INTERVIEW CHECKLIST
Name(s): ______
To be completed by the site Manager with the Applicant, Head and Co-Head of Household while reviewing the Recertification Questionnaire or Application:
Household Members
Based on the information provided on the Application or Recertification Questionnaire, has the family composition changed in any way?
Eligibility Questions
Do you have a family member who is absent from the home due to:Employment, Military Service, Placement in Foster Care, Temporarily in Nursing Home or Hospital, Permanently confined to a Nursing Home, Away at School?
Do you have a live-in attendant?
Are you expecting a change in household composition? Such asexpecting a baby, adopting a child(ren), custody of a child(ren), getting a foster child?
Do you have joint custody of a child(ren), a foster child(ren) or fosteradult?
Will a member of your household turn 18 in the next twelve months? Name ______
Income Asset
A.Income:
Based on the information provided on the Application or Recertification Questionnaire has the family income changed in any way?
I have reviewed each income category on the Application or Recertification Questionnaire with you is there any income source of any kind missing.
Did you or any other members of the household file a Federal Tax Returnlast year?
Are there any adult members of the household (18 years ofage or older) receiving income not listed on the application or recertification questionnaire?
If yes, name and specify the source of the income
B.Assets:
Based on the information provided on the Application or Recertification Questionnaire has any Asset been changed, added or closed?
I have reviewed each income category on the Application or Recertification Questionnaire with you, is there any income source of any kind missing.
Have you or any other members of your household received any lump sum payments, such as:Inheritance, Lottery Winnings, Insurance Settlement, Other?
Have you or any other household members disposed of anyasset(s) for less than fair market value in the past two (2)years?
Do you or any other household members have any assetsthat are held jointly with another person?
Allowances
Are there any full-time or part-time students 18 years of ageor older in the household?
Do you currently pay for child care services for childrenunder the age of 13 residing in your household?
Is this service necessary in order for youto be employed seek employment or to attend school?
Are there any of these expenses reimbursed byan outside source?
Elderly and Disability Allowances
Is any household member elderly (age 62 or older) or a personwith disabilities?
If yes proceed to the remaining questions.
Do you have medical expenses that are not paid for by anoutside source such as insurance?
Do you have disability expenses that are not paid for by anoutside source?
Is this service necessary in order for you or member 18 or older to be employed?
Do you have care attendant expenses?
Is this service necessary in order for youor member to be employed or to attend school?
Are there any of these expenses reimbursed byan outside source?
Penalties for committing fraud; The United States Department of Housing & Urban Development (HUD) places a high priority on preventing fraud. If your application or recertification forms contain false or incomplete information, you may be:
- Evicted
- Required to repay all overpaid rental assistance you received.
- Fined up to $10,000
- Imprisoned for up to five (5) years
- Prohibited from receiving future assistance
State and local governments may have other laws and penalties as well.
By signing below I am certifying that the answers that I have given are true and complete to the best of my knowledge. I understand that if the family composition changes, the employment status of a household member or the household income changes by $200 or more per month I must notify the office for to start the interim certification process.
//
Head of Household Date
//
Co-Head of Household Date
//
Owner/AgentConducting Interview. Date
10.26 Revision 1/1/2013 Effective 1/1/2013 Page 1 of 2