RD Application Packet

Read Carefully

APPLICATIONS will be distributed at the HOUSING AUTHORITY OFFICE at 925 N. Plainsburg Rd., Planada, CA. All applications complete or not, will be placed on the waiting list. However, priority will not be established until the applicant has submitted all required information. A letter to the applicant will be mailed within 10 days stating the items that are needed for the application to be considered complete. PRIORITY WILL NOT BE ESTABLISHED UNTIL ALL REQUIRED ITEMS ARE RECEIVED. The time and date all items are finally submitted will be noted on the waiting list to establish priority. A complete application includes receiving a signed authorization to verify employment and income. WE DO NOT HAVE EMERGENCY HOUSING.

Income Requirements

To be eligible you must earn a minimum of $5,752.50 annually from farm labor employment.

Residency Requirements

Applicants who apply for housing assistance, regardless of age, will need to submit proof of U.S. citizenship by birth, naturalization, or signed declaration of eligible immigration status.

You must provide the following information with your application:

1. Proof of legal residency
2. Written verification of income for all household members such as:
   • WAGES: check stubs, printout from employer, W-2 with income tax forms
   • UIB: printout of earnings and benefits
   • TANF: notice of action
   • SSI/SSA: printout of benefit amount

Our rents are set according to your income. The current maximum income limits are variable according to the number of occupants.

Change of Address

Please contact the Housing Authority if you have a change in your current mailing address or phone number.

I. Personal Information

Please list ALL people who will reside with you:

II. Housing History

All notices and phone calls will go to this address and phone number:

Current Address:  
Mailing Address:  
Home Number:     Work Number:     Message/Cell Number:  
Occupied From:   To:     Amount of Rent Paid:  
Reason for Leaving:  
Landlord’s Name:     Phone:  
Address:  

NOTE: If you answer yes to any of the following questions, please explain on a separate sheet of paper and attach to this application.

III. Current/Previous Employer

IV. Household Income Information

V. Assets

List ALL Saving/Checking Accounts you have. If none, mark NONE.

List any other asset (real estate, life insurance, CD’s or IRA’s, etc.) List details on a separate sheet. If none, mark NONE.

VI. Child Care

(Complete only if your child/children is/are 12 years of age or younger and living in your household.)

Do you employ childcare in order for a household member to work or continue education? ( ) Yes   ( ) No
Are these expenses paid by you? ( ) Yes   ( ) No   Amount Paid $___

VII. Medical Expenses

Do you have medical expenses that exceed three percent of your annual income? ( ) Yes   ( ) No

Note: Medical expenses can only be deducted for elderly households (head, spouse or sole member who is party to the lease must be 62 yrs of age or older OR an individual with a disability.

VIII. Deductions for Disability Expenses

Do you have any disability expenses? ( ) Yes   ( ) No

(Reasonable expenses for the care of an individual with disabilities in excess of three percent of annual income may be deducted from annual income if the expenses.)

IX. Vehicles

X. Race/Ethnicity

The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service that the federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age, and disability are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.

Ethnicity:
A. Hispanic or Latino ___   B. Not Hispanic or Latino ___

Race:

1. American Indian or Alaska Native ___
2. Asian ___
3. Black or African American ___
4. Native Hawaiian or Other Pacific Islander ___
5. White ___

Gender: Male ___   Female ___

Applicant Certification

I/We certify the housing I/We are applying for will be my/our primary home. I/We further certify that I/We will not maintain a separate subsidized rental unit in a different location.

APPLICANT HEREBY VERIFIES THAT THE ABOVE IS ACCURATE AND COMPLETE AND THAT ANY MISREPRESENTATION WILL DISQUALIFY THE APPLICANT. APPLICANT HEREBY AUTHORIZES INVESTIGATION AND VERIFICATION THEREOF.

Applicant Signature: _______________   Date: ___
Co-Applicant Signature: _______________   Date: ___

Attachment B: Net Family Assets

Do you or any member of your household:

Allowances

Do you or any member of your household:

I/we, the undersigned, hereby certify that to the best of my/our knowledge the information set forth above is true, accurate and complete, and I/we hereby authorize verification of same by the project owner and/or agent.

No. 1 Name: _______________   Signature: _______________   Date: ___
No. 2 Name: _______________   Signature: _______________   Date: ___