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FNHS HUD Healthy Homes Program – Application Form

Program Overview
The Healthy Homes Program is designed to assist eligible households in improving the safety, health, and livability of their homes. This program primarily serves individuals and families whose income falls within established program guidelines.

To determine eligibility, all household income must be disclosed and verified. Applicants are required to provide documentation for all sources of income as part of the application process. Required documents may include, but are not limited to:

  • Recent pay stubs
  • W-2 forms
  • Tax returns
  • Bank statements
  • Social Security or disability benefit statements
  • Unemployment or other assistance documentation

Applications cannot be reviewed or approved until all income has been fully verified.

Applicant/Resident Information

Applicant Name
Race of Applicant
(To help ensure groups are represented as close to the FNSB general population as possible) – Check all that apply.

Home Information

Home information
Describe any issue that you know of.

Family Information

[Each adult must be listed in the income tables]

Home residents, you must list all household members, their relationship to you, their date of birth, and their social security numbers (for everyone 18 years old or older).

Resident 1

Additional Household Member (2)?

Income

Regular income for the past 12 months (must list all income for all household members over 18).

• “Income type” – check the “Unemployed” box if unemployed.

• “Periods per year” refers to the number of times the salary or benefit is paid per year. Biweekly checks are paid 26 times a year. Monthly checks are paid 12 times a year. Seasonal jobs may be paid over different numbers of periods per year.

• Every source of income requires documentation listed on the next page –Verify these are enclosed by checking the box in the “Docs?” column.

Adult Family Member 1

Please enter: wages/salaries, SSI/SSA/Pensions, Public assistance benefits, Other income sources. Please include pay frequence, i.e., how many times per year.
Unemployed?
Docs?
Add Adult Family member? (2)

Asset Income (must list all assets)

Every asset (bank or other account) requires at least six (6) months of statements, including any income from the assets. Verify these are enclosed by checking the box in the “Docs?” column.

Family Member 1

Additional Family Member? (2)
Docs?

Required Supporting Information:

  • Application form, fully completed, signed by the homeowner or applicant
  • Current mortgage statement (if applicable), property deed, or title

All adult household members must supply: 

  • A driver’s license or state identification card for 18 and over
  • Six (6) months' most recent checking/savings bank statements, ALL pages, for each account
  • 4-6 of the most recent paycheck stubs for all jobs held in the previous year (all wage earners)
  • One (1) year of the most recent federal tax returns
  • Statements from PERS, TRS, deferred compensation, 401 (k) accounts, or other retirement holdings
  • Current Social Security/disability award letter (if applicable)
  • Current pension/annuity letter (if applicable)
  • Unemployment income (if applicable)
Agreement to House or Residence Access (In order to participate in this program, I agree to:
All must be checked

Authorization For Release of Information

CONSENT: I/we authorize and direct any Federal, State, or local agency organization, business, or individual to release to:

FAIRBANKS NEIGHBORHOOD HOUSING SERVICES

Any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under HUD Healthy Homes. I/we understand and agree that this authorization for the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) and U.S. Rural Development in administering and enforcing program rules and policies.

INFORMATION COVERED:

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

Housing Agencies Welfare Agencies State Agencies
Courts and Post Offices State Employment Agencies Native Corporations
Schools and Colleges Social Security Administration Unemployment Agency
Law Enforcement Agencies Medical/Childcare Providers Home Health Providers
Past/Present Employers Credit Providers/Credit Bureaus
Veterans Administration Utility Companies
Retirement Systems Current or Former Landlords
Criminal Activity Family Composition

CONDITIONS:

I/we agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect as long as I am an application or participant in any assisted housing program. I understand that a photocopy of this authorization is as valid as an original.

Signature

Clear Signature
Clear Signature
Clear Signature

FNHS Healthy Homes Project Acknowledgement

• Understand that to be eligible for the FNHS Healthy Homes Project, I must complete the above application, submit all required documentation, and pass the income verification step.

• Certify that all the answers given are true, complete, and correct to the best of my knowledge and belief, and they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive assistance, and that false or misleading statements may constitute disqualification of this application.

• Certify that I currently reside in the residence.

• Certify that I do not intend to sell the residence in the next three years (homeowners only). To get started, replace this text with your own.

Clear Signature
Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

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 applications 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. 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 Fairbanks Neighborhood Housing Services including all Social Security Numbers you, and all other household members, have and use. Giving the Social Security Numbers of all household members is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the required information may result in a delay or rejection of your eligibility approval.

For more information, please contact the program coordinator listed below.

Kara Carlson, Deputy Director, Fairbanks Neighborhood Housing Services Office:

907-451-7230 | Fax: 907-451-7236

properties@fnhs.org

https://www.FNHS.org