___________________________________________________________________________

The following person has been designated to coordinate com. pliance with the nondiscrimination requirement contained in HUD’s regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Attention Program Participants & Landlords! Please note the below change to the recertification process

Tenant will Move at End of Lease: If the tenant would like to move at the end of their lease, the tenant must complete and submit the Non-Renewal Form included in this packet in addition to the recertification forms. The form must be signed by both the tenant and landlord.

Tenant will NOT Move at End of Lease: If the tenant will not be moving at the end of their lease, the tenant needs only to complete their recertification packet. The landlord no longer needs to complete the Request for Tenancy Approval (RTA) Form for the tenant to stay in-place.

If the landlord has a change in rent, the landlord must complete and submit the Change of Rent Request Form, which can be found on www.saha.org > Landlords > Forms & Packets.

___________________________________________________________________________ . The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s

regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-6221 Page 1 of 4

Recertification Application

BASIC INFORMATION

Main Telephone: Alternate Telephone:

Email Address:

Current Address:

HOUSEHOLD INFORMATION

Head of Household Name

Last:

First:

Last 4 of SSN:

DOB:

62 Years or Older

Yes

No

Full-Time Student

Yes

No

Disabled Individual

Prefer Not to Answer

Yes

No

Highest Level of Education Completed

Prefer Not to Answer

No School

Grade

College

Co-Head

Spouse

Name

Last:

First:

Last 4 of SSN:

DOB:

62 Years or Older

Yes

No

Full-Time Student

Yes

No

Disabled Individual

Prefer Not to Answer

Yes

No

Highest Level of Education Completed

Prefer Not to Answer

No School

Grade

College

Relationship

Name

Last:

First:

Last 4 of SSN:

DOB:

62 Years or Older

Yes

No

Full-Time Student

Yes

No

Disabled Individual

Prefer Not to Answer

Yes

No

Highest Level of Education Completed

Prefer Not to Answer

No School

Grade

College

Relationship

Name

Last:

First:

Last 4 of SSN:

DOB:

62 Years or Older

Yes

No

Full-Time Student

Yes

No

Disabled Individual

Prefer Not to Answer

Yes

No

Highest Level of Education Completed

Prefer Not to Answer

No School

Grade

College

Relationship

Name

Last:

First:

Last 4 of SSN:

DOB:

62 Years or Older

Yes

No

Full-Time Student

Yes

No

Disabled Individual

Prefer Not to Answer

Yes

No

Highest Level of Education Completed

Prefer Not to Answer

No School

Grade

College

Relationship

Name

Last:

First:

Last 4 of SSN:

DOB:

62 Years or Older

Yes

No

Full-Time Student

Yes

No

Disabled Individual

Prefer Not to Answer

Yes

No

Highest Level of Education Completed

Prefer Not to Answer

No School

Grade

College

*Required Documentation: If a household member 18 years or older was marked as a full-time student above, you must attach proof of full-time student status.

For Office Use Only: RSO Verification Date: By:

___________________________________________________________________________ . The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s

regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-6221 Page 2 of 4

FAMILY INCOME INFORMATION

IMPORTANT: SAHA will utilize the U.S. Housing and Urban Development Enterprise Income Verification System (EIV) to verify your household income. SAHA will compare the income information you provide on this application to the information provided to us by EIV. If this process reveals unreported income and / or unreported employment, your assistance may be denied or terminated.

1. Please list the amount of all current income for all family members 18 years or older.

Income Source Household Member

Amount Name of Source Address of Source

Phone Hours (Avg. Per

Week)

Pay Rate

(Hourly) Employment

Wages (Weekly) $

$

$

TANF Earnings (Monthly) $

Child Support Income (Monthly) $

Unemployment Benefits (Weekly) $

Social Security Benefits (Monthly) $

Contributions $

Other Income $

Required Documentation: Please attach the required supporting documentation for all household income. Proof of income must not be older than 120 days.

For Employment Wages: Last 4 consecutive paystubs or letter from employer in company letterhead; If self-employed, income tax records (including Schedule C) for previous year

For TANF Earnings: TANF Award Letter

For Child Support Income: Child support court order or child support printout from Attorney General’s Office

For Social Security Benefits: Social Security/SSI Award Letter

For Unemployment Benefits: Unemployment Benefit Award Letter

For Contributions: Signed Notarized Letter from person providing contributions including frequency and amount

For Other Income: Signed Notarized Letter from person providing income including amount, frequency, and address

EMPLOYMENT INFORMATION CERTIFICATION

By signing below, I am certifying that the income information above is true and correct for each household member. Please Note: Each household member with employment information must sign below.

Household Member Signature Date

Household Member Signature Date

Household Member Signature Date

Household Member Signature Date

___________________________________________________________________________ . The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s

regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-6221 Page 3 of 4

HOUSEHOLD ASSETS

2. Please include all active accounts with financial institutions for each family household member.

Asset Type Household Member Current Balance Name of Financial Institution

Last 4 of Account Number

Checking Account(s) $

$ $ $

Savings Account(s) $

$ $

CD or IRA $

Stocks/ Bonds/Collectibles $

3. Do you own any real estate? YES NO

If Yes, please provide the address. You must provide a copy of the title deed(s) at the time you submit this application.

4. Have you sold any real estate in the past two years? YES NO

If Yes, please provide the address. You must provide a copy of the contract(s) of sale at the time you submit this application.

Required Documentation: Please attach the required supporting documentation for all household assets. Proof of income must not be older than 120 days.

Checking and Savings Accounts: (May Be Required Upon Request)Current bank statements for checking and savings accounts

CD / Stock / Bonds / Etc. Copy of certificates of deposit

Real Estate Deeds for all real estate owned, tax office

EXPENSES AND ALLOWANCES

5. Please list all expenses paid by each household member. Note: Medical Expenses include but are not limited to medical insurance premiums, Medicare deduction, prescriptions, medical supplies, etc.

Child Care Expense Medical Expense

Disability Assistance

Amount

Provider

Address Expense

Reimbursed? YES NO YES NO YES NO

6. Are any of the above expenses paid on behalf of a household member with a disability so an adult in the family, including the person with a disability, can work? YES NO If Yes, name which expense(s):

Required Documentation: Please attach the required supporting documentation for all household expenses.

Child Care Expense (For Children Under 12):

SIGNED notarized letter from child care provider to include amount paid, frequency, and provider’s address

Medical Care Expense (For Elderly/Disabled Families Only):

Pharmacy printout for medical prescriptions not covered by medical insurance within the past 12 months; medical expenses not covered by medical insurance and frequency; cost of medical premiums for health insurance

Disability Assistance: Disability/handicap expenses to care for a disabled family member

___________________________________________________________________________ . The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s

regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-6221 Page 4 of 4

OPTIONAL CONTACT PERSON OR ORGANIZATION

You have the right by law to provide 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 to identify a person/ 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. Check this box if you choose not to provide the contact information. Name of Additional Person or Organization: Address:

Telephone Number: Cell Phone Number:

E-Mail Address: Relationship to Applicant:

Reason for Contact: (Check all that apply)

Emergency Termination of rental assistance Assist with Recertification Process

Unable to contact you Eviction from unit Change in lease terms

Late payment of rent Change in house rules Other:

CERTIFICATION

IMPORTANT: According to Title 18, United States Code, Section 1001, it is a federal crime to knowingly or willfully make any materially false, fictitious or fraudulent statement or representation in any matter to a public housing authority.

The following certification must be signed by all household members 17 years or older. I hereby certify that all the information on this application is true and complete. I understand that by signing this document I authorize the San Antonio Housing Authority (SAHA) to:

• Verify all reported information, which includes comparing all reported information with information retrieved through independent sources. These verifications may include, but are not limited to, the following: Social Security and Supplemental Security Income, state wage information, collection agencies, current and former employers, Temporary Assistance for Needy Families (TANF), child support benefits, child care, financial institutions, veteran’s benefits, worker’s compensation, domestic employment, full-time student status, and pension.

• Obtain all of my criminal history records, if any, from any law enforcement agency. I understand that such records will include arrests and convictions for misdemeanors and felonies, if any, as well as any probation or parole information. This may include screening my records for state lifetime sex offender registrations, if any, using the Dru Sjodin National Sex Offender Database and/or other official federal, state, and local resources.

• Obtain all of my credit history records, if any, from any credit reporting agency, and to obtain a copy of my credit report. SIGNATURES DATE Head of Household

Co-Head /Spouse

Household Member 17 years or older

Household Member 17 years or older

Household Member 17 years or older

Household Member 17 years or older

Household Member 17 years or older

Original is retained by the requesting organization. form HUD-9886 (07/14)ref. Handbooks 7420.7, 7420.8, & 7465.1

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014

and the Housing Agency/Authority (HA) exp. 07/31/2017

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

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

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

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

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 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: (1)HUD and the Housing Agency/Authority (HA) to request verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

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

U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing

Original is retained by the requesting organization. form HUD-9886 (07/14)ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________Head of Household Date

___________________________________________Social Security Number (if any) of Head of Household

__________________________________________________ _______________Spouse Date

__________________________________________________ _______________Other Family Member over age 18 Date

__________________________________________________ _______________Other Family Member over age 18 Date

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

This consent form expires 15 months after signed.

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

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 ofinformation 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 willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $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, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby 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 FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-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 regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor 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 memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.

___________________________________________________________________________ . The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s

regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-5234

FAMILY OBLIGATIONS AND REASONS FOR TERMINATION

The family must find a SAHA-approved unit prior to the Housing Choice Voucher expiration date. Any requests for an extension of the voucher term must be submitted to SAHA in writing before the voucher expiration date. If SAHA extends the voucher term, the family must use the voucher to lease a unit before the extension expiration date stated on the voucher.

The family must supply any information that SAHA or HUD determines necessary in the administration of the program, including submission of required evidence of citizenship or eligible immigration status.

The family must disclose and verify social security numbers and must submit consent forms for obtaining information.

The family must supply any information requested by SAHA or HUD for use in a regularly scheduled reexamination or interim reexamination of family income and composition in accordance with HUD requirements.

The family must attend all reexamination appointments scheduled by SAHA. The family may reschedule an appointment for good cause, or if it is needed as a reasonable accommodation for a person with disabilities. Good cause is defined as an unavoidable conflict, which seriously affects the health, safety or welfare of the family. Requests to reschedule appointments must be made orally or in writing.

The family must report to SAHA in writing any change of income within 10 business days of the change.

Initials The composition of the assisted family residing in the unit must be approved by SAHA. The family must notify SAHA in writing of the birth, adoption, or court-awarded custody of a child within 10 business days.

Initials The family must request SAHA approval to add any other family member as an occupant of the unit. No other person except members of the family may live in the unit except for SAHA-approved foster children or live-in aids.

Initials The family must notify SAHA in writing within 10 business days if any family member no longer lives in the unit.

Initials The family must supply any information requested by SAHA to verify that the family is living in the unit or information related to family absence from the unit.

Initials If any family member will be absent from the unit for a period greater than 45 consecutive days, the family must notify SAHA in writing within 10 days of the member leaving the unit.

Initials The family must notify SAHA and the owner before moving out of the unit or terminating the lease. The family must comply with lease requirements regarding written notice to the owner. The family must provide written notice to SAHA at the same time the owner is notified.

Initials Any information supplied by the family must be true and complete.

Initials The family is responsible for any Housing Quality Standards (HQS) deficiencies caused by the family caused by failure to pay tenant-provided utilities or appliances, or damages to the dwelling unit or premises beyond normal wear and tear caused by any member of the household or guest. Damages beyond normal wear and tear will be considered to be damages which could be assessed against the security deposit.

Initials The family must pay utility bills and provide and maintain any appliances that the owner is not required to provide under the lease. [Form HUD-52646, Voucher]

Initials

Initials

Initials

Initials

Initials

Initials

___________________________________________________________________________ . The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s

regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-5234

Initials The family must allow SAHA to inspect the unit at reasonable times and after reasonable notice.

Initials The family must not commit any serious or repeated violation of the lease. Serious and repeated lease violations include, but are not limited to, nonpayment of rent, disturbance of neighbors, destruction of property, living or housekeeping habits that cause damage to the unit or premises, and criminal activity.

Initials The family must provide SAHA a copy of any eviction notice within 10 business days of the date on the notice from the landlord or the date on the court judgment.

Initials

The family must use the assisted unit for residence by the family. The unit must be the family’s only residence.

Initials The family must not sublease the unit, assign the lease, or transfer the unit. Subleasing includes receiving payment to cover rent and utility costs by a person living in the unit who is not listed as a family member.

Initials The family must not own or have any interest in the unit.

Initials Family members must not commit fraud, bribery, or any other corrupt or criminal act in connection with the program.

Initials If the lease states that utilities will be provided by the landlord, the family must not be the account holder for the landlord-provided utilities or maintain the utilities under any family member’s name. This is considered fraud.

Initials Family members must not engage in drug-related criminal activity or violent criminal activity or other criminal activity that threatens the health, safety or right to peaceful enjoyment of other residents and persons residing in the immediate vicinity of the premises.

Initials Members of the household must not engage in abuse of alcohol in a way that threatens the health, safety or right to peaceful enjoyment of the other residents and persons residing in the immediate vicinity of the premises.

Initials An assisted family or member of the family must not receive HCV program assistance while receiving another housing subsidy, for the same unit or a different unit under any other federal, state or local housing assistance program.

Initials A family must not receive HCV program assistance while residing in a unit owned by a parent, child, grandparent, grandchild, sister or brother of any member of the family, unless SAHA has determined (and has notified the owner and the family of such determination) that approving rental of the unit, notwithstanding such relationship, would provide reasonable accommodation for a family member who is a person with disabilities. [Form HUD-52646, Voucher]

Initials The family must repay all debts owed to SAHA. If the family enters a repayment agreement with SAHA, the family must abide by the terms of the repayment agreement.

By signing below, I acknowledge that I have been informed of the Section 8 certification process, my obligations as a participant in the Section 8 program, and the reasons SAHA may terminate my housing assistance. I understand that failure to abide by the HUD regulations and SAHA policies listed above will result in termination of my family’s housing assistance.

Signature of Head of Household Date

Any individual with a disability or other medical need who requires an accommodation should contact the San Antonio Housing Authority at (210) 477-6262. Si usted no comprende este documento porque está escrito en inglés, por favor llame al (210) 477-6262 para asistencia. Rev. 2/5/14

AHP-2304

This page intentionally left blank.

Family Self-Sufficiency (FSS) Program

ABOUT THE FSS PROGRAM

The San Antonio Housing Authority (SAHA) established the Family Self-Sufficiency (FSS) program to help Public Housing residents and Housing Choice Voucher Program (Section 8) participants to achieve economic independence.

SAHA supports the belief that change is within reach for all families. The FSS program pulls together training, skills development and supportive resources to foster the self-confidence necessary to earn an income that can support the family without assistance.

The goal of the program is to encourage, motivate, assist and provide tools for participants to seek higher education or job training and gain permanent employment in a good paying job with a positive financial future.

BENEFITS / PROGRAM

● Develop tools to becomeself-sufficient

● Learn about job trainingopportunities

● Receive social services referrals● Escrow Account

SERVICES

● Personal case managementservices

● Education and Training CareerCounseling Parenting SkillsFinancial Literacy

● Referrals for social services

APPLICATION PROCESS

Interested head of households should contact the FSS office to complete an application and meet with an FSS case manager.

Eligible applicants will sign a five year contract of participation and complete an individual training and service plan (ITSP) that will serve as a roadmap for achieving goals.

The five years of program participation will be set on achieving the goals listed on the ITSP. The FSS case manager will provide resources and feedback to assist in every participant’s success.

Contact us at:

Monica Gonzalez

210-477-6273

monica_gonzalez@saha.org

ELIGIBILITY: To be eligible for the program, applicants must meet the following guidelines:

● Residents of Public Housing or the Housing Choice Voucher (HCV) Program (Section 8)● Head of Household must be willing to sign a Contract of Participation● Participant must be able to obtain full-time employment (32+ hours per week)● Family should be in good standing with the San Antonio Housing Authority

Any individual with a disability or other medical need who requires an accommodation should contact the San Antonio Housing Authority at                                         (210) 477-6262. Si usted no comprende este documento porque está escrito en inglés, por favor llame al (210) 477-6262

para asistencia.Rev. 10/01/17 | AHP-2304

Family Self-Sufficiency (FSS) Program/Follow Up

Are you interested in receiving services that can help you become self-sufficient?

THE FSS PROGRAM CAN HELP!

SERVICES: ✓ Personal case management services✓ Education and training✓ Career counseling✓ Parenting skills✓ Financial literacy✓ Referrals for social services

BENEFITS/PROGRAM: ✓ Develop tools to become self-sufficient✓ Learn about job training opportunities✓ Receive assistance with job placement✓ Receive social services referrals

For more information, please complete this form and return today! Monica_Gonzalez@saha.org (210) 477-6273 (HCV) Armando_Juarez@saha.org (210) 477-6490 (PH) or mail to 818 S. Flores St., 78204.

Name: ___________________________________________________ Last 4 of SSN: ______________________ Current Address/Property: _____________________________________________________ Zip: _____________ Phone Number: _______________________ Email : _________________________________________ Annual Income: $ ______________________ Number of Members in Household: ______________________

Please check all that apply:

☐ I am looking for a job

☐ I need job training

☐ I need help getting my GED

☐ I have a job but I need help with childcare

☐ I have a job but I need help with transportation

☐ I am interested in higher education opportunities

☐ I am interested in getting my High School Diploma

☐ I would like to take a financial literacy class

_______________________________________ _________________________________ Signature Date

Referred by: _______________________________________________

The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’s regulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

___________________________________________________________________________

.The following person has been designated to coordinate compliance with the nondiscrimination requirement contained in HUD’sregulations implementing Section 504: Benjamin Lugg, 818 South Flores, San Antonio, Texas 78204.

Rev. 10/01/17 | AHP-5341

NON-RENEWAL NOTICE TO LANDLORD/HOUSING AUTHORITY

We, the above named participant and owner, hereby mutually agree to terminate the lease between us for the property occupied by the participant.

Effective Date of Termination: Date

It is further agreed that the Housing Assistance Payments (HAP) being paid to both the owner and the participant under this HAP Contract will cease as of the above effective date. It is understood that if a new HAP Contract is not executed, and should the participant remain in the unit beyond this date, the participant is responsible, in-full, for payment of all rent due.

By signing below, the owner acknowledges that a claim for vacancy loss or damages may not be filed with the San Antonio Housing Authority.

Participant Signature Date

Owner Signature Date

Marque esta casilla si habla español.

PARTICIPANT INFORMATION

Date:

Email:

Work Telephone:

Participant Name (print):

Last 4 of SSN:

Home Telephone:

Current Address:

City: State: Zip Code: OWNER INFORMATION

Owner Name (print): Date:

Email:

Home Telephone: Work Telephone:

Current Address:

City: State: Zip Code:

NOTICE OF OCCUPANCY RIGHTS UNDER THE VIOLENCE AGAINST WOMEN ACT

U.S. Department of Housing and Urban Development OMB Approval No. 2577-0286

Expires 06/30/2017

Form HUD-5380 (06/2017)

San Antonio Housing Authority (SAHA)

Notice of Occupancy Rights under the Violence Against Women Act1

To all Tenants and Applicants

The Violence Against Women Act (VAWA) provides protections for victims of domestic

violence, dating violence, sexual assault, or stalking. VAWA protections are not only available

to women, but are available equally to all individuals regardless of sex, gender identity, or sexual

orientation.2 The U.S. Department of Housing and Urban Development (HUD) is the Federal

agency that oversees that SAHA’s Assisted Housing Programs are in compliance with VAWA.

This notice explains your rights under VAWA. A HUD-approved certification form is attached

to this notice. You can fill out this form to show that you are or have been a victim of domestic

violence, dating violence, sexual assault, or stalking, and that you wish to use your rights under

VAWA.”

Protections for Applicants

If you otherwise qualify for assistance under the Assisted Housing Programs you cannot be

denied admission or denied assistance because you are or have been a victim of domestic

violence, dating violence, sexual assault, or stalking.

Protections for Tenants

If you are receiving assistance under the Assisted Housing Programs, you may not be denied

assistance, terminated from participation, or be evicted from your rental housing because you are

or have been a victim of domestic violence, dating violence, sexual assault, or stalking.

1 Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual orientation. 2 SAHAs cannot discriminate on the basis of any protected characteristic, including race, color, national origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or marital status.

2

Form HUD-5380 (06/2017)

Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,

dating violence, sexual assault, or stalking by a member of your household or any guest, you

may not be denied rental assistance or occupancy rights under the Assisted Housing Programs

solely on the basis of criminal activity directly relating to that domestic violence, dating

violence, sexual assault, or stalking.

Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom

you stand in the place of a parent or guardian (for example, the affiliated individual is in your

care, custody, or control); or any individual, tenant, or lawful occupant living in your household.

Removing the Abuser or Perpetrator from the Household

SAHA may divide (bifurcate) your lease in order to evict the individual or terminate the

assistance of the individual who has engaged in criminal activity (the abuser or perpetrator)

directly relating to domestic violence, dating violence, sexual assault, or stalking.

If SAHA chooses to remove the abuser or perpetrator, SAHA may not take away the rights of

eligible tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or

perpetrator was the sole tenant to have established eligibility for assistance under the program,

SAHA must allow the tenant who is or has been a victim and other household members to

remain in the unit for a period of time, in order to establish eligibility under the program or under

another HUD housing program covered by VAWA, or, find alternative housing.

In removing the abuser or perpetrator from the household, SAHA must follow Federal, State, and

local eviction procedures. In order to divide a lease, SAHA may, but is not required to, ask you

for documentation or certification of the incidences of domestic violence, dating violence, sexual

assault, or stalking.

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Form HUD-5380 (06/2017)

Moving to Another Unit

Upon your request, SAHA may permit you to move to another unit, subject to the availability of

other units, and still keep your assistance. In order to approve a request, SAHA may ask you to

provide documentation that you are requesting to move because of an incidence of domestic

violence, dating violence, sexual assault, or stalking. If the request is a request for emergency

transfer, the SAHA may ask you to submit a written request or fill out a form where you certify

that you meet the criteria for an emergency transfer under VAWA. The criteria are:

(1) You are a victim of domestic violence, dating violence, sexual assault, or

stalking. If SAHA does not already have documentation that you are a victim of

domestic violence, dating violence, sexual assault, or stalking, SAHA may ask

you for such documentation, as described in the documentation section below.

(2) You expressly request the emergency transfer. SAHA may choose to

require that you submit a form, or may accept another written or oral request.

(3) You reasonably believe you are threatened with imminent harm from

further violence if you remain in your current unit. This means you have a

reason to fear that if you do not receive a transfer you would suffer violence in the

very near future.

OR

You are a victim of sexual assault and the assault occurred on the premises

during the 90-calendar-day period before you request a transfer. If you are a

victim of sexual assault, then in addition to qualifying for an emergency transfer

because you reasonably believe you are threatened with imminent harm from

further violence if you remain in your unit, you may qualify for an emergency

transfer if the sexual assault occurred on the premises of the property from which

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Form HUD-5380 (06/2017)

you are seeking your transfer, and that assault happened within the 90-calendar-

day period before you expressly request the transfer.

SAHA will keep confidential requests for emergency transfers by victims of domestic violence,

dating violence, sexual assault, or stalking, and the location of any move by such victims and

their families.

SAHA emergency transfer plan provides further information on emergency transfers, and SAHA

must make a copy of its emergency transfer plan available to you if you ask to see it.

Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,

Sexual Assault or Stalking

SAHA can, but is not required to, ask you to provide documentation to “certify” that you are or

have been a victim of domestic violence, dating violence, sexual assault, or stalking. Such

request from SAHA must be in writing, and SAHA must give you at least 14 business days

(Saturdays, Sundays, and Federal holidays do not count) from the day you receive the request to

provide the documentation. SAHA may, but does not have to, extend the deadline for the

submission of documentation upon your request.

You can provide one of the following to SAHA as documentation. It is your choice which of the

following to submit if SAHA asks you to provide documentation that you are or have been a

victim of domestic violence, dating violence, sexual assault, or stalking.

• A complete HUD-approved certification form given to you by SAHA with this notice,

that documents an incident of domestic violence, dating violence, sexual assault, or

stalking. The form will ask for your name, the date, time, and location of the incident of

domestic violence, dating violence, sexual assault, or stalking, and a description of the

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Form HUD-5380 (06/2017)

incident. The certification form provides for including the name of the abuser or

perpetrator if the name of the abuser or perpetrator is known and is safe to provide.

• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or

administrative agency that documents the incident of domestic violence, dating violence,

sexual assault, or stalking. Examples of such records include police reports, protective

orders, and restraining orders, among others.

• A statement, which you must sign, along with the signature of an employee, agent, or

volunteer of a victim service provider, an attorney, a medical professional or a mental

health professional (collectively, “professional”) from whom you sought assistance in

addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of

abuse, and with the professional selected by you attesting under penalty of perjury that he

or she believes that the incident or incidents of domestic violence, dating violence, sexual

assault, or stalking are grounds for protection.

• Any other statement or evidence that SAHA has agreed to accept.

If you fail or refuse to provide one of these documents within the 14 business days, SAHA does

not have to provide you with the protections contained in this notice.

If SAHA receives conflicting evidence that an incident of domestic violence, dating violence,

sexual assault, or stalking has been committed (such as certification forms from two or more

members of a household each claiming to be a victim and naming one or more of the other

petitioning household members as the abuser or perpetrator), SAHA has the right to request that

you provide third-party documentation within thirty 30 calendar days in order to resolve the

conflict. If you fail or refuse to provide third-party documentation where there is conflicting

evidence, SAHA does not have to provide you with the protections contained in this notice.

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Form HUD-5380 (06/2017)

Confidentiality

SAHA must keep confidential any information you provide related to the exercise of your rights

under VAWA, including the fact that you are exercising your rights under VAWA.

SAHA must not allow any individual administering assistance or other services on behalf of

SAHA (for example, employees and contractors) to have access to confidential information

unless for reasons that specifically call for these individuals to have access to this information

under applicable Federal, State, or local law.

SAHA must not enter your information into any shared database or disclose your information to

any other entity or individual. SAHA, however, may disclose the information provided if:

• You give written permission to SAHA to release the information on a time limited basis.

• SAHA needs to use the information in an eviction or termination proceeding, such as to

evict your abuser or perpetrator or terminate your abuser or perpetrator from assistance

under this program.

• A law requires SAHA or your landlord to release the information.

VAWA does not limit SAHA’s duty to honor court orders about access to or control of the

property. This includes orders issued to protect a victim and orders dividing property among

household members in cases where a family breaks up.

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Form HUD-5380 (06/2017)

Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or

Assistance May Be Terminated

You can be evicted and your assistance can be terminated for serious or repeated lease violations

that are not related to domestic violence, dating violence, sexual assault, or stalking committed

against you. However, SAHA cannot hold tenants who have been victims of domestic violence,

dating violence, sexual assault, or stalking to a more demanding set of rules than it applies to

tenants who have not been victims of domestic violence, dating violence, sexual assault, or

stalking.

The protections described in this notice might not apply, and you could be evicted and your

assistance terminated, if SAHA can demonstrate that not evicting you or terminating your

assistance would present a real physical danger that:

1) Would occur within an immediate time frame, and

2) Could result in death or serious bodily harm to other tenants or those who work on the

property.

If SAHA can demonstrate the above, SAHA should only terminate your assistance or evict you if

there are no other actions that could be taken to reduce or eliminate the threat.

Other Laws

VAWA does not replace any Federal, State, or local law that provides greater protection for

victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to

additional housing protections for victims of domestic violence, dating violence, sexual assault,

or stalking under other Federal laws, as well as under State and local laws.

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Form HUD-5380 (06/2017)

Non-Compliance with the Requirements of This Notice

You may report a covered housing provider’s violations of these rights and seek additional

assistance, if needed, by contacting or filing a complaint with the San Antonio HUD Field Office

located at Hipolito Garcia Federal Building, 615 East Houston Street, Suite 347, San Antonio,

TX 78205-2001, Phone: 210-475-6806, TTY: 800- 877-8339.

For Additional Information

You may view a copy of HUD’s final VAWA rule at https://www.federalregister.gov/d/2016-

25888.

Additionally, SAHA must make a copy of HUD’s VAWA regulations available to you if you ask

to see them.

For questions regarding VAWA, please contact SAHA Fair Housing Representative Laura

Longoria by phone: 210- 477-6508, or by email: Laura_Longoria@saha.org.

For help regarding an abusive relationship, you may call the National Domestic Violence Hotline

at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may

also contact Battered Women and Children’s Centers through the 24-Hour Crisis Line: 210-733-

8810.

For tenants who are or have been victims of stalking seeking help may visit the National Center

for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-

programs/stalking-resource-center.

For help regarding sexual assault, you may contact Rape Abuse and Incest National Network

(RAINN) through the National Sexual Assault Hotline: 1-800-656-HOPE (4673).

Victims of stalking seeking help may contact the National Center for Victims of Crime at 1-855-

4-VICTIM (84-2846).

Attachment: Certification Form HUD-5382

Form HUD-5382 (06/2017)

CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286 DOMESTIC VIOLENCE, and Urban Development Exp. 06/30/2017 DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING, AND ALTERNATE DOCUMENTATION Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and program participants in certain HUD programs from being evicted, denied housing assistance, or terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual orientation.

Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your housing provider may give you a written request that asks you to submit documentation about the incident or incidents of domestic violence, dating violence, sexual assault, or stalking. In response to this request, you or someone on your behalf may complete this optional form and submit it to your housing provider, or you may submit one of the following types of third-party documentation:

(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an attorney, or medical professional, or a mental health professional (collectively, “professional”) from whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or “stalking” in HUD’s regulations at 24 CFR 5.2003. (2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or administrative agency; or (3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or tenant.

Submission of Documentation: The time period to submit documentation is 14 business days from the date that you receive a written request from your housing provider asking that you provide documentation of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing provider may, but is not required to, extend the time period to submit the documentation, if you request an extension of the time period. If the requested information is not received within 14 business days of when you received the request for the documentation, or any extension of the date provided by your housing provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or issuance of this form does not serve as a written request for certification. Confidentiality: All information provided to your housing provider concerning the incident(s) of domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details shall not be entered into any shared database. Employees of your housing provider are not to have access to these details unless to grant or deny VAWA protections to you, and such employees may not disclose this information to any other entity or individual, except to the extent that disclosure is: (i) consented to by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing regarding termination of assistance; or (iii) otherwise required by applicable law.

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Form HUD-5382 (06/2017)

TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE, DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING 1. Date the written request is received by victim: _________________________________________ 2. Name of victim: ___________________________________________________________________ 3. Your name (if different from victim’s):________________________________________________ 4. Name(s) of other family member(s) listed on the lease:___________________________________ ___________________________________________________________________________________ 5. Residence of victim: ________________________________________________________________ 6. Name of the accused perpetrator (if known and can be safely disclosed):____________________ __________________________________________________________________________________ 7. Relationship of the accused perpetrator to the victim:___________________________________ 8. Date(s) and times(s) of incident(s) (if known):___________________________________________ _________________________________________________________________ 10. Location of incident(s):_____________________________________________________________ This is to certify that the information provided on this form is true and correct to the best of my knowledge and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence, dating violence, sexual assault, or stalking. I acknowledge that submission of false information could jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or eviction. Signature __________________________________Signed on (Date) ___________________________ Public Reporting Burden: The public reporting burden for this collection of information is estimated to average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The information provided is to be used by the housing provider to request certification that the applicant or tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is subject to the confidentiality requirements of VAWA. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid Office of Management and Budget control number.

In your own words, briefly describe the incident(s): ______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

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