WAITING LIST REQUESTS

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1 Please complete this form and the attachments and forward to the Leasing Department at the address provided. WAITING LIST REQUESTS NAME: If I qualify, I wish to be placed on the following waiting lists: (it is to your advantage to choose more than one list) COVENANT PLACE I - ONE BEDROOM (Must be 62 years of age or older to qualify) Affordable Rate (HUD Section 8 Rent Subsidy) COVENANT PLACE I - ONE BEDROOM (Must be 62 years of age or older to qualify) Affordable Market Rate (Maximum annual income: one person: $39,400; two people: $45,000) COVENANT HOUSE II - ONE BEDROOM (Must be 62 years of age or older to qualify) (HUD Section 8 Rent Subsidy) CHAI APARTMENTS - ONE BEDROOM (Must be 62 years of age or older to qualify) (HUD Section 8 Rent Subsidy) CHAI APARTMENTS - ONE BEDROOM FOR PERSONS WITH DISABILITIES (Must be 18 years of age or older to qualify) (HUD Section 8 Rent Subsidy) Date Signature OFFICE USE ONLY Complete Incomplete 2 nd Submission Received Date Returned to Prospective Resident on Received Date Time By Time By By 04/04/2016 Covenant Place does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. The Executive Director of Community Housing has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development s regulations implementing Section 504 (24CFR, part 8 dated June 2, 1988) Sponsoring Organization: Jewish Federation of St. Louis.

2 INCOME LIMITS ELIGIBILITY QUESTIONNAIRE FOR COVENANT PLACE The Department of Housing and Urban Development annually sets the Income-Eligibility Limits. For 2016 the Income Limits are as follows: Affordable Market One Person: $24,650 $39,400 Two People: $28,150 $45,000 Based on the information you provide in this eligibility questionnaire, we will make a preliminary determination of your eligibility. PROSPECTIVE RESIDENT INFORMATION Name of Prospective Resident(s): (List Head of Household first) #1 #2 (Last) (First) (M.I.) (Last) (First) (M.I.) Current Address: (Street) (City) (State) (Zip) Telephone: Home: Work: Marital Status: Single Married Separated Widowed Divorced Is any member of the household a student? Yes No If yes, who: Gender of prospective resident(s): #1 #2 Decline to report Date of Birth (each prospective resident): #1 2 Will the prospective resident(s) listed above be the sole occupant(s) of the unit for which you are applying? Yes No If no, what are the names and addresses of other proposed occupants? 06/17// Covenant Place Eligibility Questionnaire

3 TRANSLATION ASSISTANCE Will you require assistance communicating with Covenant Place management during the leasing process? This may include interpreter services and/or written materials translated into languages other than English. Yes No If you answered YES, you will need assistance communicating between English and what other language? Will you require sign language assistance? Yes No SPECIAL NEEDS Do you have any special needs regarding your potential tenancy at Covenant Place? Please describe any needs or accommodations you may require. FINANCIAL AND RESOURCE DATA The Department of Housing & Urban Development and Covenant Place Apartments require that you provide a summary of your GROSS income, assets, and liabilities so that Covenant Place management can determine whether you meet the income requirements of this facility. Please completely fill in the applicable areas below for all prospective residents. Use a separate sheet of paper if necessary. REGULAR GROSS INCOME: ANNUAL AMOUNT (Enter N/A if not applicable) Salary / Wages #1 $ #2 $ Social Security #1 $ #2 $ Supplemental Security Income #1 $ #2 $ 3 Covenant Place Eligibility Questionnaire

4 06/17/2016 Pension #1 $ #2 $ Annuities #1 $ #2 $ Rental Property Income $ Trust Income #1 $ #2 $ Other Income $ Regular Gross Income Subtotal $ (Add this amount to the Assets Subtotal amount on next page.) ASSETS: TOTAL FACE ANNUAL VALUE INTEREST Savings Accounts $ $ $ $ Checking Accounts $ $ Certificates of Deposit or Money Markets $ $ $ $ $ $ Stocks $ $ 4 Covenant Place Eligibility Questionnaire

5 $ $ Bonds $ $ Value of Home $ $ (Address) Assets Sub Total: $ $ Regular Gross Income Total: $ $ (From previous page) TOTAL = $ $ Have you or any members of your household, transferred, disposed of or given away any assets for less than fair market value during the past two years? Yes No If yes, describe the assets you disposed of, who received them and the date the transaction(s) occurred: LIABILITIES: Home Mortgage Medical Expenses (non-reimbursed) Other (Please specify) Current Monthly Rent $ $ $ $ STATUS Do you have the legal right to be in the United States? (Please answer for both prospective residents) #1 #2 Yes, because I am a United States Citizen #1 #2 Yes, because I have valid documentation from the Bureau of Citizenship and Immigration Services (formerly the Immigration and Naturalization Service).* #1 #2 No 5 Covenant Place Eligibility Questionnaire

6 *If you answered Yes because you are a non-us Citizen with valid documentation, you must provide documentation and complete paperwork required by the Department of Housing and Urban Development so we can verify that you are a non-citizen with eligible immigration status. I (We) understand that the above information is required to determine my (our) eligibility for residency. I (We) certify and warrant that that the information I (we) have provided is a complete, true and accurate statement of my (our) total income and that all of the information contained herein is true and correct to the best of my (our) knowledge. I (We) further understand that any deviation between the above figures and my (our) actual financial status can affect my (our) eligibility for admission. I (We) understand that making false statements about the information in this form is grounds for rejection or termination of my (our) lease. I (We) understand that this Eligibility Questionnaire is not binding upon Covenant Place or Community Housing Management Corp. (CHMC) and authorize them to obtain any information from any source they deem appropriate regarding the statements in this eligibility questionnaire and agree that this eligibility questionnaire shall remain the property of Covenant Place or CHMC, whether or not this rental is approved. 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 and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosure or improper uses of information collected based on the consent form. Use of the information colleted 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 a prospective resident or participant may be subject to a misdemeanor and fined not more than $5,000. Any prospective resident or participant affected by negligent disclosure of information may bring a civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing Social Security numbers are contained in the Social Security Act at 42 USC 408 (f), (g), and (h). I (We) understand that the information provided in this eligibility questionnaire will be kept in the strictest of confidence. I (We) understand that Covenant Place does not provide nursing care, personal care or any supervision services for residents. Residents themselves must arrange and pay for any services required to meet their needs. Prospective Resident s Signature & Date Prospective Resident s Signature & Date 6 Covenant Place Eligibility Questionnaire

7 06/17/2016 U.S. Department of Housing and Urban Development Office of Inspector General November 2004 Things You Should Know Don t risk your chances for federally assisted housing by providing false, incomplete, or inaccurate information on your application forms. Purpose This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if you knowingly omit information or give false information. Penalties for Committing Fraud The United States Department of Housing and Urban Development (HUD) places a high priority on preventing fraud. If your application or recertification forms contain false or incomplete information, you may be: Evicted from your apartment or house: Required to repay all overpaid rental assistance you received: Fined up to $ 10,000: Imprisoned for up to 5 years; and/or Prohibited from receiving future assistance. Your State and local governments may have other laws and penalties as well. Asking When you meet with the person who is to fill out your application, you should Questions know what is expected of you. If you do not understand something, ask for clarification. That person can answer your question or find out what the answer is. Completing the Application Income When you answer application questions, you must include the following information: All sources of money you or any member of your household receive (wages, welfare payments, alimony, social security, pension, etc.): Any money you receive on behalf of your children (child support, social security for children, etc.); Income from assets (interest from a savings account, credit union, or certificate of deposit: dividends from stock, etc.); Earnings from a second job or part time job; Any anticipated income (such as a bonus or pay raise you expect to receive) 7 Covenant Place Eligibility Questionnaire

8 Assets Assets All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that are owned by you and any adult member of your family s household who will be living with you. Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children. The names of all of the people (adults and children) who will actually be living with you, whet or not they are related to you. Signing Do not sign any form unless you have read it, understand it, and are sure the everything is complete and accurate. Application When you sign the application and certification forms, you are claiming that they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information. Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State, or private agencies to verify that it is correct. Recertifications You must provide updated information at least once a year. Some programs require that you report any changes in income or family/household composition immediately. Be sure to ask when you must recertify. You must report on recertification forms: All income changes, such as increases of pay and/or benefits, change or loss of job and/or benefits, etc., for all household members. Any move in or out of a household member; and, All assets that you or your household members own and any assets that was sold in the last 2 years for less than its full value. Beware of You should be aware of the following fraud schemes: Fraud Do not pay any money to file an application; Do not pay any money to move up on the waiting list; Do not pay for anything not covered by your lease; Get a receipt for any money you pay; and, Get a written explanation if you are required to pay for anything other than rent (such as maintenance charges). Reporting If you are aware of anyone who has falsified an application, or if anyone tries to Abuse persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible, then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline at (800) You can also write to: HUD-OIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington, DC Covenant Place Eligibility Questionnaire

9 HUD OIG THIS DOCUMENT MAY BE REPRODUCED WITHOUT PERMISSION 9 Covenant Place Eligibility Questionnaire

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