Public Housing/Mixed Finance Annual Recertification

Public Housing/Mixed Finance Annual Recertification

You should only complete this form if your recertification specialist has contacted you and asked you to do so. If you are receiving an error when trying to submit your form, confirm you did not miss any questions or try a different browser (Google Chrome, Firefox, etc.) or a different computer/device.

Program Type*

If you do not see your program listed below, please go back to the AMHA main page and select the correct Annual Recertification for your program.

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Public Housing Development Name*

Please select the development in which you live. If you are not on this program type, select "None of the properties listed." If you live at one of these properties, please make sure you have selected "Public Housing" for your Program Type above.

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Head of Household Last 4 SSN*

Head of Household First Name*

Head of Household Last Name*

Phone*

Email Address*

We may need to contact you for additional information, so please provide your email address. If you don't have an email address, please put n/a.

Address*

List your full address including CITY, STATE, and ZIP CODE.

If you need to change, update, or remove your contact person’s information from Form HUD-92006, Optional Contact Information, please mark yes here.

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Household Composition

1.) Current Household Composition*

For each household member, including yourself, list: 1. Name 2. Last 4 of SSN 3. Sex 4. Relationship to you

2.) Has anyone moved out of your household in the past 12 months?*

Including by death, marriage, divorce, separation, permanent placement in nursing home, placement in a foster home, etc

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Name of person(s) who has moved out of your unit:*

Please provide proof of their new address.

Move Out Date*

3.) Is any member of your household subject to a lifetime registration requirement under a state sex offender registration program?*

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If yes, name of person who is subject to sex offender registration:*

4.) Are you currently married and your spouse does not reside in the household?*

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If yes, what is your spouse's name:*

If yes, what is your spouse's address?*

If yes, what is the amount your spouse contributes to your household*

Income Checklist

Be sure to include ALL income for every member of your household. If you need more space for additional income, there will be room at the end of this section to add more income.

5.) Will any household member be receiving any type of income from employment?*

Please provide 3 current and consecutive pay stubs for each job.

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Household Member Name*

Employer Name and Address*

Rate of Pay*

Hours Worked Per Week*

Household Member Name (2)

Employer Name (2)

Rate of Pay (2)

Hours Worked Per Week (2)

6.) Has any employment ended for anyone in your household in the last 12 months?*

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What employment has ended?*

For each job that has ended, list: 1. Household member name 2. Employer name and address 3. Start date 4. End date

7.) Has anyone in the household earned income from self-employment or occasional income currently or in the past 12 months?*

Such as bottle/can collecting, yard work, baby sitting, car repair, independent contractor, day laborer, etc. Please provide Schedule C or other proof of income.

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If yes, did they file taxes using the IRS Schedule C for self-employment?*

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Household Member Name*

Self-Employment Description*

Type of business AND date business started

Self-Employment Monthly Income*

8.) Is anyone in the household currently or in the past 12 months receiving Social Security, Dual Entitlement or SSI?*

Please provide a copy of the current award letter.

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Household Member Name*

SS/SSI Monthly Income*

Household Member Name (2)

SS/SSI Monthly Income (2)

9.) Is anyone in the household currently or in the past 12 months receiving TANF/OWF or any State cash assistance?*

Please provide a current award letter or a print-out from the DJFS portal showing the benefit amount.

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Household Member Name*

TANF Monthly Income*

10.) Is anyone in the household currently or in the past 12 months receiving alimony or child support payments?*

Please provide a 12 month print-out or proof of no payment for ALL child support cases.

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Household Member Name*

What county (or counties) is your child support paid through?*

Child Support Monthly Income*

Household Member Name (2)

Child Support Monthly Income (2)

11.) Is anyone in the household currently or in the past 12 months receiving unemployment compensation, disability compensation or severance pay?*

Please provide proof of the current benefit amount.

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Is anyone in the household waiting on an unemployment determination?

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Household Member Name*

Unemployment Weekly Amount*

Household Member Name (2)

Unemployment Weekly Amount (2)

12.) Is any household member, 18 or older, currently or in the past 12 months receiving pay as a member of the Armed Services?*

Please provide 3 current and consecutive pay stubs.

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Household Member Name*

Armed Forces Monthly Income*

13.) Is any household member currently or in the past 12 months receiving recurring monetary contributions or other payments to help the assisted family from a non-household member?*

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Household Member Name*

Name and Address of Person(s) Providing Assistance*

Monthly Amount*

Will these contributions last longer than the next 12 months?*

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14.) Is anyone in the household currently or in the past 12 months receiving periodic payments from annuities, insurance policies, retirement funds, pensions, death benefits, or other similar amounts?*

Please provide a current award letter.

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Household Member Name*

Benefit Provider Name*

Benefit Monthly Amount*

15.) Does your household have any other income currently or in the past 12 months that is not already listed above?*

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Other Income Description*

For each additional type of income please list: 1. Household member name 2. Type of income 3. Income per month

16.) Is there an adult in your household that currently has zero income?*

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Name of household member that has no income.*

How much PER MONTH does the zero income person pay total for their phone, cleaning products, personal care items, gas, bus passes, loans or credit card payments, and cable/internet?*

Type in amount paid per month for all expenses.

Have your expenses been the same over the last 12 months?*

Select or enter value

If no, which months were different and what was the amount?*

List the month and the total amount of monthly expenses for that month.

Who will pay for these expenses for the zero income person?*

List the person’s name, address, and phone number of who you anticipate will pay.

Will these contributions last longer than the next 12 months?*

Select or enter value

As the head of household, I am certifying that this member has NO income. I understand that I am required to report within 10 days, in writing, any changes in income and household composition. Failure to report this information may result in owing AMHA back rent and/or the termination of my subsidy.*

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Deductions Checklist

All questions apply to every member of your household.

17.) Is any household member over the age of 18 currently attending school?*

Please provide a current school schedule listing the student's credit hours.

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Are they receiving financial assistance?*

Please provide proof of current financial assistance amounts and cost of tuition.

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Household Member Name*

Name of School*

Are they attending full-time or part-time?*

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18.) Is any household member paying for unreimbursed childcare expenses?*

Please provide proof of payment for childcare.

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Household Member Name*

Childcare Provider Name and Address*

Out of Pocket Monthly Childcare Expense*

19.) Is the head of household, co-head, or spouse elderly (62 or older), handicapped, or disabled?*

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Will any household member be paying any type of unreimbursed medical expenses?*

Including but not limited to: Medicare, pharmacies, doctor visits, dentist, medical insurance providers, hospitals bills which you are paying on, or other related medical expenses.

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Will the expenses be UNDER $500 or OVER $500?*

If you select over $500, you MUST provide proof of all medical expenses you have paid in the last 12 months to receive credit.

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Medical Expense Description*

For each provider list: 1. Provider name 2. Provider address 3. Anticipated annual expense Please provide proof of payment for medical expenses.

20.) Are there any deductions from your Social Security or SSI Checks?*

Please provide proof of deduction amount and reason from Social Security.

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How much is deducted and for what reason?*

21.) Is anyone in your household paying child support/alimony?*

Not applicable to rent calculation for HUD Project Based Section 8 Properties.

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How much is paid out monthly?*

Asset Checklist

All questions apply to every member of your household.

Does your household have assets with a net value under or over $50,000?*

Examples of assets include checking and savings accounts, trust funds, real estate, stocks, bonds, certificates of deposit, mutual funds, money market funds, pensions that you are not withdrawing from, whole life insurance policies, personal investment items such as coin or stamp collections, etc. The annual income from your net assets (as defined in 24 CFR Part 5) will be included in the total gross income for this household.

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If UNDER, I/We certify that our net assets do not exceed $50,000. Please list the amount of income received from your assets (interest, dividends, etc.). If no income is received from your assets, please put $0.*

If OVER, our household assets are held in the following accounts:*

For each asset, list: 1. Asset/Bank Name 2. Account Type 3. Address of Provider 4. Total Net Asset

32.) Have you disposed of any assets for less than Fair Market Value in the past two years?*

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Asset Disposal Description*

For each asset disposed of list: 1. Type of asset 2. Fair Market Value of asset 3. Amount disposed of asset for

Document Attachment

Please attach proof of ALL income, expenses, and assets that you marked above.

File Attachments

Drag and drop files here or

Personal Information

33.) Emergency Contact*

Please list: 1. Name 2. Relationship to you 3. Address including city, state, and zip code 4. Phone number

Community Service and Self-Sufficiency Requirement

Each adult resident (18 years or older) of the PHA shall:

Contribute 8 hours per month of community service (not including political activities) within the community in which that adult resides; or
Participate in an economic self-sufficiency program (defined below) for 8 hours per month; or
Perform 8 hours per month of combined activities (community service and economic self-sufficiency program).

Complete the below questions for each household member age 18 or older.

Head of Household: I certify that I am eligible for exemption from the Community Service requirement for the following reason: (Choose all that apply)*

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Adult 1 CSSR Other*

Adult #2: I certify that I am eligible for exemption from the Community Service requirement for the following reason: (Choose all that apply)*

If there are no additional adults in the household, select "no one else 18 or older in household" in drop down list.

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Adult 2 CSSR Other*

Adult #3: I certify that I am eligible for exemption from the Community Service requirement for the following reason: (Choose all that apply)*

If there are no additional adults in the household, select "no one else 18 or older in household" in drop down list.

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Adult 3 CSSR Other*

Resident Certifications

Please review each statement and choose "Yes" that you have read and understand the statement. If you have any questions regarding the certifications, please contact your recertification specialist.

Reporting Changes*

I understand that I am required to report within 10 days of my knowledge, in writing, any changes in income and household composition. I am also required to report, in writing, any absence from my subsidized unit that will last for 30 days or more. If the entire family is absent for more than 60 consecutive days, the unit will be considered vacated and assistance will be terminated. Failure to report this information may result in owing AMHA back rent and/or the termination of my subsidy.

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Non-Waiver Acknowledgement*

The Akron Metropolitan Housing Authority (AMHA) and the Tenant, (the Parties) acknowledge that the tenancy involved herein is a Federally subsidized public housing tenancy. The Parties further acknowledge a mutual duty to comply with various Federal rules and regulations, including annual recertification. In order to prevent any interruption of the Tenant’s receipt of current subsidy and to assure compliance with both federal regulation and state law, the Parties wish to proceed with recertification but agree that completing the recertification is not intended and shall not be considered to create a new tenancy or as the extension of any current tenancy. Any breach of the terms of the tenancy occurring prior to the date of recertification shall remain a current and continuing breach of the tenancy after recertification subject to federal and state law limitations; shall not be extinguished or waived by AMHA’s processing of recertification and; may result in lease termination.

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AMHA Hardship Policies*

What is a hardship?

• A request to be exempted from one of AMHA’s MTW policies.

What should I do if I have a hardship?

• Go to AMHA’s website (www.akronhousing.org) under the Resources tab. Click on Income Change/Hardship Form. You must attach the required proof of your hardship or the request will be denied.

Hardship policies – not all may apply to your household.

• Tiered Rent Hardship

o Who: Households that were assigned to have their rent calculated by the tiered rent method.

o Reasons:

Decreased income

At least $2,500 in qualifying childcare expenses

Large family (6 or more dependents)

Newly full-time student (not head, co-head, or spouse)

Other circumstances (such as a significant increase in expenses like a large medical bill, death in the family, etc.)

o Required hardship proof: Complete the form and attach ALL current income for ALL household members.

• Elderly/Disabled Household Triennial Reexaminations Hardship

o Who: Households with an elderly or disabled head or co-head who have been assigned to income reviews every three years instead of annually.

o Reason: If the household has a hardship that cannot be handled with the income change/change of family status process.

o Required hardship proof: Complete the form and attach proof of the hardship.

• Standardized Medical Deduction Hardship

o Who: Households with a head or co-head that is elderly or disabled and have unreimbursed medical expenses of more than $500.

o Reason: Unreimbursed medical expenses are more than $500.

o Required hardship proof: Complete the form and attach proof of all paid medical expenses.

What happens after I submit a hardship?

• AMHA staff will review the hardship in a timely manner. If AMHA denies the hardship, you will be sent a letter explaining why the hardship was denied.

• If you disagree with the hardship decision, you may use the following grievance procedure:

o Request a grievance review within and including ten (10) business days of the decision to deny or limit the hardship request.

Where can I find more information?

• Go to AMHA’s website (www.akronhousing.org) under the Resources tab. Go to Annual Plan and review the full plan for your program (Public Housing ACOP or HCVP Admin Plan) and the MTW Supplement.

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Request for Reasonable Accommodation Procedure*

Federal and Ohio laws state that qualified individuals with disabilities shall not be discriminated against and shall be assured an equal opportunity to participate in the housing programs, activities, and services offered by the Akron Metropolitan Housing Authority (AMHA). An individual with a disability may request a reasonable accommodation by completing the Request for Reasonable Accommodation and Authorization for Release of Information form and submitting it to the RA Coordinator at 100 West Cedar Street, Akron, Ohio 44307. Alternative means of requesting reasonable accommodations can be arranged upon request. Reasonable accommodations may include, but are not limited to, the following categories: 1.) A change in AMHA policies and procedures 2.) A repair or change in your apartment 3.) A repair or change to some other part of the property 4.) A change in location 5.) A change in the way AMHA communicates with you The determination of reasonable accommodation is an interactive process which may include consultation with the individual seeking an accommodation, his/her medical professional, and/or his/her designee. An accommodation must be both reasonable and have an identifiable and substantial relationship to the individual's disability. All requests are reviewed on a case-by-case basis. In determining whether a request for accommodation is reasonable, the following questions will be considered: 1.) Is there an identifiable relationship or nexus between the request and disability? 2.) Is an alternative accommodation possible? 3.) Does the request pose a direct threat to others? 4.) Is the request a fundamental alteration of the nature of AMHA services and/or programs? 5.) Does the request pose an undue financial and administrative burden? If additional information or verification of disability-related information is needed, including additional medical verification, you will be contacted to discuss your request. AMHA will provide the decision in writing or, where appropriate, in another format accessible to the individual requesting the accommodation. If the applicant wishes to appeal the decision, he/she may do so, in writing, within fourteen (14) working days from the date the decision letter was sent to the applicant. For questions, contact the AMHA RA Coordinator at 330-376-9788 or 330-762-9631 (Ohio Relay: 1-800-750-0750 TTY/TTD).

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REMINDER

Your annual certification is NOT COMPLETE until you also sign the electronic release forms. Link provided after you hit Submit on this form.

Electronic Signature - Type your FULL NAME*

I/We certify that the above information given to the Akron Metropolitan Housing Authority on household composition, income, net family assets, allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We certify that I have disclosed where I received any previous Federal Housing Assistance and whether or not any money was owed. I/We also understand that giving false statements or information can be grounds for termination of housing assistance and is punishable under Federal or State criminal law.

If there is a 2nd adult in your house, please have them electronically sign below.

If there is a 3rd adult in your house, please have them electronically sign below.

If there is a 4th adult in your house, please have them electronically sign below.

Please review the electronic signature lines above. Do the correct, FULL NAMES show?*

If no, please re-type your name on the Electronic Signature line.

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