Download - MAINE STATE HOUSING AUTHORITY Stability … › 2015 › 02 › all-step...4. Rental income from real or personal property. 5. Interest/dividends from Assets: savings/checking accounts,

MAINE STATE HOUSING AUTHORITY

Stability Through Engagement Program (STEP) 353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

NAME: INSTITUTION:

SSN: ADDRESS:

RE: ASSET VERIFICATION

Federal Law and regulations require us to verify the sources and amounts of income of all applicants for

admission as tenants to our federally assisted housing program and to re-examine periodically the incomes of

existing tenant families. All information is confidential and will be used only in determining eligibility for

rental assistance.

*****************************************************************************************

SAVINGS ACCOUNT(S) Current Balance Interest Rate Date

$________________ ____________% _________________

$________________ ____________% _________________

$________________ ____________% _________________

CHECKING ACCOUNT(S): Current Balance Interest Rate Date

$________________ ____________% _________________

$________________ ____________% _________________

Average balance for the past (six) months: $__________________ PLEASE LIST ANY OTHER ASSET ACCTS (CD’S, MONEY MARKETS, IRA’S, TRUSTS, ETC.)

Type Interest Rate Balance Cash Value

____________________ _______________% $________________ $________________

____________________ _______________% $________________ $________________ **NOTE: THE CASH VALUE IS THE CURRENT VALUE MINUS PENALTIES FOR EARLY WITHDRAWAL

__________________________________________________ _____________________________

Signature/Title Date

Phone ____________________________________


Stability Through Engagement Program (STEP)

353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 624-5768

7-1-1 (Maine Relay)

Name: Institution:

SS#: Address:

SUBJECT: Assets: Stocks/Bonds/Securities

Federal law and regulations require us to verify the sources and amounts of income of all applicants for

admission as tenants to our federally assisted housing program and to re-examine periodically the incomes of


rental assistance.

Number of Current Market Current Dividends Earned

Type Shares Owned Value per Share Dividend Rate Past 12 months

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

____________ __________ _____________ ____________ _______________

__________________________________________ ________________________


__________________________________

Phone

Penalties for misusing this consent: Title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties fur 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 any applicant or participant may be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and see 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.

CERTIFICATION OF ZERO INCOME

MaineHousing STEP Program

Household Name: SSN:

Address: City:

I hereby certify that I do not individually receive income from any of the following sources: 1. Employment wages including: overtime, commissions, tips, bonuses, fees etc.

2. Unemployment compensation. 3. Income from operation of a business: sales from self-employment resources.

4. Rental income from real or personal property. 5. Interest/dividends from Assets: savings/checking accounts, annuities, insurance policies,

retirement funds, pensions or death benefits.

6. Social Security (SS) and/or Supplemental Security Income (SSI) benefits. 7. Public assistance payments including: General Assistance, TANF and/or Food Stamps.

8. Regular contributions/gifts received from person not living in the household. 9. Alimony and/or Child Support payments.

Please list the payment sources for the following expenses. If you need additional space, please use back side of this form: Monthly Expenses: Source of Funds: Address of Source:

Food. Grocery bill X 4 wks

Communications. Telephone

/cell phone, internet connection.

Transportation. Bus fares. Taxi

fares. Personal car expenses: gas, insurance, maintenance, or tires.

Medical. Unreimburseable .

Living. Clothing. Cleaning

supplies, personal grooming and paper products.

Entertainment. magazines,

memberships, etc.

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. I understand that providing false, misleading or incomplete information may result in the termination of my housing assistance. ________________________ ________________________ _________________ Tenant/Applicant Signature Printed Name Date

Penalties for misusing this consent: Title 18, Section 1001 of the US Code states that a person is guilty of felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties fur 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 any applicant or participant may be subject to a misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and see 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.

For additional space, please enter below: Monthly Expenses: Source of Funds: Address of Source:

Food. Grocery bill X 4 wks

Communications. Telephone

/cell phone, internet connection.

Transportation. Bus fares. Taxi

fares. Personal car expenses: gas, insurance, maintenance, or tires.

Medical. Unreimburseable .

Living. Clothing. Cleaning

supplies, personal grooming and paper products.

Entertainment. Cable or Dish

TV, magazines, club memberships, liquor/beer/wine, lottery tickets, cigarettes.



353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768 7-1-1 (Maine Relay)

CHILD CARE VERIFICATION

NAME PROVIDER

SSN ADDRESS

NAME(S) OF CHILD(REN) BEING CARED FOR:

_________________________________ ________________________________

__________________________________ ________________________________

__________________________________ ________________________________

HOW MANY DAYS PER WEEK? _______________ HOURS PER DAY ________________

CHARGE PER DAY _____________ PER WEEK _______________ PER HOUR__________

DO CHARGES VARY FOR ANY REASON? (example: child in school) IF YES, PLEASE

EXPLAIN. ____________________________________________________________________

______________________________________________________________________________

DO YOU RECEIVE MONEY FROM ANY OTHER PERSON OR AGENCY TOWARD THE

AMOUNT YOU CHARGE FOR THE ABOVE NAMED CHILD(REN)? IF YES, WHO?

_____________________________________________________________________________

TOTAL AMOUNT YOU RECEIVED FOR THE LAST 12 MONTHS: ____________________

_______________________________________ _________________________

Signature Date

____________________________________

Telephone



353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

CHILD SUPPORT PAYMENTS BY INDIVIDUAL

__________________________________

__________________________________

__________________________________

Date: Re:

Please provide the amounts of child support you paid for the months that have X’s in front of

them.

A signed Release of Information is enclosed authorizing you to provide the requested

information.

2010 2011

_____ January ____________ _____ January _____________

_____ February ___________ _____ February ____________

_____ March ____________ _____ March _____________

_____ April ____________ _____ April _____________

_____ May ____________ _____ May _____________

_____ June ____________ _____ June _____________

_____ July ____________ _____ July _____________

_____ August _____________ _____ August ______________

_____ September __________ _____ September ___________

_____ October ____________ _____ October _____________

_____ November __________ _____ November ____________

_____ December __________ _____ December ____________

Please return this form by the date requested on the cover letter.

Authorized Signature: ___________________________________ DATE: ________________

TEL. __________________________



353 Water Street

Augusta, ME 04330


Name: _______________________________ Agency: ____________________________

SS#: _______________________________ Address: ____________________________

____________________________________

SUBJECT: Disability Benefits

Federal law and regulations require us to verify the sources and amounts of income and expenses for all

applicants for admission as tenants to our federally assisted housing programs and to re-examine periodically

the incomes/expenses of existing tenant families. All information is confidential and will be used only in

determining eligibility for rental assistance.

Gross amount of Disability payment: $ _______________ per ______________(week/month)

Initial date received: ________________ Amount $ _________________

Have benefits been continuous since initial start? _________ If not, dates not received ___________________

_________________________________________________________________________________________

If benefits are expected to terminate, what is the expected date? ____________________

Will there be a settlement, how much? _________________________ Date of settlement ________________

___________________________________________ __________________________


_____________________________

Phone


353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

EMPLOYMENT VERIFICATION

NAME : EMPLOYER:

SS#:

Date of Employment: ___________________ Occupation: ____________________________

Full or Part Time: ___________________ Effective Date: __________________________

Day Week Month

Average Hours Worked Per: _________ _________ _________

Average Hours of Overtime Per: _________ _________ _________

Average Anticipated Tips Per: _________ _________ _________

*PLEASE DO NOT INCLUDE WAGES FROM ADVANCED EARNED INCOME CREDIT PAYMENT

PLAN. It is not considered income for Housing Authority purposes.

Hourly Rate: $ ___________ Overtime Rate $ ______________ Salary $ ______________ Per ________

Effective Date of Present Pay: ______________________

Any other compensation not included above (commissions, bonuses, incentive allowance, etc.)

Type: _____________________ Amount $_______________per _____________wk/mo/yr

Total pay received over the last 12 months: $_____________________

Medical deductions: $________________ Per _____________wk/mo/yr

_________________________________________________ __________________________


________________________________

Telephone Number



AUGUSTA, ME 04330 (207) 626-4600 or Fax: (207) 624-5768

7-1-1 (Maine Relay)

MEDICAL/DENTAL EXPENSE VERIFICATION

NAME: PROVIDER

SSN:

Federal law and regulations require us to verify the sources and amounts of certain types of expenses of all

applicants for admission as tenants to our federally assisted housing program and to re-examine periodically the

expenses of existing tenant families. All information is confidential and will be used only in determining

eligibility for rental assistance.

**NOTE: Please provide your best estimate of medical/dental expected over the next 12 months, based on

experience/costs over the last 12 months and/or anticipated costs for applicant/family’s current

medical/dental condition. To the extent that you are aware that medical/dental insurance covers

some/all of the charges, please answer accordingly.

Your assistance and prompt response will be greatly appreciated.

Maine State Housing Authority

*****************************************************************************************

Total medical/dental expense for the above named individual for the coming 12 month period: $___________

Amount individual is expected to pay out-of-pocket (amount not covered by insurance): $___________

If the individual does not pay in full for all services at the time rendered, is there a current balance? _________

If yes, what is the balance? $___________

If applicant/tenant is making regular payments on an outstanding balance, what is the amount and frequency

regularly paid. $ ___________per ___________

Amount How often

________________________________________ ________________________


_____________________________

Phone



Augusta, Maine 04330

(207) 626-4600 or Fax: (207) 624-5768 7-1-1 (Maine Relay)

NAME: ADDRESS:

SS #:

SUBJECT: Medical/Dental Insurance Premiums

Federal law and regulations require us to verify the sources and amounts of certain types of expenses of

all applicants for admission as tenants to our federally assisted housing program and to re-examine

periodically the expenses of existing tenant families. All information is confidential and will be used only

in determining eligibility for rental assistance.

A signed Release of Information is enclosed.

Please provide the following information. Your assistance and prompt response will be most appreciated.

Amount of premium: __________

How often premium is paid: _________________

Amount of deductible, if any: _____________ Annually? __________

Is this a primary or secondary insurance? ________________________

Date: ___________________ Signature: __________________________

Tel #: ___________________ Title: ______________________________



Augusta, ME 04330

Tel. 207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

OTHER UNEARNED INCOME

I / We (name of person/s giving money)____________________________________ give

(person receiving that money)______________________________ $_________________

per (day, week, month, etc) ___________________. This money is given for __________

_________________________________________________________________________.

Additional comments, if any: _________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________ ______________________

Signature Date

_________________________________________ ______________________ Relationship to Recipient Phone

OTHER UNEARNED INCOME



Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

PENSION/ANNUITY BENEFITS VERIFICATION

NAME: ADDRESS:

SS#:

File #

A signed Release of Information is included.

Type of retirement benefit: ___________________________________________________________

Date Benefits started : ______________________

Gross monthly amount: $________________

Effective date of current amount: ______________________

Medical Insurance Deduction per month: $_______________

Comments:_____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________ ________________________

Signature Date

__________________________________________ ________________________

Title Phone



353 Water Street

Augusta, ME 04330


PRESCRIPTION DRUGS

NAME PHARMACY:

SSN ADDRESS:

DOB:

Federal law and regulations require us to verify the sources and amounts of income and allowable expenses of

all applicants for admission as tenants to our federal assisted housing program and to reexamine periodically the

incomes and allowable expenses of existing tenant families. All information is confidential and will be used

only in determining eligibility for rental assistance.

Your assistance and prompt response will be appreciated.

MaineHousing

*****************************************************************************************

What is the anticipated amount paid by the customer for prescription drugs for an ongoing basis.

$ __________________ per month or $ _______________per year? Of the amount/s entered, is there a

balance owed that the customer is responsible for? _______ If yes, how much is owed ______________?

Signature: _________________________________ Date: _____________________

Tel # ____________________________________



Augusta, ME 04330

626-4600 or Fax: 624-5768

7-1-1 (Maine Relay)

SELF–CERTIFICATION OF EMPLOYMENT For use when paid by cash or taxes are not deducted

Name: ____________________________ SSN _________________________

Address: ____________________________ Phone: _________________________

____________________________

Mailing Address: ______________________________________________________________

I receive $___________ Hrly _____ Daily _____ Wkly _____ Bi-monthly _____ Mthly _____

I receive my pay by: Check _________ Cash ________ Money Order _________

Person paying: Name _____________________________________

Address _____________________________________

_____________________________________

Phone _____________________________________

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make

willful false statements of misrepresentation to any Department or Agency of the U.S. as to any

matter within it’s jurisdiction.

I certify that the above information is true and complete to the best of my knowledge and

understand that my subsidy may be terminated if I do not report all income coming into my

household.

__________________________________ _________________________

Signature Date

SELF-CERTIFICATION OF EMPLOYMENT For use when paid by cash or taxes are not deducted


353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

SOCIAL SECURITY VERIFICATION

FEDERAL

NAME: ADDRESS: Social Security Administration

SS#: PO Box 1075

Claim # Augusta, ME 04332

A signed Release of Information is attached.

SOCIAL SECURITY

Gross Monthly amount:

$_____________

Deduction for Medicare Premiums: $_____________

SUPPLEMENTAL SECURITY INCOME (Federal Amount only)

Gross Monthly amount: $____________

_______________________________________________________________________________

__________________________________________ _____________________


____________________________

Telephone #



Augusta, ME 04330

207-626-4600 or 207-624-5768

7-1-1 (Maine Relay)

SOCIAL SECURITY VERIFICATION

STATE

NAME ADDRESS: Dept. of Human Services

BFI

SS#: 11 SHS Whitten Rd.

Augusta, ME 04333

A signed Release of Information is attached.

SUPPLEMENTAL SECURITY INCOME (State amount only)

Gross Monthly amount: $____________

Food Stamp (monthly amount) $__________ ______________________________________________________________________________________________________

__________________________________________ _____________________


____________________________

Telephone #

THANK YOU



Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

UNEMPLOYMENT BENEFITS

NAME: ADDRESS: 45 Commerce Drive

Augusta ME 04330

ATTN: UC Director’s Office

SS#: Fax: 287-2305

Federal law and regulations require us to verify the sources and amounts of income of all applicants for

admission as tenants to our federally assisted housing program and to reexamine periodically the incomes of


rental assistance.

Your assistance and prompt response will be appreciated.

MaineHousing

__________________________________________________________________________________

Gross weekly payment: $________________ Date of Initial Payment:___________________________

Ending Date if known:____________________________

Is the client entitled to an extension of benefits: Yes ___________ No __________

If yes, for how long? ____________________________________________________________

If no, what is termination date of benefits: ___________________________________________

REMARKS:

___________________________________________________________________________________

___________________________________________________________________________________

Date: __________________________ Signature/title: _______________________________________

Tel.#: __________________________



353 Water Street

Augusta, ME 04330

207-626-4600 or Fax 207-624-5768

7-1-1 (Maine Relay)

VA BENEFITS VERIFICATION

NAME: ADDRESS: Dept of Veterans Affairs

SSN: 402/21

VA Claim # Togus, ME 04330

A signed Release of Information is included.

Gross amount of VA Disability per month: $______________ Date Started: _______________________

Gross amount of VA Pension per month: $______________ Date Started: _______________________

Gross amount of Survivor Benefits per month: $ _____________ Date Started: _______________________

Do Survivor Benefits include amounts for child/ren? ____________ If yes, gross per month $ ____________

Gross amount of Education Stipend per month $_____________ Date Started: _______________________

Comments:__________________________________________________________________________________________

_________________________________________________________________________________________

______________________________________________ ___________________________________

Signature Date

______________________________________________ ____________________________________

Title Phone



353 Water Street

Augusta, ME 04330


Name: _______________________________ Agency: ____________________________

SS#: _______________________________ Address: ____________________________

____________________________________

SUBJECT: Worker’s Compensation

Federal law and regulations require us to verify the sources and amounts of income and expenses for all

applicants for admission as tenants to our federally assisted housing programs and to re-examine periodically

the incomes/expenses of existing tenant families. All information is confidential and will be used only in

determining eligibility for rental assistance.

Gross amount of Worker’s compensation: $ _______________ per ______________(week/month)

Initial date received: ________________ Amount $ _________________

Have benefits been continuous since initial start? _________ If not, dates not received ___________________

_________________________________________________________________________________________

If benefits are expected to terminate, what is the expected date? ____________________

Will there be a settlement, how much? _________________________ Date of settlement ________________

___________________________________________ __________________________


_____________________________

Phone