Neodesha Housing Authority
118 South 6th / P.O. Box 185
Neodesha, KS 66757
PH 620-325-2440 / FX 620-325-2468
TTY 1-800-766-3777
Equal Opportunity Provider and Employer
Welcome to the Neodesha Housing Authority. Enclosed you will find a handout with information that is beneficial to you in filling out the application. You will also find the application for Public Housing. The information packet is yours to keep. You only need to return the application. If you have any question or need any help at all, feel free to call. E-mail is another great way to stay in contact and ask questions. If you would like to use e-mail please direct them to
or .
Thank you.
Neodesha Housing Authority
118 South 6th / P.O. Box 185
Neodesha, KS 66757
PH 620-325-2440 / FX 620-325-2468
TTY 1-800-766-3777
PROGRAMS THROUGH THE NEODESHA HOUSING AUTHORITY
The Neodesha Housing Authority administers two subsidized housing programs. You may be placed on the waiting lists by signing the request at the bottom of the page. The programs are based on income and have specific guidelines:
A) HUD Public Housing: There are 60 units of housing for elderly, handicapped or disabled persons, and families.
B) USDA/Rural Development: There are 24 units of housing for elderly, handicapped or disabled.
In order to streamline the application procedure you may fill out one application (for either or both of the programs) and by signing the authorization, it will begin the application process to add your name to our waiting list.
Applying For:
____ HUD Public Housing
____ USDA/Rural Development
Signature______Date______
Neodesha Housing Authority
118 South 6th / P.O. Box 185
Neodesha, KS 66757
PH 620-325-2440 / FX 620-325-2468
TTY 1-800-766-3777
TIME/DATE STAMP
BEDROOM SIZE APPLYING FOR ______
THIS AREA TO BE FILLED OUT BY APPLICANT
Name ______SS# ______
Date of Birth ______
Street Address ______
Mailing Address______
City ______State ______Zip ______
Home Phone # ______Cell Phone # ______Work Phone # ______
E-mail ______
Name and phone number of two friends or relatives that we can contact if we are unable to reach you at the phone number(s) listed above.
Name ______Telephone # ______
Name ______Telephone # ______
LIST ALL PERSONS WHO WILL LIVE IN THE RENTAL UNIT WHILE YOU ARE ON THIS PROGRAM. LIST HEAD OF HOUSEHOLD FIRST.
FULL NAME (including middle) RELATIONSHIP BIRTHDATE AGE SEX
(1)______
Occupation ______SS# ______
Place of Birth ______
Race (1) White (2) Black (3) American Indian or Alaskan (4) Asian (5) Hawaiian / Pacific Islander (6) Mixed
(1)Hispanic or Latino (2) Not Hispanic or Latino
(1)______
Occupation ______SS# ______
Place of Birth ______
Race (1) White (2) Black (3) American Indian or Alaskan (4) Asian (5) Hawaiian / Pacific Islander (6) Mixed
(1)Hispanic or Latino (2) Not Hispanic or Latino
(1)______
Occupation ______SS# ______
Place of Birth ______
Race (1) White (2) Black (3) American Indian or Alaskan (4) Asian (5) Hawaiian / Pacific Islander (6) Mixed
(1)Hispanic or Latino (2) Not Hispanic or Latino
(1)______
Occupation ______SS# ______
Place of Birth ______
Race (1) White (2) Black (3) American Indian or Alaskan (4) Asian (5) Hawaiian / Pacific Islander (6) Mixed
(1)Hispanic or Latino (2) Not Hispanic or Latino
(1)______
Occupation ______SS# ______
Place of Birth ______
Race (1) White (2) Black (3) American Indian or Alaskan (4) Asian (5) Hawaiian / Pacific Islander (6) Mixed
(1)Hispanic or Latino (2) Not Hispanic or Latino
(1)______
Occupation ______SS# ______
Place of Birth ______
Race (1) White (2) Black (3) American Indian or Alaskan (4) Asian (5) Hawaiian / Pacific Islander (6) Mixed
(1)Hispanic or Latino (2) Not Hispanic or Latino
***Race identification is used for statistical purposes only***
SPECIAL ASSISTANCE
Are you or any member of your household claiming to be disabled and/or handicapped?
Yes/No ______
If you answered YES to the above question, please fill in the information for elderly, disabled and handicapped listed below.
ELDERLY, DISABLED AND HANDICAPPED ONLY
Are you on Medicare? Yes/No ______
Do you have a medical card issued through the DCF Department? Yes/No ______
Do you have a supplemental insurance policy such as Blue Cross, AARP? Yes/No ______
If yes, what amount of premium do you pay and how often? $______, per ______
Are you making payments on outstanding medical bills? Yes/No ______
If yes, what is your monthly payment, to whom do you pay, and what is the balance due?
$ ______, Balance on Account $ ______
To Whom: ______
Address ______City ______State ______Zip _____
Do you take prescription drugs on a regular basis? Yes/No ______
If yes, please list the name and address of the pharmacies where you purchase these prescriptions.
Pharmacy ______City ______
Pharmacy ______City ______
Pharmacy ______City ______
Pharmacy ______City ______
Pharmacy ______City ______
Is there any special assistance that may be required from any outside agency or the Housing Authority? ______
______
INCOME & ASSET QUESTIONNAIRE
Name & Address of Head of Household: ______
The following is a list of items the government counts as income in determining eligibility for federal housing assistance. Check “Yes” for a particular type of income that any household member receives. Check “No” if there are no members of the household receiving that particular type of income.
Warning: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful or false statements, or misrepresentations of any material fact involving the use of obtaining of federal funds.
1) Adult’s employment income (This does not include income of 3) Welfare Assistance (This includes lump-sum payments received
children under 18 yrs. of age or live-in aides). because of delays in processing benefits, but not grants or other
amounts received specifically for medical expenses or care and
Wages/Salaries/Overtime ____Yes ____No equipment for a disabled person). ____Yes ____No
Company ______Amount receiving $______
Address ______Food Stamps – Total Monthly Amount Receiving $______
City State ______
Rate per Hour $______Hrs. Worked per week ______4) TANF ____Yes ____No
Amount Receiving $______Date you started ______
Commissions/Fees/Tips/Bonuses ____Yes ____No County Office ______
Name of Company______Address ______
Address______City/State/Zip ______
City/State/Zip______Name of Case Worker______
How often paid ______Phone Number ______
Any other income adult household members earn from working for Are you on Work Penalty? ____Yes ____No
other people or from their own business. ____Yes ____No Are you under sanction for non-compliance? __Yes __No
Amount receiving $______5) Child Support/ Alimony ____Yes ____No
Name of Company______
Address______Court District______
City/State/Zip______City/State/Zip______
Rate of Pay $______per ______Name of person who pays ______
Amount received per month $______
2) Benefit Payments (This includes lump-sum payments received
because of delays in processing benefits, but not lump-sum payment 6) Annuities/Royalties/Dividends ____Yes ____No
received under settlements with insurance companies or lump-sum Type ______
payments of Social Security or Supplemental Security Income). Value $______
Name of Company______
Social Security ____Yes ____No $______Address ______
SSI ____Yes ____No $______City/State/Zip______
Workers Comp. ____Yes ____No $______Amount Paid $______Per ______
Disability Pay ____Yes ____No $______
Unemployment ____Yes ____No $______7) Stocks/ Bonds ____Yes ____No
Severance Pay ____Yes ____No $______Type ______Company______
Insurance Policy City/State/Zip______
Payments ____Yes ____No $______Interest or Dividends Earned ______
Pensions ____Yes ____No $______
Retirement Benefits ____Yes ____No $______8) Checking/ Savings Account ____Yes ____No
Death Benefits ____Yes ____No $______Name of Bank(s)______
Other Benefits ____Yes ____No $______Address______
City/State/Zip______
Name of Company(s) ______Interest Rate (if any) ______
______
Address______9) Certificate of Deposits (CD’s) ____Yes ____No
City/State/Zip______Type______
Amount receiving $______Per ______Name of Bank(s)______
______
INCOME and ASSET QUESTIONNAIRE, CONTINUED
We need to know about the “assets” that every member of your household owns - including the assets they own with someone who is not a household member. The following is a list of items the government counts as assets for determining eligibility for federal housing assistance. Check “yes” if a household member owns an asset, or “no” if he or she does not.
10) Cash - Money held in bank accounts, safe deposit boxes, at 19) Lump Sum Receipts - Such as inheritances, capital gains
home, or anywhere else. ___Yes ___No from the sale of stock or other assets, one-time lottery
winnings, or settlements on insurance and other claims.
11) Trusts - Money or property held for a household member’s ___Yes ___No
benefit by another person who acts as a trustee. But a trust
doesn’t count as an asset if a household member can’t control 20) Personal Property Held as Investment - Such as gems,
the trust - for example, can not revoke the trust arrangement, jewelry, or coin or stamp collections. This does not include
make a decision on how the principal is invested, or withdraw items for personal use, such as clothing, furniture, cars,
any of the principal, ___Yes ___No vehicles specially equipped for the handicapped, or wedding
rings and other personal jewelry . ___Yes ___No
12) Rental Property or Other Capital Investments - Real estate,
equipment, or machinery rented to other people or held as an 21) Assets Disposed of Within Last Two Years - Please check
investment. Example: Jane Doe is a farm worker. She owns “yes” if a household member has sold, given away, or put
a small rowboat that she rents to fishermen on weekends. into trusts any of the assets listed above in items 1
The rowboat counts as an asset. through 8 within the last two years. ___Yes ___No
But do not include property that is part of a business the
household member owns, if that business is the person’s main Special Circumstances - Please check “yes” if any of the above
occupation and not an investment. Example: John Doe’s main listed assets are held in a household member’s name under
occupation is delivering produce to local groceries. He owns either of the following circumstances:
a delivery truck as part of his business. The delivery truck
does not count as an asset. ___Yes ___No > The assets and any income they earn benefit someone else
(e.g., a bank account held by a household member as the
13) Securities - Stocks, bonds, treasury bills, certificates of guardian for a mentally impaired relative), and the other
deposit (CDs), money market funds. ___Yes ___No person is responsible for paying taxes on income generated
by the assets. ___Yes ___No
14) Individual Retirement Accounts (IRAs) and Keogh Accounts -
Money for retirement that’s been deposited in special accounts. > The assets are not accessible and provide no income to the
___Yes ___No household member (e.g., they are controlled by an
estranged spouse.) ___Yes ___No
15) Real Estate ___Yes ___No
Location______Specify which asset(s)______
Value $______
Legal Description______
Names on Title______
16) Education grants, scholarships, or Veterans Administration 22) Any other source of income ___Yes ___No
benefits covering rent, utility costs, and board of a student
who is a household member (This does not include student If yes, please specify:______
loans or amounts received under Title IV of the Higher ______
Education Act of 1965). ___Yes ___No ______
$______
17) Lottery winnings in periodic payments
___Yes ___No
$______NOTE: The following items do not count as assets:
*Life insurance policies
18) Money regularly given by persons not living in the unit (This *Equity in a co-op unit occupied by the household
includes rent or utility payments regularly paid by someone on *Interests in Indian trust land
behalf of the household, but does not include annual rent
credits or rebates paid to senior citizens or payments received
for the care of foster children) ___Yes ___No
I hereby certify that all of the above information is true and correct to the best of my knowledge.
Signature of Head of Household.______Date______
RECURRING MEDICAL INFORMATION
**TO BE FILLED OUT ONLY BY THOSE CLAIMING ELDERLY, DISABLED, OR HANDICAPPED STATUS**
1) MEDICARE ___YES ___NO AMOUNT $______PER______
2) SUPPLEMENTAL INSURANCE (BLUE ___YES ___NO AMOUNT $ ______PER______
CROSS/BLUE SHIELD, AARP ETC.) NAME OF COMPANY ______
3) PHARMACY - PRESCRIPTIONS ___YES ___NO AMOUNT $______PER______
NAME ______
ADDRESS ______
CITY, STATE, ZIP ______
4) DOCTOR EXPENSES OR PAYMENTS ___YES ___NO AMOUNT $______PER______
NAME ______
ADDRESS ______
CITY, STATE, ZIP ______
5) HOSPITAL EXPENSES OR PAYMENTS ___YES ___NO AMOUNT $______PER______
NAME ______
ADDRESS ______
CITY, STATE, ZIP ______
6) OTHER MEDICAL EXPENSES ___YES ___NO AMOUNT $______PER______
NAME ______
ADDRESS ______
CITY, STATE, ZIP ______
PROGRAM INFORMATION for all applicants
Have you ever participated in a rent subsidized program such as Section 8, Public Housing or USDA/RD before?
___Yes ___No
If yes, name and address of Housing Authority/ Landlord/ Property ______
______
Do you have a balance due? ___Yes ___No If yes, amount due $______
HOW DID YOU HEAR ABOUT THE NEODESHA HOUSING AUTHORITY
PLEASE MARK ONE -
FRIEND OR RELATIVE ______
NEWSPAPER AD ______
RADIO OR T.V. ______
SOCIAL SERVICE AGENCY ______
OTHER ______
SIGNATURE______DATE ______
APPLICANT/TENANT CERTIFICATION FOR CHILDCARE EXPENSES
I/We hereby certify that the following represents true and accurate statements regarding our household circumstances related to childcare.
___ Child/Children cared for are under 13 years of age.
REASON FOR CHILDCARE (CHECK ONE).
___ Such care enables a family member to work:
Members Name______
Occupation______
Employer, Address, Phone# ______
______
Hours Worked ______per ____week, ____month
___Such care enables a family member to seek employment after losing a job.
___Such care enables a family member to attend vocational or academic courses:
Members Name______
Course(s)______
Institution Name, Address, Phone# ______
______
Hours Attending______
___Childcare costs are not paid to anyone living in our household. They are paid to:
Name ______
Address, Phone #______
Number of Hours ______week. Amount ______week.
___No adult household member is capable of providing care during the time in which care is needed.
___I/We do not receive reimbursement for childcare cost from any agency or individual outside the household.