verification System (EIV). EIV provides information about project-based and tenant-based HUD assistance recipients. This database is also used to verify certain types of reported income with records maintained in the Social Security Administration databases and the Department of Health and Human Service (HHS) National Database of New Hires. HHS provides information about current and past employment and unemployment insurance information. At your move-in or at your annual certification, all adult household members give consent to the release of this information by signing HUD Forms 9887 and 9887A. If HUD indicates that there is a discrepancy discovered by the EIV database, we will contact you so that we continue to ensure that you are receiving assistance for which you are eligible. If it is discovered that any member of the household failed to disclose income as required, it will be considered a material lease violation. The household will be required to return any assistance paid in error and additional penalties may apply including eviction and pursuit of fraud.
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 7 of 8 Revised 5/29/18
You should have already received a pamphlet entitled EIV and You. Please review the information provided in the pamphlet so that you understand how the EIV system works.
PENALTIES FOR MISUSING THIS VERIFICATION FORM 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 willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and 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 number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
By my signature I certify that the information I have provided above is true and complete. I understand that if I furnish false or incomplete information I can be fined up to $10,000 or imprisoned up to five years, and/or lose the subsidy HUD pays and/or have my rent increased. Any assistance paid in error must be returned to HUD. ________________________________________ _______________________________ Signature of Applicant/Resident Date cc: Applicant/Resident File
Enter the Project Name
Address
City, State Zip
QUESTIONNAIRE FOR APPLICANTS/RESIDENTS WHO CLAIM ZERO or SPORADIC INCOME
Page 8 of 8 Revised 5/29/18
See attached 2019 NC Allowable Living Expense Housing Standards.
This worksheet shows how much income a person must have to be able to live. This does not include food stamps or WIC. Since these are not counted as income.
2019 Allowable Living Expenses Housing Standards
County
State Name
2019
Published
Housing and
Utilities for a
Family of 1
2019
Published
Housing and
Utilities for a
Family of 2
2019
Published
Housing and
Utilities for a
Family of 3
2019
Published
Housing and
Utilities for a
Family of 4
2019
Published
Housing and
Utilities for a
Family of 5
Alamance County North Carolina 1,231 1,445 1,523 1,698 1,726
SB/SE - Research - Team #1 Page 61 of 104 March 25, 2019
2019 Allowable Living Expenses Housing Standards
County
State Name
2019
Published
Housing and
Utilities for a
Family of 1
2019
Published
Housing and
Utilities for a
Family of 2
2019
Published
Housing and
Utilities for a
Family of 3
2019
Published
Housing and
Utilities for a
Family of 4
2019
Published
Housing and
Utilities for a
Family of 5
Alexander County North Carolina 1,090 1,280 1,349 1,504 1,528
Alleghany County North Carolina 1,107 1,300 1,370 1,528 1,552
Anson County North Carolina 1,067 1,254 1,321 1,473 1,497
Ashe County North Carolina 1,156 1,358 1,431 1,596 1,621
Avery County North Carolina 1,119 1,314 1,385 1,544 1,569
Beaufort County North Carolina 1,282 1,506 1,587 1,770 1,798
Bertie County North Carolina 1,135 1,333 1,405 1,567 1,592
Bladen County North Carolina 1,108 1,301 1,371 1,529 1,553
Brunswick County North Carolina 1,382 1,624 1,711 1,908 1,939
Buncombe County North Carolina 1,343 1,577 1,662 1,853 1,883
Burke County North Carolina 1,101 1,293 1,363 1,520 1,544
Cabarrus County North Carolina 1,399 1,644 1,732 1,931 1,962
Caldwell County North Carolina 1,052 1,236 1,302 1,452 1,475
Camden County North Carolina 1,689 1,983 2,090 2,330 2,368
Carteret County North Carolina 1,408 1,653 1,742 1,942 1,974
Caswell County North Carolina 1,121 1,316 1,387 1,547 1,571
Catawba County North Carolina 1,153 1,354 1,427 1,591 1,617
Chatham County North Carolina 1,534 1,802 1,899 2,117 2,152
Cherokee County North Carolina 1,061 1,246 1,313 1,464 1,488
Chowan County North Carolina 1,256 1,476 1,555 1,734 1,762
Clay County North Carolina 1,167 1,370 1,444 1,610 1,636
Cleveland County North Carolina 1,100 1,292 1,361 1,518 1,542
Columbus County North Carolina 1,125 1,321 1,392 1,552 1,577
Craven County North Carolina 1,319 1,549 1,632 1,820 1,849
Cumberland County North Carolina 1,265 1,485 1,565 1,745 1,773
Currituck County North Carolina 1,577 1,852 1,952 2,176 2,212
Dare County North Carolina 1,681 1,974 2,080 2,319 2,357
Davidson County North Carolina 1,164 1,367 1,440 1,606 1,632
Davie County North Carolina 1,242 1,459 1,537 1,714 1,741
Duplin County North Carolina 1,166 1,369 1,443 1,609 1,635
Durham County North Carolina 1,446 1,699 1,790 1,996 2,028
SB/SE - Research - Team #1 Page 62 of 104 March 25, 2019
2019 Allowable Living Expenses Housing Standards
County
State Name
2019
Published
Housing and
Utilities for a
Family of 1
2019
Published
Housing and
Utilities for a
Family of 2
2019
Published
Housing and
Utilities for a
Family of 3
2019
Published
Housing and
Utilities for a
Family of 4
2019
Published
Housing and
Utilities for a
Family of 5
Edgecombe County North Carolina 1,119 1,314 1,385 1,544 1,569
Forsyth County North Carolina 1,253 1,472 1,551 1,729 1,757
Franklin County North Carolina 1,244 1,461 1,540 1,717 1,745
Gaston County North Carolina 1,223 1,436 1,513 1,687 1,714
Gates County North Carolina 1,353 1,589 1,674 1,867 1,897
Graham County North Carolina 972 1,142 1,203 1,341 1,363
Granville County North Carolina 1,306 1,534 1,616 1,802 1,831
Greene County North Carolina 1,142 1,341 1,413 1,575 1,601
Guilford County North Carolina 1,311 1,539 1,622 1,809 1,838
Halifax County North Carolina 1,131 1,329 1,400 1,561 1,586
Harnett County North Carolina 1,269 1,490 1,570 1,751 1,779
Haywood County North Carolina 1,235 1,450 1,528 1,704 1,731
Henderson County North Carolina 1,281 1,504 1,585 1,767 1,796
Hertford County North Carolina 1,084 1,274 1,342 1,496 1,520
Hoke County North Carolina 1,212 1,424 1,500 1,673 1,700
Hyde County North Carolina 1,150 1,350 1,423 1,587 1,612
Iredell County North Carolina 1,333 1,566 1,650 1,840 1,869
Jackson County North Carolina 1,231 1,446 1,524 1,699 1,727
Johnston County North Carolina 1,293 1,518 1,600 1,784 1,813
Jones County North Carolina 1,154 1,355 1,428 1,592 1,618
Lee County North Carolina 1,214 1,426 1,503 1,676 1,703
Lenoir County North Carolina 1,179 1,385 1,459 1,627 1,653
Lincoln County North Carolina 1,255 1,474 1,553 1,732 1,760
McDowell County North Carolina 1,048 1,231 1,297 1,446 1,470
Macon County North Carolina 1,106 1,299 1,369 1,526 1,551
Madison County North Carolina 1,252 1,471 1,550 1,728 1,756
Martin County North Carolina 1,099 1,291 1,360 1,516 1,541
Mecklenburg County North Carolina 1,461 1,716 1,808 2,016 2,048
Mitchell County North Carolina 1,126 1,322 1,393 1,553 1,578
Montgomery County North Carolina 1,118 1,313 1,384 1,543 1,568
Moore County North Carolina 1,387 1,628 1,716 1,913 1,944
SB/SE - Research - Team #1 Page 63 of 104 March 25, 2019
2019 Allowable Living Expenses Housing Standards
County
State Name
2019
Published
Housing and
Utilities for a
Family of 1
2019
Published
Housing and
Utilities for a
Family of 2
2019
Published
Housing and
Utilities for a
Family of 3
2019
Published
Housing and
Utilities for a
Family of 4
2019
Published
Housing and
Utilities for a
Family of 5
Nash County North Carolina 1,248 1,466 1,545 1,723 1,750
New Hanover County North Carolina 1,517 1,782 1,878 2,094 2,128
Northampton County North Carolina 1,097 1,289 1,358 1,514 1,539
Onslow County North Carolina 1,313 1,542 1,625 1,812 1,841
Orange County North Carolina 1,756 2,062 2,173 2,423 2,462
Pamlico County North Carolina 1,237 1,453 1,531 1,707 1,735
Pasquotank County North Carolina 1,386 1,628 1,715 1,912 1,943
Pender County North Carolina 1,364 1,602 1,688 1,882 1,913
Perquimans County North Carolina 1,299 1,526 1,608 1,793 1,822
Person County North Carolina 1,174 1,379 1,453 1,620 1,646
Pitt County North Carolina 1,338 1,572 1,656 1,846 1,876
Polk County North Carolina 1,281 1,504 1,585 1,767 1,796
Randolph County North Carolina 1,126 1,323 1,394 1,554 1,579
Richmond County North Carolina 1,019 1,197 1,261 1,406 1,429
Robeson County North Carolina 1,067 1,254 1,321 1,473 1,497
Rockingham County North Carolina 1,092 1,282 1,351 1,506 1,531
Rowan County North Carolina 1,163 1,366 1,439 1,604 1,630
Rutherford County North Carolina 1,075 1,263 1,331 1,484 1,508
Sampson County North Carolina 1,144 1,344 1,416 1,579 1,604
Scotland County North Carolina 1,096 1,287 1,356 1,512 1,536
Stanly County North Carolina 1,208 1,419 1,495 1,667 1,694
Stokes County North Carolina 1,143 1,343 1,415 1,578 1,603
Surry County North Carolina 1,113 1,308 1,378 1,536 1,561
Swain County North Carolina 1,134 1,331 1,403 1,564 1,590
Transylvania County North Carolina 1,239 1,455 1,533 1,709 1,737
Tyrrell County North Carolina 1,127 1,324 1,395 1,555 1,581
Union County North Carolina 1,506 1,769 1,864 2,078 2,112
Vance County North Carolina 1,134 1,332 1,404 1,565 1,591
Wake County North Carolina 1,576 1,851 1,951 2,175 2,210
Warren County North Carolina 1,147 1,347 1,419 1,582 1,608
Washington County North Carolina 1,151 1,352 1,425 1,589 1,615
SB/SE - Research - Team #1 Page 64 of 104 March 25, 2019
2019 Allowable Living Expenses Housing Standards
County
State Name
2019
Published
Housing and
Utilities for a
Family of 1
2019
Published
Housing and
Utilities for a
Family of 2
2019
Published
Housing and
Utilities for a
Family of 3
2019
Published
Housing and
Utilities for a
Family of 4
2019
Published
Housing and
Utilities for a
Family of 5
Watauga County North Carolina 1,407 1,652 1,741 1,941 1,973
Wayne County North Carolina 1,185 1,391 1,466 1,635 1,661
Wilkes County North Carolina 1,106 1,299 1,369 1,526 1,551
Wilson County North Carolina 1,244 1,461 1,539 1,716 1,744
Yadkin County North Carolina 1,115 1,310 1,380 1,539 1,564
SB/SE - Research - Team #1 Page 65 of 104 March 25, 2019