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WHA Housing Stability Services Application

Do you represent an agency?(Required)

Yes

Agency Code(Required)

Agency Email Address(Required)

Agency Name(Required)

Tenant Contact and Income Information

Prior to submitting your application, you should gather the documents mentioned above to ensure your application is complete. Applications missing information may delay the award of services. In order for your application to be processed, please fully complete the application.

Please enter the contact information below for the person seeking services of the Housing Stability Services Program (this person must be on the lease).

How did you hear about this program?(Required)

Are you currently working with an agency in your area?(Required)

Yes

What agency are you working with?(Required)

What other agency are you working with?(Required)

Applicant Information

Name(Required)

First Last

Address

Apartment Number

City

State

Zip(Required)

County(Required)

Phone (Main)

Type

Phone (Second)

Type

Email Address(Required)

Head of Household

First Name

Last Name

Unique Identifier

Household & Income Information

Are there children in the household under age 18?

Yes

Are there adults in the household over age 62?

Yes

Is anyone in the household a person with a disability?

Yes

Is anyone in the household a veteran?

Yes

First time recipient of HSS Services?

Yes

Gender of applicant?

Male

Female

Nonbinary

Declined to Answer

Self-identified race of household?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Multi-Racial/Other

Declined to Answer

Self-identified ethnicity of household?

First Name

Last Name

Birthdate

MM slash DD slash YYYY

Gross Monthly Income

Gross Income

Household Gross Monthly Income

Are you able to provide the required income documentation?

Yes

Household Income Attestation

Administrator: Waco Housing Authority and Affiliates

If you cannot provide the required documentation, please use this form to document your income. If you have the required documentation and plan to provide it as a part of your application, you can skip to this section.

Note that the self-attestation of household income will require that you re-certify income every three months in order to receive future funding.

I certify that the income provided is accurate. (Sign with Initials)(Required)

Please briefly explain why you are unable to provide the required documentation.

Applicant Signature(Required)

I attest that the information stated above is true and accurate, and understand that any intentional or negligent misrepresentation(s) of the information contained in this form may result in civil liability and/or criminal penalties including, but not limited to fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to McLennan County, and any other person who may suffer any loss due to reliance upon my misrepresentation.

Date

MM slash DD slash YYYY

Do you plan to move soon?

Yes

Instructions

If you are transitioning from one household to another, please fill out as much as you can. If we can gather this information now, it will allow us to speed up the payment process.

Name of New Landlord or Apartment

New Landlord Address

Street Address Address Line 2 City State ZIP Code

New Landlord Phone

How much will you be paying for rent?

What fees will you be requesting?

Rental Deposit

Application Fees

Utility Deposit

Pet Deposit

Moving Fees

Are you an apartment or property manager?

Yes

Required Documentation To Apply

As part of the Program application, all applicants will be required to submit the following documentation required to perform the eligibility review:

Government- or other personal ID for at least one household member
Copy of rent or lease agreement, if applicable
Evidence of unemployment benefits, if applicable
Notices of eviction, if applicable
Copies of past due utility bills, if utility assistance is being requested
Income Documentation for all household members

Landlord Information

Landlord Name(Required)

Landlord Phone(Required)

Street Address

City

State

Zip

Landlord Email(Required)

Housing Information

Housing Type(Required)

Household Type(Required)

Monthly Rent Amount(Required)

Utilities Included?(Required)

Yes

Utility Information

Electric Service Provider

Account Number

Service Use

Natural Gas Service Provider

Account Number

Service Use

Propane Service Provider

Account Number

Service Use

Water Service Provider

Account Number

Eviction Diversion

Are you undergoing eviction proceedings?(Required)

Yes

Eviction Diversion Program Participation

A portion of the HSS funds have been set aside specifically for households whose landlords have already sued for eviction in their local court. The application process is the same, however, please complete this section if you are undergoing eviction proceedings. If your landlord has not started eviction proceedings, then you may skip this section.

Please provide the information related to your eviction lawsuit.

Court Docket Number

Justice of the Peace Precinct

County

DUPLICATION OF BENEFITS CERTIFICATION

This document must be completed and signed by any person who has applied for and/or received any services from the TDHCA Housing Stability Services Program.

This section identifies any sources of funds that you have received or applied for as a result of the COVID-19 crisis. Sources of funds include, but are not limited to: Federal, State and Local loan/grant programs, insurance, private or bank loans, nonprofit donations, or loans. Receipt of or pending receipt of any benefit amounts must be disclosed to Waco Housing Authority and Affiliates. By submitting this application, you certify that the benefits disclosed above have been accurately reported. You hereby authorize HUD, the County and each of their respective designees to verify this information and if requested, you agree to provide any information required.

If the information you provided is incorrect, or if your financial circumstances change after the date of your application such that the information disclosed above has become incorrect, you are required to provide written notification to WHA and provide corrected information within five (5) business days. Upon receipt of the updated or corrected information,WHA will determine if there has been a duplication of benefits under Section 312 of the Stafford Act. Written notification should be sent to: Waco Housing Authority and Affiliates, Attention: HSS Program Management, 4400 Cobbs Drive, Waco, TX 76712.

You agree to repay any assistance that is determined by WHA to be a duplication of benefits under the Stafford Act and you further hereby assign to WHA all of your future rights to reimbursement and all payments received from any grant, subsidized loan, or insurance policies of any type or coverage or under any reimbursement or relief program related to or administered by the Federal Emergency Management Agency or the Small Business Administration or any other program, but only to the extent the proceeds are determined by WHA to be a duplication of benefits under the Stafford Act.

Have you applied for and/or received any services from the TDHCA Housing Stability Services Program?

Yes

Service 1

Organization/Benefit provider

(ex: Texas Rent Relief)

Type/Purpose of Assistance

(ex: rent)

Period of Assistance

(ex: 6 months)

Amount of Assistance

(ex: $3900)

Status (pending or received)

Service 2

Organization/Benefit provider

(ex: Texas Rent Relief)

Type/Purpose of Assistance

(ex: rent)

Period of Assistance

(ex: 6 months)

Amount of Assistance

(ex: $3900)

Status (pending or received)

Service 3

Organization/Benefit provider

(ex: Texas Rent Relief)

Type/Purpose of Assistance

(ex: rent)

Period of Assistance

(ex: 6 months)

Amount of Assistance

(ex: $3900)

Status (pending or received)

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Applicant Signature

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

RELEASE OF CLIENT INFORMATION

I certify that the information provided on this application is true and correct to the best of my knowledge and belief. If granted assistance and fraud is proved, I will repay any funds spent on my behalf.
I authorize utility companies, landlords and other sources to release information to Waco Housing Authority and Affiliates for the purpose of certification under this program.
I authorize Waco Housing Authority to use the information I provide to screen me for any additional services available throughWHA and its partner agencies.
This certification is being made with the full knowledge and understanding that this statement and all applicable documents deemed necessary to substantiate my eligibility is subject to full disclosure and verification by authorized Waco Housing Authority officials.
I understand that I may be responsible for making a co-payment and/or paying the balance on my utility bill and/or lease agreement.
I will not hold Waco Housing Authority responsible or liable if my services are shut off and/or an eviction notice is received, as a result of non-payment.
My signature below will certify I fully understand the above statement and I agree to the terms of assistance as stated in the Assistance Guidelines included in this application.

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Applicant Signature

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

Acknowledgement of Housing Instability

Risk of Housing Instability

Self-Declaration of Homelessness

N/A

(select one, if applicable)

This field is hidden when viewing the form

Initials

I certify that I (and my household) am/are at risk of experiencing homelessness or housing instability, or will need to move to an unsafe environment if I do not receive housing stability assistance.

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Initials

I certify that I (and my household) am/are currently experiencing homelessness, or are survivors of domestic violence fleeing from abuse.

Initials(Required)

I certify that I (and my household) am/are at risk of experiencing homelessness or housing instability, or will need to move to an unsafe environment if I do not receive housing stability assistance.

Initials(Required)

I certify that I (and my household) am/are currently experiencing homelessness, or are survivors of domestic violence fleeing from abuse.

COVID- 19 SELF-ATTESTATION FORM

Acknowledgement of Being Financially Impacted by the Pandemic

Applicant Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

I hereby certify under penalty of perjury that the following information is true

I was laid off due to the Covid-19 pandemic

I was employed at a facility at which the employer made a general announcement that the facility will close

My hours were reduced due to the Covid-19 quarantine

I was subject to a quarantine required by medical professional or state or local health officer

I am a parent who must stay home to care for a child due to a school closure

I am totally unemployed

My work separation from my employer was during the Covid-19 quarantine

I am partially unemployed

I was furloughed or unemployed through no fault of my own

I am physically unable to work

I am available for work

I am ready and willing to accept work immediately

I am actively looking for work

(check all that apply)

Briefly explain how Covid-19 has impacted your ability to make rent and/or utility payments.

Certification

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Applicant Signature

I attest that the information stated above is true and accurate, and understand that any intentional or negligent misrepresentation of the information obtained in this form may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq and liability for monetary damages to McLennan County, and any other person who may suffer any loss due to reliance upon my misrepresentation which I have made on this form. I attest that the information stated above is true and accurate, and understand that any intentional or negligent misrepresentation of the information obtained in this form may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq and liability for monetary damages to McLennan County, and any other person who may suffer any loss due to reliance upon my misrepresentation which I have made on this form.

Applicant Signature(Required)

Date(Required)

MM slash DD slash YYYY

Upload Documents

My Files

Row ID	Document Type	File	Notes	Actions

There are no Documents.

Maximum number of documents reached.

Please provide any documents that may be needed to verify your application.

Important: Please do not upload Social Security Card(s).

By signing below, I (the applicant and/or staff) certify that this information is correct to the best of my knowledge.

Please sign with your full signature, not just your initials.

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Applicant Signature

I certify that by signing/submitting this application, I am income-eligible to receive any of the services offered above through the TDHCA Housing Stability Services Program.

I also certify that all the information I am submitting with this application is true and correct.

Applicant Signature(Required)

Legal Consent(Required)

I agree to the terms and conditions.

Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures

Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically.

You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below.

Scope of Consent
By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below.

Paper Copies
You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies.

Withdrawal of Consent
You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below.

Withdrawing your consent, requesting a paper copy, or updating your contact information
You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices.

“Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address.

“Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy .

“Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number.

The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically.

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Case Analytics Tracking System

WORKFORCE PARTNERS MANAGEMENT GROUP, LLC

WHA Housing Stability Services Application

Tenant Contact and Income Information

Applicant Information

Head of Household

Household & Income Information

Household Member 1 (Head of Household)

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Household Member 7

Household Member 8

Household Member 9

Household Member 10

Gross Income

Household Income Attestation

Instructions

Required Documentation To Apply

Landlord Information

Housing Information

Utility Information

Eviction Diversion

Eviction Diversion Program Participation

DUPLICATION OF BENEFITS CERTIFICATION

Service 1

Service 2

Service 3

RELEASE OF CLIENT INFORMATION

COVID- 19 SELF-ATTESTATION FORM

Certification

Upload Documents

Important: Please do not upload Social Security Card(s).

Please sign with your full signature, not just your initials.