Complete ONE interview per adult or emancipated minor:Please use additional interview forms for EACH adult household member. ALL ADULT household members must complete an Applicant/Resident Interview answering only questions applicable to the member completing the form and his/her dependents.

Date: / Resident Current Unit or Applicant Pending Unit #:

In order to complete your certification/recertification, please bring this questionnaire and all relevant paperwork with you to your appointment. Please be sure to answer all questions “yes” or “no”. Each adult or emancipated minor will answer/complete his/her own “Interview”. If you have questions or need assistance, please call the Management Office at:

NOTE: The office staff will make photocopies of any documents you bring with you to your Interview. Your “original” documents will “not” be kept. Thank you!Please answer ALL questions listed below. Do NOT leave any blank lines.

Section 1 – Contact Information
Resident Name:
Mailing Address:
City: / State / Zip Code
Telephone: / Cell: / Work:
E-mail:
Section 2 – Race and Ethnicity:The information regarding race and ethnicity solicited on this Interview is requested in order to comply with the Programs required reporting requirements and to assure the Federal Government that the Federal Laws prohibiting discrimination against Applicants/Residents on the basis of race, color, national origin, religion, sex, familial status, age, religious preference, sexual orientation and disability are complied with. Your response is optional. However, if you choose not to furnish the information, the Owner is required to note the race/ethnicity of individual Applicants/Residents on the basis of visual observation or surname. Please compete BOTH race and ethnicity sections below.
Ethnicity: Hispanic Non-Hispanic
Race: White Black Asian American Indian/Native Alaskan Native Hawaiian/Pacific Islander
Black/African American & White Other: ______
Section 3 – Household Status Information:List everyone living in household including yourself and their relationship to the Head of Household:
Name of Household Member / Relationship / Elderly/Disabled
(as applicable)
Your Marital Status:Single Married Divorced Never Married Widow/Widower Separated Legally Separated
Documentation required as applicable, Divorce Decree, Marriage License, Statement of Marital Separation (TC-81), etc.
Section 3 – Household Status Information– continued: / Yes / No / Household Member Name / When/Where?
Have you removed any person(s) from your household since you completed an application or certification?
TC-34 or RS-30ahp if removing from application & Documentation required.
Have you added any person(s) to your household since you completed an application or certification? Documentation required.
Do you anticipate adding any new household members in the next 12 months? (marriage, child custody, unborn children, adoption, etc.) Documentation required.
Are any household members temporarily absent? (school, military, nursing home, etc.)
Are there foster children/adults who are a part of your household? Documentation required.
Are there any live-in care attendants who will live in your household? Documentation required.
Section 4 – Student Status Information: / Yes / No / If Yes, List Name(s) / If Yes, List School(s)
Are ANY current household members, age 18 years or older currently attending school?
If Yes: Full Time? Part Time?
If “yes”, use Form TC-13 & Current School Schedule
Have ANY current household members attended school in any of the past 12 consecutive calendar months? (Include K-12) Dates of attendance:______
Section 5 – Earned Income: / Yes / No / If Yes, List Source(s) / Amount
Has your Employment Status changed since you applied or certified within the last 6 months? Forms: TC-1, TC-18, and/or TC-19 / $
Are you currently employed? 6-8 Consecutive Pay Stubs / $
Has Employment been continuous? / $
Is Employment:Full Time Part Time / $
Is Employment Seasonal? / $
Do you work overtime? / $
Do you earn tips/commissions/bonuses? / $
Self-Employment? Form TC-10 Provide Schedule C from Federal Tax Return; accountant statement, gross receipts, etc. / $
Has self-employment been continuous? / $
Income under a work program? (such as: Work-study, Job Training, Job Core, etc.) Form TC-1 (may or may not be exempt) / $
Income under Title V of the Older American Act? (such as: RSVP, Green Thumb, Senior Aides, Older American Community Service Employment Program, etc.) Form TC-1 (may or may not be exempt) / $
Are you receiving severance pay from a previous employer?
Form TC-18 / $
Do/Will you serve in the Armed Forces? Form TC-7 / $
Active Duty? / $
Reserves or National Guard? / $
Section 6– Unearned Income: / Yes / No / If Yes, List Source(s) / Amount
Do/Will you or any of your dependents receive SSA and/or SSI benefits (Social Security Admin. and/or Supplemental Security Income)? Form TC-6 / $
Do/Will you or any of your dependents receive Veterans, Civil Service or other pensions? Form TC-2 or TC-3 / $
Do/Will you receive a Lump Sum payment from any source? Form TC-2 / $
Do/Will you receive Worker’s Compensation? Form TC-17 / $
Do/Will you receive any Student Loans, Grants, Scholarships, GI Bill, etc.? Form TC-13 / $
Do/Will you receive any Graduate Student Assistanceships, etc.?
Form TC-13 / $
Do/Will you receive any Disability Pay or Benefits (not listed above)?Form TC-2 / $
Section 6– Unearned Income- continued: / Yes / No / If Yes, List Source(s) / Amount
Do you receive money from Death/Health/Accident insurance payments not listed above? Form TC-47, Form TC-2 / $
Are you entitled to, have filed or been awarded Unemployment Benefits? Form TC-4 / $
Do/Will you receive General Assistance/TANF, Food Stamps?
Form TC-5 / $
Do/Will you receive monetary (cash) or non-cash contributions from persons/agencies outside your household? (rent, utilities, cell phone, car payments, insurance, living expenses, etc.)?
Form TC-11; for WIC: TC-5, TC-20 / $
Do/Will you receive inheritances and/or lottery winnings? Form TC-15 / $
Do/Will you receive income for foster children/adults? Form TC-5 / $
Are you entitled to Child Support/Alimony? / $
Is the support Court ordered? / $
Are you receiving your Child Support/Alimony?
Form TC-11 or TC-11a / $
If you are NOT collecting your Child Support/Alimony what legal steps have you taken to collect? / $
Do/Will you receive other income not listed above? TC Forms / $
Do you receive ZERO Income? Form TC-19 / $
Section 7 – Assets:
List all assets for you and your dependents
Source Name(s), Address(es), phone(s) and Fax required / Yes / No / If Yes, List Source(s) / Amount
Are any asset(s) held jointly with another person(s)?
Form TC-15a / $
Checking/Draft Account(s)?
Form TC-15 & 6 Months Consecutive Statements / $
Savings/Share Account(s)?
Form TC-15 & Current Statement / $
Certificates of Deposit(s)/Time Deposits (?)
Form TC-15 & Current Statement / $
Money Market Fund(s)? Form TC-15 / $
IRA/KEOGH Account(s) or Other Capital Account(s)?
Form TC-15 & Current Statement / $
Investment(s), Land Contract(s), etc.?
Form TC-15, TC-16 or TC-16a & Current Statement / $
Stock(s)/Bond(s), Lump Sum Receipt(s), etc.?
Form TC-15 & Current Statement / $
Trust(s)?
Form TC-15 & Current Statement / $
If yes, are they irrevocable? / $
Do you have Rental Property or Real Estate? (Home, Mobile Home, Land, etc.) Form TC-16, TC-16a & Current Mortgage and Tax Bill / $
Personal Property Held as Investment(s) (coin collection, art work, antiques, etc.)? Form TC-15 & Documentation required / $
Whole/Term/Burial Life Insurance Policy(ies)?
Form TC-47 & Documentation required / $
Cash Held (on-hand, safe deposit box(es), etc.)?
Form TC-46 & Self-Affidavit / $
Have you disposed of assets for less than fair market value within the past two years? (sold a home, gave/loaned money, etc.)
Form TC-80hrt & Form TC-16, TC-16a (as relevant) & Documentation Required / $
Section 8 – Pets and/or Assistive Animals / Yes / No / If Yes, List Name(s)
Are there any animals in the household?
Proof of current License and vaccinations required.
How Many?
Type and Size:
Section 9- Reasonable Accommodation
If you or a member of your family has a disability and you believe you might need or want a reasonable accommodation, you may request it at any time during or after admission to the property. This is up to you. If you prefer not to discuss your situation with Management…that is your right. Please check appropriate box:
Yes, I wish to request reasonable accommodations (use Form RS-9 and RS-10).
No, reasonable accommodations are not needed. Initials:______
I wish not to discuss the situation with Management.
Section 10- Sex Offender Registration Status
Are you or any member of your household, including minors, subject to a lifetime sex offender registration requirement in any state?
No Yes, If “Yes” please explain:______
______
Section 11- Emergency Contact Information
I authorize ______Address
Phone:E-mail______
In the event of hospitalization, incapacitation, or death to enter my unit and gain access to my possessions.
Additional Reasons for Contact: (Check all that apply)
Emergency
Unable to contact you
Termination of rental assistance / Assist with Recertification Process
Change in lease terms
Late payment of rent / Eviction from unit
Change in house rule
Other:______
PENALTIES FOR MISUSING THIS FORM
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, RHS, Section 42, the PHA and any owner (or any employee of HUD, RHS, Section 42, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person, who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, RHS, Section 42, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
STATEMENT: I certify that all the information on this Questionnaire is true and complete to the best of my knowledge. I understand it is a provision of the Rental Agreement and Housing Program that I report and assist in the verification of actual income of all members of my household. Any false statements or information are punishable under federal law as stated above.
Signature Date

AHPResident Interview (12/2012)Page 1 of 4TC-59a(ahp)