Providing qualified individuals with affordable housing and resources to assist in their personal growth


Online Application

Low Income Public Housing Application for Admission Packet

Housing Authority of Henry County 125 N. Chestnut St. Kewanee, IL 61443 Phone: Office: (309) 852-2801 Contact Person for PH: Alison Womack


You are encouraged to read all information in this Application for Admission Packet. Additionally, you may request the Violence Against Women Act Notice and the Community Service and Self Sufficiency Requirement Policy from the Agency. Please be aware that all public housing rental units and common areas are smoke-free.

Note: A single person with disabilities or a family that includes a person with disabilities may request a reasonable accommodation at any time during the application or occupancy process.

Those submitting an application for public housing may also apply for all programs with an "open” waiting list. To obtain an application for other programs administered by the Public Housing Agency (PHA) please ask the receptionist which programs are accepting applications.

The application and all supplemental forms must be filled out in full and signed by all adult family members. If all information required on the application and listed below is not received by the Housing Agency within ten (10) calendar days of the application date, the application will be denied.

If an applicant's spouse is temporarily absent from the home, he/she must be listed on the application and is subject to the same screening criteria as all other household members. If a spouse is permanently absent, he/she should not be listed on the application and will not be allowed to live in the rental unit.

A criminal history check will be run on all household members aged eighteen (18) and over. The PHA may require that a family member provide fingerprints to be run through the FBI's national fingerprint system if criminal activity is revealed in the local or state systems. The PHA is screening for specific criminal backgrounds stipulated in the Admissions and Continued Occupancy Policy, as well as criminal activities that prohibit a person from receiving housing assistance during his/her lifetime. Lifetime prohibitions include persons required to register under a state lifetime sex offender registration program and persons who have been convicted of methamphetamine production in federally assisted housing. An application will not be denied if the criminal history check reveals a single minor or petty criminal activity. If an applicant is offered an apartment before the background check information is received by the PHA and the results of the check reveals drug-related or violent criminal activity, any lease agreement executed may be terminated

In addition to completion of the written application and signing all forms in the application packet, the applicant must provide:

  • Social Security numbers and current Social Security cards for all members of the household
  • A current driver's license or state-issued photo identification for each adult household member
  • For each minor listed on the application, original proof of custodianship or right to live with the family (such as birth certificate or divorce decree)
  • The name and address of any parent who will not be living in the household
  • Additional verification forms as determined necessary to verify income, family composition, deductions, and allowances based on review of the application by the PHA

The application will be reviewed within thirty (30) days following receipt to determine initial eligibility. Information provided will be verified as the applicant nears the top of the waiting list to determine suitability and final eligibility. The applicant will be contacted if additional information is required.

If it is determined during the review process that the applicant failed to disclose relevant information requested or provided false information on the application or at the interview, the application will be denied.

The applicant will be mailed a letter of initial eligibility or denial at the address provided on the application. If the application is denied, the applicant may, within ten (10) days of the date of the denial, request an informal meeting, at which time he/she could provide documentation that would disprove the validity of the information relied upon in denying the application.

Eligible applicants are placed on the appropriate waiting list and offered an apartment in accordance with the HUD approved Tenant Selection and Assignment Plan, which is available for review upon request in the management office. Applicant screening and offers of rental units will be made without discrimination regarding race, color, religion, sex, age, handicap, familial status, or national origin.

All applicants determined eligible initially will be interviewed prior to determining final eligibility and suitability and being offered a rental unit. At the time of the interview, current verifications of income, assets, and deductible expenses will be obtained for use in calculating rent. These required verifications must be original documents less than 60 days old at the time of the interview.

The applicant must notify the PHA in writing of any changes in income, household members, assets, address, or telephone number while on the waiting list. This information is used in determining eligibility and unit size for which the family is eligible and for contacting the applicant. If the PHA is unable to contact the applicant due to a change in address or telephone number that has not been reported in writing, the application will be removed from the waiting list. If the applicant can provide verification that he/she was unable to respond due to circumstances beyond his/her control, the application may be reinstated.

When an apartment of the appropriate size becomes available, the offer will be mailed to the applicant at the address on the application. Subsequently, the applicant will be contacted at the telephone number provided on the application. If the PHA is unable to contact the applicant, the PHA will leave a recorded message at the most recent telephone number provided.

The applicant must accept the apartment offered or decline it within three (3) calendar days from the date of the offer. If the apartment offered is declined, but the applicant desires to remain on the waiting list, his/her name will be moved to the appropriate place on the waiting list as detailed in the Tenant Selection and Assignment Plan. Failure to respond to an offer within three (3) calendar days will result in removal from the waiting list unless the applicant can provide verification that he/she was unable to respond due to circumstances beyond his/her control at the time of the offer.

If the offer is accepted, the applicant must:

  • Execute the lease and lease addenda within five (5) business days of the offer date
  • Provide proof of ability (receipts) to have utilities turned on in the unit in an adult household member’s name.
  • Pay the security deposit (and pet deposit, if applicable).
  • Pay the pro-rated rent for the month in which he/she is renting.
  • Inspect the unit with a PHA representative. Any repairs needed in the apartment that are not noticed at the move-in inspection may be reported and recorded within seven (7) calendar days of execution of the lease. After that time, the tenant assumes responsibility for any needed repairs beyond normal wear and tear.

125 North Chestnut Street, Kewanee, IL 61443 - Phone: 309-852-2801- Fax: 309-854-6007

Please check all developments that you are applying for:

Family Developments

  • Fairview Apartments (1-4 Bedroom Units): Located in Kewanee. All utilities included with the cost of rent.
  • Lakeland Terrace Apartments: (2-4 Bedroom Units): Located in Kewanee. Must be able to obtain gas/electric in your name with Ameren IP and maintain a bill.
  • Colona House: (3 bedroom/single family home): Located in Colona. Must be able to obtain gas/electric in your name with MidAmerican, and water with the City of Colona, and maintain bills.

Elderly/Near Elderly (50 +)/ Disabled High Rises

  • Hollis House (1-2 Bedroom Units): Located in Kewanee. Must be able to obtain electric in your name with Ameren IP and maintain a bill.
  • Washington Apartments (0-1 Bedroom Units): Located in Kewanee. Must be able to obtain electric in your name with Ameren IP and maintain a bill.
  • Lincoln House (1-2 Bedroom Units): Located in Galva. Must be able to obtain electric in your name with Ameren IP and maintain a bill.
  • Maple City Apartments (1-2 Bedroom Units): Located in Geneseo. All utilities included with the cost of rent.

For Office Use Only


Yes No
Yes No
Yes No


Low Income Public Housing Program

Limited English Proficiency:

Do you require oral and/or written information in any language other than English?

If yes, contact the Applications Office for assistance. If no, continue.

Yes No

Instructions for Completing Form:

Use the legal name for each person who will reside in the rental unit exactly as it appears on his/her Social Security card. All persons aged18 and over must sign this application certifying the information pertaining to them is correct. Do not leave any section of the application blank. Any required information not received by the Public Housing Agency (PHA) within10 business days of the date of this application will result in denial of the application

Applicant Head of Household Information

Current housing:

Yes No
Yes No

Social Security

Is any household member's legal name different from the name on his/her Social Security card?

Have you or any other adult member ever used any name(s) or Social Security number(s) other than the one currently being used?


Place a check mark in the appropriate boxes in each section below to identify any language or disability needs in communication.

I Do Not Require Any Alternate Means Of Communication.


(List all persons who will live in the rental unit. No person may reside in a subsidized unit whose residency has not been previously approved by the Housing Authority.)

* Please Note

No applicant for housing assistance will be discriminated against because of a disability. Applicants are not required to disclose a disability. However, benefits for which persons with disabilities are eligible cannot be provided unless disability status is disclosed.


Use the following codes to describe each adult member's relationship to the Head of Household: A = Adult who is not a full-time student F = Foster Adult E = Full-time student aged 18 or older who is not the Head. Spouse, or Co-Head L = Live-in Aide (if required by an elderly/disabled applicant)

Full Name as It Appears on Social Security Card Social Security # Relation to Head Sex Race and Ethnicity Date of Birth Age Disabled Yes/No List Most Recent Date
M F Decline to Disclose Employed Received TANF

If A Social Security Number Is Not Provided For Any Adult Household Member, Check The Reason Below:

(Name of household member) is an ineligible non-citizen.

(Name of household member) has not been assigned a Social Security number, was receiving HUD housing assistance on January 31, 2010, and was 62 or older as of January 31, 2010


Use the following codes for describing each minor's relationship to the Head of Household. Y = Youth F = Foster Child L = Child of Live-in Aide

Full Name as It Appears on Social Security Card Social Security # Relation to Head Sex Race and Ethnicity Date of Birth Age Disabled Yes/No List Most Recent Date
M F Decline to Disclose

If A Social Security Number Is Not Provided For Any Minor Household Member, Complete The Reason Below:

(Name of minor) is an ineligible non-citizen.

(Name of minor) has not been issued a Social Security number. I/we understand that if this application is approved, I/we will not receive a rental offer until a Social Security number has been provided to the PHA.

Yes No
Yes No
Yes No
Yes No


All families must be income-eligible to receive housing assistance. Check Yes or No for each type of income, and list gross amounts of income received before any deductions are withheld. Check box to indicate if paid by the hour (Hr.), Week (Wk.), or Month (Mo.).

Type of Income Yes No Name of Family Member with This Type of Name Company, Agency, or Individual Making Payment Gross Income Payment Period
Hr Wk Mo
Wages or Earnings
Personal or Company Pension or Retirement
Social Security
Unemployment Benefits
Worker's Compensation
Regular Gifts, Payments, or Contributions from persons outside household
Military Income
Self-Employed (lawn care,hair stylist, manicures, childcare, etc.)
Temporary/Seasonal Work
Student Financial Assistance (Grants, (Scholarships, Work-Study, etc.)
Lump Sum Payments
Veterans Benefits
Other (list)

Previous Year's Tax Return. Indicate The Amount Of Gross Income Shown By Each Family Member Residing In your Household Who Submitted An Individual Or Joint Federal Income Tax Return.

Taxpayer: Date of Return: Gross Income:
Taxpayer: Date of Return: Gross Income:
Yes No

Yes No
Yes No
Yes No
Yes No


Yes No

What will you do with the house if you move into rental housing?

Yes No

How much did you receive?

Type Of Asset Value Income Generated by asset per year
Real Estate (house, land) Yes No
Stocks Yes No
Bonds Yes No
Retirement or Pension Fund Yes No
Insurance Settlements Yes No
Checking Accounts Yes No
Savings Accounts Yes No
Certificates of Deposit Yes No
Trusts Yes No
Other (list) Yes No


Has any household member lived in public housing or participated in the Section 8 Housing Choice Voucher Program after reaching the age of 18? Yes No

List information about each Housing Agency where any family member has lived or received assistance.

Were any wages disregarded in calculating your rent? Yes No Do not know


1. Has any household member been arrested, charged, or convicted for any of the following?

a. Violent criminal activity

Yes No

b. Domestic violence, dating violence, sexual assault, or stalking

Yes No

c. Alcohol-related activity

Yes No

d. Manufacture of methamphetamines

Yes No

e. Possession, use, sale, or distribution of illegal drugs

Yes No

2. If required to report, list name and telephone number of probation/parole officer.

3. Has any household member participated in drug rehabilitation during the past 12 months?

Yes No

4. Is any household member required to register in any state as a Sex Offender?

Yes No

5.Has any household member been evicted from federally assisted housing in the past 3 years?

Yes No


1. List all medical expenses the family anticipates paying during the next 12 months that will NOT be reimbursed by insurance or another outside source. Do NOT include life or burial insurance premiums. (Complete only if the Head of Household or Spouse is disabled or is 62 years of age or older.)





2. Do you pay for attendant care or an auxiliary apparatus for any disabled household member in order for him/her or any other adult family member to work?

Yes No


1. Do you pay for child care for children aged 12 or younger while you work, attend school, or seek employment?

Yes No

Is any portion reimbursed?

Yes No

2. Address of child care provider:

What amount is reimbursed?



Yes No
Yes No
Yes No
Yes No
Yes No
Yes No


1. List a business where you have made payments in the past 24 months:

2. List two references (to whom you are not related by blood or marriage) who have knowledge of your ability and willingness to abide by a lease agreement.


1. Is any person listed on this application currently a victim of domestic violence, dating violence, sexual assault, or stalking?

Yes No

2. List all vehicles that household members will park on PHA-owned property.

Do you have a pet?

Yes No


The following documents must be executed along with this application form for the application to be considered complete:

  • 214 Citizenship Declaration for each family member
  • Form HUD-92006, Emergency Contact Form
  • HUD Privacy Act/Release of Information(form HUD-9886) for Public Housing or HUD Privacy Act/Release of Information (form HUD-9887) for Section 8 New Construction
  • Release for Criminal History Background Check for each adult household member
  • Preference(s) Claim Sheet (if applicable)
  • Form HUD-52675, "Debts Owed to PHAs" signed by each adult household member
  • Other release forms, as applicable


All family members aged 18 or older must certify to the accuracy of the information provided and sign this application.

  • I/we certify that the information provided in this application is accurate and complete to the best of my/our knowledge and belief.
  • I/we understand that providing false statements or information is punishable under Federal Law and constitutes grounds for denial of my/our application, as well as termination of housing assistance and eviction after leasing a dwelling unit.
  • I/we understand that all information provided in this application and required supplements and during the eligibility interview is subject to verification.
  • I/we further understand that any changes to information provided in this application must be provided to the PHA within 14 days of such change for this application to remain valid.
  • By my/our signature(s) below, I/we do hereby swear and attest that all information in this application is true and correct. (Application must be signed by all adults who will live in the rental unit.)


    If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll-free hotline at 1-800-669-9777.

    Certification of Preferences

    The Housing Authority of Henry County offers preference points to applicants in accordance with our Admissions and Continued Occupancy Policy. These preference points will determine your placement on the waiting list. Once you are offered a unit, you will be required to provide proof that you still qualify for the preferences you are claiming. If you do not, or no longer qualify for the preferences, it will be removed and you will be reassigned a position on the waiting list. It is important if you have a change in preferences that you notify us immediately so we can adjust your position. Please indicate by checking the line next to any preference that your family qualifies for:

    • Elderly (62+) / Disabled:I certify that the Head of Household, Spouse or Co-Head of my family is elderly or disabled.
    • Residency:I certify that the Head of Household, Spouse, or Co-Head of my family either lives, works, or has been hired to work anywhere in Henry or Stark County.
    • Victim of Domestic Violence:I certify, and can provide documentation, that my family has been displaced due to fleeing a domestic violence situation, or is currently in a living situation where a member of my family is being subject to domestic violence.

    Housing Authority of Henry County


    Housing Agencies are authorized under Public Law 104-120 signed 3/28/96 and amended in 1998 (codified in24 CFR part 5) to obtain local and national criminal history records of all adult applicants for, or tenants of, public housing and the Section8 housing choice voucher programs for purposes of applicant screening, lease enforcement, and eviction.

    Criminal history background checks may be performed for drug-related activity, violent criminal activity, sex crimes, and alcohol abuse. If any state or national history is revealed in this search, the specific information may be verified for the Housing Authority by the State and/or NCIC. If matching records are revealed, the applicant/tenant may be required to submit fingerprints for positive identification of records. Failure to submit fingerprints when a possible match has been made is grounds for immediate termination of the application process or housing assistance. Failure to provide authorization for these checks is grounds for denial of application.

    Applicant/Tenant authorizes, by signature below, these criminal history checks during both the application process and during program participation without requirement of future signatures, releases, or additional authorization.

    Do not write below this line — for screening use only

    [] No records with State or NCIC

    [] Possible match with State

    [] Possible match with State

    [] No record of conviction for drug activity, criminal activity, or sex crimes

    [] Registration required under lifetime State Sex Offender Registration program

    [] Local record of activity described below




    I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to and verify my application for participation, and/or to maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-Income Public and Indian Housing, and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies. I also consent for HUD or the manager to release information from my file about my rental history to HUD credit bureaus, collection agencies, or future landlords. This includes records on my payment history, and any violations of my lease or occupancy policies.


    I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquiries that may be requested include but are not limited to:

    • Identity and Marital Status
    • Medical or Child Care Allowances
    • Residence and Rental Activity
    • Employment, Income and Assets
    • Credit and Criminal Activity


    Previous Landlords (including Public Housing Authorities)

    • Courts and Post Offices
    • Schools and Colleges
    • Law Enforcement Agencies
    • Medical and Child Care Providers
    • Retirement Systems
    • Utility Companies
    • Past and Present Employers
    • Welfare Agencies
    • State Unemployment Agencies
    • Social Security Administration
    • Support and Alimony Providers
    • Veterans Administration
    • Banks and other Financial Institutions


    I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file in the management office and will stay in effect for one year and one month from the date signed. I understand I have the right to review my file and correct any information that I can prove is incorrect.


    Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants


    Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

    Reason for contact:(Check all that apply)

    Change in house rules
    Assist with Recertification Process
    Unable to contact you
    Change in lease terms
    Termination of rental assistance
    Late payment of rent
    Eviction from unit

    Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

    Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

    Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant's application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

    Check this box if you choose not to provide the contact information

    The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD's assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.

    Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.


    NOTICE TO APPLICANTS AND TENANTS: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the United States. Please read the Declaration statement carefully, sign and return it to the Housing Authority office. Please feel free to consult with an immigration lawyer or other immigration expert of your choice

    • I am a citizen by birth, a naturalized citizen, or a national of the United States; or
    • I have eligible immigration status and I am 62 years of age or older.(attach proof of age); or
    • I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing eligible immigration status and signed verification consent form.
    • Immigrant status under 101(a or 1010(a)(20) of the INA 3/; or
    • Permanent residence under 249 of INA 4/; or
    • Refugee, asylum, or conditional entry status under 207, 208,or 203 of the INA /5; or
    • Parole status under 212(d)(5) of the INA /6; or
    • Threat to life or freedom under 243(h) of the INA /7; or
    • Amnesty under 245A of the INA 8/.

    *PARENT/GUARDIAN must sign for family members under age 18. DO NOT sign child's name


    Thank you for applying for Housing Assistance with the Housing Authority of Henry County. Your application has been accepted and will be reviewed for preliminary determination of eligibility. If you meet our eligibility requirements, your application will be placed on our waiting list.

    It is our desire to provide you with safe, decent, and sanitary housing. The Housing Authority of Henry County acknowledges the responsibility to the extent provided by the law to protect information it receives in determining the applicant’s/participant's eligibility for housing assistance.

    Warning! Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States, or the Department of Housing & Urban Development.

    I have read and am aware of the following:

    • 1. My application has been submitted.
    • 2. I may not receive immediate assistance. Many developments have moderate to lengthy waiting lists. The Housing Authority of Henry County does not have emergency housing.
    • 3. If my application is initially approved, the Housing Authority will place me on the waiting list, and at a later date will verify all other information on my application.
    • 4. It is my responsibility to ensure that all changes to this application, including changes in address, phone number, household members and income are submitted in writing to our office. Telephone changes will NOT be accepted, unless due to a reasonable accommodation for advisability. Failure to report changes in writing will result in removal from the waiting list.
    • 5. If my application is removed from the waiting list, I will need to reapply when the Housing Authority is accepting applications.
    • 6. My application for housing assistance may be denied because of criminal activity or debts to another housing authority of any household member.
    • 7. This application does not obligate the Housing Authority of Henry County to provide housing nor does it obligate me to accept housing assistance.

    I do hereby swear and attest that all the information above about myself and my household is true and correct. I understand that providing any false information will result in my application being cancelled or denied, or in the termination of my housing assistance. I declare under penalty of perjury under the laws of the United States of America and the State of Illinois that the information contained in this application of facts is true, correct and complete.

    If a person other than the participant completes this application, please sign and complete the following:

    Authorization for the Release of Information/Privacy Act Notice

    to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA)

    U.S. Department of Housing and Urban Development Office of Public and Indian Housing

    PHA requesting release of information; (Cross out space if none) (Full address, name of contact person, and date)

    PHA requesting release of information: (Cross out space if none) (Full address, name of contact person, and date)

    Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

    This law requires that you sign a consent form authorizing: HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.

    Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household's income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.

    Uses of Information to be obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.

    Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.

    Persons who apply for or receive assistance under the following programs are required to sign this consent form:

    • PHA-owned rental public housing
    • Turnkey III Homeownership Opportunities
    • Mutual Help Homeownership Opportunity
    • Section 23 and 19(c) leased housing
    • Section 23 Housing Assistance Payments
    • HA-owned rental Indian housing
    • Section 8 Rental Certificate
    • Section 8 Rental Voucher
    • Section 8 Moderate Rehabilitation

    Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA's grievance procedures and Section 8 informal hearing procedures.

    Sources of Information To Be Obtained State Wage Information Collection Agencies.(This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.)

    U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self-employment information and payments of retirement income as referenced at Section 6103(1) (7) (A) of the Internal Revenue Code.)

    U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)

    Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.

    Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.

    This consent form expires?
    15 months after signed

    Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government's financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

    Penalties for Misusing this Consent: HUD, the HA and any owner (or any employee of HUD, the HA 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 the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. 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 HA or the owner responsible for the unauthorized disclosure or improper use.

    What is EIV?

    The Enterprise Income Verification (EIV) system is a web-based computer system that contains employment and income information of individuals who participate in HUD rental assistance programs. All Public Housing Agencies (PHAs) are required to use HUD's EIV system.

    What information is in EIV and where does it come from?

    HUD obtains information about you from your local PHA, the Social Security Administration (SSA), and U.S. Department of Health and Human Services (HHS).

    HHS provides HUD with wage and employment information as reported by employers; and by employers; and by the State Workforce Agency (SWA).

    SSA provides HUD with death, Social Security (SS)and Supplemental Security Income (SSI) information.

    What is the EIV information used for? Primarily, the information is used by PHAs (and management agents hired by PHAs) for the following purposes to:

    1.Confirm your name, date of birth (DOB), and Social Security Number (SSN) with SSA.

    2. Verify your reported income sources and amounts.

    3. Confirm your participation in only one HUD rental assistance program.

    4. Confirm if you owe an outstanding debt to any PHA.

    5. Confirm any negative status if you moved out of a subsidized unit (in the past) under the Public Housing or Section 8 program.

    6. Follow up with you, other adult household members, or your listed emergency contact regarding deceased household members.

    EIV will alert your PHA if you or anyone in your household has used a false SSN, failed to report complete and accurate income information, or is receiving rental assistance at another address. Remember, you may receive rental assistance at only one home!

    EIV will also alert PHAs if you owe an outstanding debt to any PHA (in any state or U.S. territory) and any negative status when you voluntarily or involuntarily moved out of a subsidized unit under the Public Housing or Section 8 program. This information is used to determine your eligibility for rental assistance at the time of application.

    The information in EIV is also used by HUD, HUD's Office of Inspector General (OIG), and auditors to (OIG), and auditors to rules.

    Overall, the purpose of EIV is to identify and prevent fraud within HUD rental assistance programs, so that limited taxpayer's dollars can assist as many eligible families as possible. EIV will help to improve the integrity of HUD rental assistance programs.

    Is my consent required in order for information to be obtained about me?

    Yes, your consent is required in order for HUD or the PHA to obtain information about you. By law, you are required to sign one or more consent forms. When you sign a form HUD-9886 (Federal Privacy Act Notice and Authorization for Release of Information) or a PHA consent form (which meets HUD standards), you are giving HUD and the PHA your consent for them to obtain information about you for the purpose of determining your eligibility and amount of rental assistance. The information collected about you will be used only to determine your eligibility for the program unless you consent in writing to authorize additional uses of the information by the PHA.

    Note: If you or any of your adult household members refuse to sign a consent form, your request for initial or continued rental assistance may be denied. You may also be terminated from the HUD rental assistance program.

    What are my responsibilities?

    As a tenant(participant) of a HUD rental assistance program, you and each adult household member must disclose complete and accurate information to the PHA, including full name, SSN, and DOB; income information; and certify that your reported household composition (household members), income, and expense information is true to the best of your knowledge.

    Remember, you must notify your PHA if a household member dies or moves out. You must also obtain the PHA's approval to allow additional family members or friends to move in your home prior to them moving in.

    What are the penalties for providing false information? Knowingly providing false, inaccurate, or incomplete information is FRAUD and a CRIME.

    If you commit fraud, you and your family may be subject to any of the following penalties:

    • Eviction
    • Termination of assistance
    • Repayment of rent that you should have paid had you reported your income correctly
    • Prohibited from receiving future rental assistance for a period of up to 10 years
    • Prosecution by the local, state, or Federal prosecutor, which may result in you being fined up to $10,000 and/or serving time in jail.

    Protect yourself by following HUD reporting requirements.When completing applications and reexaminations, you must include all sources of income you or any member of your household receives.

    If you have any questions on whether money received should be counted as income or how your rent is determined, ask your PHA. When changes occur in your household income, contact your PHA immediately to determine if this will affect your rental assistance.

    What do I do if the EIV information is incorrect? Sometimes the source of EIV information may make .an error when submitting or reporting information about you. If you do not agree with the EIV information, let your PHA know.

    If necessary, your PHA will contact the source of the information directly to verify disputed income information. Below are the procedures you and the PHA should follow regarding incorrect EIV information.

    Debts owed to PHAs and termination information reported in EIV originates from the PHA who provided you assistance in the past. If you dispute this information, contact your former PHA directly in writing to dispute this information and provide any documentation that supports your dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record from EIV.

    Employment and wage information reported in EIV originates from the employer. If you dispute this information, contact the employer in writing to dispute and request correction of the disputed employment and/or wage information. Provide your PHA with a copy of the letter that you sent to the employer. If you are unable to get the employer to correct the information, you should contact the SWA for assistance.

    Unemployment benefit information reported in EIV originates from the SWA, If you dispute this information, contact the SWA in writing to dispute and request correction of the disputed unemployment benefit information. Provide your PHA with a copy of the letter that you sent to the SWA.

    Death, SS and SSI benefit information reported in EIV originates from the SSA, If you dispute this information, contact the SSA at (800)772-1213, or visit their website at: www.socialsecuritmov. You may need to visit your local SSA office to have disputed death information corrected.

    Additional Verification.The PHA, with your consent, may submit a third party verification form to the provider (or reporter) of your income for completion and submission to the PHA.

    You may also provide the PHA with third party documents (i.e. pay stubs, benefit award letters, bank statements, etc.) which you may have in your possession.

    Identity Theft. Unknown EIV information to you can be a sign of identity theft. Sometimes someone else may use your SSN, either on purpose or by accident.So, if you suspect someone is using your SSN, you should check your Social Security records to ensure your income is calculated correctly (call SSA at (800)772-1213); file an identity theft complaint with your local police department or the Federal Trade Commission (call FTC at (877) 438-4338, or you may visit their website at: http://www.ftc.gov). Provide your PHA with a copy of your identity theft complaint.

    Where can i obtain more information on EIV and the income verification process?

    Your PHA can provide you with additional information on EIV and the income verification process. You may also read more about EIV and the income verification process on HUD's Public and Indian Housing EIV website

    The information in this Guide pertains to applicants and participants (tenants) of the following HUD-PIH rental assistance programs:

    • Public Housing (24 CFR 960); and
    • Section 8 Housing Choice Voucher (HCV), (24 CFR 982); and
    • Section 8 Moderate Rehabilitation(24 CFR 882); and
    • Project-Based Voucher (24 CFR 983)

    My signature below is confirmation that I have received this Guide.

    Signature :

    Date :

    U.S. Department of Housing and Urban Development

    Office of Public and Indian Housing


    Paperwork Reduction Notice: Public reporting burden for this collection of information is estimated to average 7 minutes per response. This includes the time for respondents to read the document and certify, and any record keeping burden. This information will be used in the processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The OMB Number is 2577-0266, and expires 08/31/2016.


    • Public Housing (24 CFR 960)
    • Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)
    • Section 8 Moderate Rehabilitation (24 CFR 882)
    • Project-Based Voucher (24 CFR 983)

    The U.S. Department of Housing and Urban Development maintains a national repository of depts. Owed to Public Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs. This information is maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors. The EIV system is designed to assist PHAs and HUD in ensuring that families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.

    HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program. This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights. PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2. Each adult household member must sign this form.

    What information about you and your tenancy does HUD collect from the PHA? The following information is collected about each member of your household (family composition): full name, date of birth, and Social Security Number.

    The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit:

    • 1. Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges such as damages, utility charges, etc.); and
    • 2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
    • 3. Whether or not you have defaulted on a repayment agreement; and
    • 4. Whether or not the PHA has obtained a judgment against you; and
    • 5. Whether or not you have filed for bankruptcy; and
    • 6. The negative reason(s) for you end of participation or any negative status (i.e., abandoned unit, fraud, lease violations, criminal activity, etc.) as of the end of participation date.

    Who will have access to the information collected?

    This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

    How will this information be used?

    PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants, PHAs will be able to access this information to determine a family's suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements. If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance, subject to PHA policy.

    How long is the debt owed and termination information maintained in EIV?

    Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date.

    What are my rights?

    In accordance with the Federal Privacy Act of 1974, as amended(5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:

    • To have access to your records maintained by HUD, subject to 24 CFR Part 16.
    • To have an administrative review of HUD's initial denial of your request to have access to your records maintained by HUD.
    • To have incorrect information in your record corrected upon written request.
    • To file an appeal request of an initial adverse determination on correction or amendment of record request within 30 calendar days after the issuance of the written denial.
    • To have your record disclosed to a third party upon receipt of your written and signed request.

    What do I do if I dispute the debt or termination information reported about me?

    If you disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The PHA's name, address, and telephone numbers are listed on the Debts Owed and Termination Report.You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or termination information must be made within three years from the end of participation date; otherwise the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record. Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD's EIV system. However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status.

    The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute. If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record. If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.

    This Notice was provided by the below-listed PHA:

    I hereby acknowledge that the PHA provided me with the Debts Owed to PHAs & Termination Notice:

    Signature :

    Printed Name :

    Date :

    Upload Required Documents :

    Accept: yes

    By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and Housing Authority of Henry County. You are also confirming that you are the person authorized to enter into this Agreement.