12
COMMUNITY INCOME RESTRICTIONS AND PREFERENCES APPLY. Please refer to the Resident Selecon Criteria at: hp://property.midpen-housing.org/LeasingNow for more informaon, available on 9/12/16. NEW AFFORDABLE 1, 2 & 3 BEDROOM APARTMENTS SWEENEY LANE APARTMENTS—Opens early 2017 and is located at 6800 Mission, Daly City, CA (currently, no public access) NOW LEASING! Applicaons Available online on 9/12/16 thru 10/7/16 at hp://property.midpen- housing.org/LeasingNow or at the Temporary Leasing Office located at: 295 -89th St., Suite 101, Daly City, California Applicaons also available via email at: [email protected]. COMMUNITY FEATURES:: Community Room with Kitchen Computer Lab & Tot Lot Bicycle Storage & Fitness Center Close to recreaon and shopping Aſter school program On Site Resident Services and Events Onsite laundry facility Gated Parking Offering affordable housing to qualified households: 20—One bedrooms, rents between $1,153—$1,383 16—Two bedrooms, rents between $1,383—$1,660 16—Three bedrooms, rents between $1,537—$1,919 **Rents Subject to Change. 26 units will be filled under the Project Based Secon 8 Voucher Program. Inquire at Leasing Office for more informaon. Leasing Office Phone: 650-466-7098 or email: [email protected] Developed by: Mid-Peninsula The Farm, Inc. MidPen Property Management Corporaon, BRE# 00822390 Apply in Person (turn in applicaons) at the Temporary Leasing Office address above beginning 9/26/16 through 10/7/16 between the hours of 8:30am—5pm (closed between 12pm-1pm, M-F; closed Saturday and Sunday)

NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

  • Upload
    others

  • View
    2

  • Download
    0

Embed Size (px)

Citation preview

Page 1: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

COMMUNITY INCOME RESTRICTIONS AND PREFERENCES APPLY. Please refer to the Resident Selection Criteria at:

http://property.midpen-housing.org/LeasingNow for more information, available on 9/12/16.

NEW AFFORDABLE 1, 2 & 3 BEDROOM APARTMENTS

SWEENEY LANE APARTMENTS—Opens early 2017 and is located at

6800 Mission, Daly City, CA (currently, no public access)

NOW LEASING!

Applications Available online on 9/12/16 thru 10/7/16 at http://property.midpen-

housing.org/LeasingNow or at the Temporary Leasing Office located at:

295 -89th St., Suite 101, Daly City, California

Applications also available via email at: [email protected].

COMMUNITY FEATURES::

Community Room with Kitchen

Computer Lab & Tot Lot

Bicycle Storage & Fitness Center

Close to recreation and shopping

After school program

On Site Resident Services and Events

Onsite laundry facility

Gated Parking

Offering affordable housing to qualified households:

20—One bedrooms, rents between $1,153—$1,383

16—Two bedrooms, rents between $1,383—$1,660

16—Three bedrooms, rents between $1,537—$1,919 **Rents Subject to Change. 26 units will be filled under the Project Based Section 8 Voucher Program. Inquire at Leasing Office for more information.

Leasing Office Phone: 650-466-7098 or email: [email protected]

Developed by: Mid-Peninsula The Farm, Inc.

MidPen Property Management Corporation, BRE# 00822390

Apply in Person (turn in applications) at the Temporary Leasing Office address above beginning

9/26/16 through 10/7/16 between the hours of 8:30am—5pm

(closed between 12pm-1pm, M-F; closed Saturday and Sunday)

Page 2: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to
Page 3: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

Sweeney Lane Apartments Fact Sheet

Sweeney Lane Apartments operates under affordable housing programs for individuals or families with low, very low, and extremely low income. This program is operated by Sweeney Lane Apartments without regard to race, color, sex, creed, religion, national origin, physical or mental status, familial status, age, ancestry, marital status, source of income, sexual orientation, gender, or any other arbitrary personal characteristic. This fact sheet is only an outline of the requirements necessary to qualify for a home in this community. There may be other restrictions which apply to this community. Please refer to the Resident Selection Criteria for any additional requirements. The Resident Selection Criteria is available in the Leasing Office or can be sent electronically by request.

SELECTION CRITERIA SUMMARY

Income Eligibility: Household income must be below the maximum limits indicated for this community's housing programs included on the income limit table on the back of this document. Minimum income limits also apply.

Minimum/Maximum Occupancy Requirements

One Bedroom 1-3 occupants Three Bedroom 3-7 occupants Two Bedroom 2-5 occupants

Preferences and Eligibility Restrictions

1. Preference will be given on two Section 8 Project-Based Voucher Program units will for homeless households. Referrals for these two units will be made by the San Mateo County Housing Authority by preference through its waiting list. Please see full Resident Selection Criteria for more information.

2. Preference will be given on four units for Supportive Services households which will be targeted to persons needing supportive housing services in order to remain successfully housed; to assist the household to stabilize, maintain housing, and live as independently as possible. MidPen Housing will receive referrals for these four units directly from HIP Housing’s (Human Investment Project, Inc.) Housing Opportunities Program. Please see full Resident Selection Criteria for more information.

3. Credit, Criminal and Rental History: Sweeney Lane Apartments evaluates the credit, criminal and rental history for any person aged 18 or over and emancipated minors. Negative reports may disqualify applicants.

RESIDENT SELECTION PROCESS

1. When your pre-application is considered for a unit, we will contact you to come in to the Management Office for an interview and to complete a more detailed full application at that time. Interviews and verifications may be processed in advance of unit availability. Your application may be processed in anticipation of an upcoming vacancy and will be held for the next available vacant unit.

2. Third party verification will be obtained from all related sources to confirm certain components of the eligibility/qualification requirements; for example, income, assets, landlord references, and preference eligibility.

3. It is your responsibility to inform the management in writing of any change to the information on your pre-application or application (e.g., address, household size, and total household income). You must respond to the waitlist update letter when mailed to your address on file, which typically occurs every six months. Failure to contact the Management Office about a change in information or failure to respond to the waitlist update letter can result in removal of your application from the waiting list.

Page 4: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

A full, detailed Resident Selection Criteria describing application and qualification processes is available to all applicants in the Leasing or Management Office or electronically if requested.

The lottery process that determines the waiting list position of applicants after the waiting list is opened is a two-part process. The first part includes entry of applicants into the lottery system by MidPen staff after a determination of initial eligibility. The second part is an automated system that randomly selects and places applicants on the waiting list for the unit size requested. While the potential for error is greatly reduced from earlier lottery methods, the potential still exists. In the event there is an error that causes Applicant to inadvertently be excluded from the lottery and the resulting waiting list, Applicant agrees to be placed at the end of the waiting list. Applicant acknowledges and agrees that being placed at the end of the waiting list is the only recourse for a mistake on the behalf of Applicant, Management, or a technical problem.

____________ ______________

HOH Initials Management Initials

Sweeney Lane Apartments Income Limits & Rents

Maximum Income Per Household (2016 AMI)

New Limits published by HUD March 28, 2016; Income Limits at time of Move-In are used for final qualification

1 people 2 people 3 people 4 people 5 people 6 people 7 people

30% $25,830 $29,520 $33,210 $36,900 $39,870 $42,810 $45,780 35% $30,135 $34,440 $38,745 $43,050 $46,515 $49,945 $53,410 50% $43,050 $49,200 $55,350 $61,500 $66,450 $71,350 $76,300 60% $51,660 $59,040 $66,420 $73,800 $79,740 $85,620 $91,560

PROJECT BASED SECTION 8 TENANT RENT LEVELS per Unit (2016 AMI)*

Contract Rent Limit Inquire with Management for any Maximum and Minimum Rent Clarifications AMI Limit 1 Bedroom 2 Bedroom 3 Bedroom

50% $1,553 $1,956 $2,668

Note: Actual tenant rent portion will be determined based on the household calculated gross annual income.

TENANT RENT LEVELS per Unit (2016 AMI) Rent Floor - Excluding any Utility Allowance

Inquire with Management for any Maximum and Minimum Rent Clarifications

AMI Limit 1 Bedroom 2 Bedroom 3 Bedroom 30% $691 $830 $959 35% $807 $968 $1,119 50% $1,153-$1,230 $1,383 $1,537-$1,599 60% $1,291-$1,383 $1,660 $1,845-$1,919

Page 5: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

TENANT RENT LEVELS per Unit (2016 AMI)* HOME Program

AMI Limit 1 Bedroom 2 Bedroom 3 Bedroom

50% $1,153 $1,383 $1,599 60% $1,383 $1,660 $1,845-$1,919

*All Rents are subject to change as set by the governing agency. Not all AMI Rent limits shown above are available for all units and may be set forth for referral units only.

Page 6: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

Sweeney Lane Apartments

Temporary Leasing Office 295 89th St., Suite 101, Daly City, CA 94015

Telephone: (650) 466-7098

Dear Applicant:

Thank you for your interest in Sweeney Lane Apartments! Please read the following instructions carefully to ensure that you have completed the necessary documentation to apply for Sweeney Lane Apartments and all of the specific programs for which you may qualify.

Applicants who wish to apply for an Affordable Housing (non-Project Based Section 8) unit at Sweeney Lane Apartments (26 units, 4 of which include a preference as outlined in the Resident Selection Criteria):

1. Must complete the MidPen Pre-Application, attached. a. You MUST meet the income and other requirements as shown in the Resident Selection Criteria, available at

the Leasing Office or online at http://property.midpen-housing.org/LeasingNow. b. Completed pre-application must be submitted only during the open application period which begins on

Monday, September 26, 2016 and closes on Friday, October 7, 2016. Pre-applications may be submitted at the Temporary Leasing Office located at 295 89th St., Suite 101, Daly City, CA, Monday through Friday, 8:30am to 5:00pm during the open application period.

c. A lottery will be held for these units in late October 2016. All applicants will be notified of their position after the lottery via mail. Applicants in range to be called in for an intake interview (typically 3-5 applicants for every 1 unit available) will receive notification of their scheduled date/time of interview, along with the list of documents required for the interview.

Applicants who wish to apply for Project Based Section 8 Housing at Sweeney Lane Apartments (26 units, 2 of which include a preference as outlined in the Resident Selection Criteria):

1. Must complete the MidPen Pre-Application, attached. In addition to the MidPen Pre-Application, applicants must complete the San Mateo County Housing Authority’s waitlist application, attached. a. You MUST meet the Housing Authority’s income and other requirements (see San Mateo County Housing

Authority’s eligibility criteria, attached), AND the income and other requirements as shown in the Resident Selection Criteria, available at the Leasing Office or online at http://property.midpen-housing.org/LeasingNow.

b. If you have been referred because you meet the criteria for a homeless unit (as defined in the Resident Selection Criteria), you must also submit the Homeless Preference Certification along with the above-referenced applications. There are 2 Homeless units available.

c. Completed applications must be submitted WITH (1) the completed MidPen Pre-Application AND (2) the San Mateo County Housing Authority’s application only during the open application period which begins on Monday, September 26, 2016 and closes on Friday, October 7, 2016. Applications may be submitted at the Temporary Leasing Office located at 295 89th St., Suite 101, Daly City, CA, Monday through Friday, 8:30am to 5:00pm during the open application period.

d. A lottery will be held for these units in late October 2016. Applicants in range to be called in for an intake interview (typically 3-5 applicants for every 1 unit available) will receive notification of their scheduled date/time of interview, along with the list of documents required for the interview.

Intake Interview:

All applicants in the household over the age of 18 years must attend the intake interview. Applicants will be asked to complete the income and asset questionnaire in detail. A basic prequalification will occur to determine if application information is sufficient to meet our criteria.

Page 7: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

Sweeney Lane Apartments Temporary Leasing Office

295 89th St., Suite 101, Daly City, CA 94015 Telephone: (650) 466-7098

Applicants will be required to provide documentation to verify all information included in the Rental Application—a list of required documents to bring to the intake interview will accompany the appointment letter.

Applicants will be required to pay a $30 per adult applicant screening fee. The fee must be paid with a money order or cashier’s check only. No personal checks or cash will be accepted. Applicants will be screened for credit and criminal at this time.

Additional Documentation:

MidPen may often require additional documentation to verify an applicant’s information. Staff may request additional documentation during or after the intake interview. An applicant has ten (10) days from the date of the request to provide all requested documentation. If this timeline is unable to be met, the application will be denied.

Approved Applicants:

Once applicants are fully certified and all information has been verified and their file has been approved, applicants will be offered the next available unit in position number order for which they qualify.

At that time, a holding deposit (1/2 of the security deposit) will be required to be paid. (Holding Deposits: 1 Bedroom = $150; 2 Bedroom = $250 and 3 Bedroom = $350.) The holding deposit will be applied toward the security deposit at the time of move in. The holding deposit must be paid within five (5) days of the offer of a unit and a Holding Deposit Agreement signed. If applicant is unable to meet this timeline, the unit may be offered to another application, in position number order.

Once the units are ready for occupancy, applicants will be notified of the time and date of their move in appointment. At the move in appointment, all adults in the household must be present. The remaining balance of the security deposit and a full months’ rent will be required (in the form of a money order or cashier’s check). If applicant is unable to meet these requirements, the unit may be offered to another resident, in position number order.

If applicant fails to take possession of unit as the lease requires, applicant will forfeit their holding deposit.

Again, we’d like to thank you for your interest in Sweeney Lane Apartments and we look forward to meeting you! If you have any questions, please feel free to contact the Temporary Leasing Office at (650)466-7098.

Sweeney Lane Apartments Leasing Staff

Page 8: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

Rev. 8/12/2016

Housing Authority of the County of San Mateo

Waiting List Opening for Sweeney Lane Apartments

General Instructions

(12 one-bedroom, 7 two-bedroom, and 7 three-bedroom units)

(This opening is NOT for the Section 8 Housing Choice Voucher waiting list) Opening Period: In order for your application to be considered, a completed application must be received by MidPen Housing in person (preferred) or by mail at: 295 89th St., Suite 101, Daly City, CA 94015 between 09/26/2016 and 10/07/2016.

Note: Applications received prior to 09/26/2016 or postmarked on or before 10/07/2016 but received after 10/07/2016, will be rejected.

Selection: All completed applications will be placed on the Sweeney Lane Apartments waiting list. All completed applications will be selected and ordered using a random lottery system.

Eligibility: Low-income households that meet HACSM’s eligibility criteria, as outlined below are encouraged to submit an application. Please note that the project owner may have additional screening criteria. For more information please review the Resident Selection Criteria from the MidPen Housing website at http://property.midpen-housing.org/LeasingNow.

HACSM eligibility criteria include, but are not limited to the following: Income, assets, criminal history, and citizenship or eligible immigration status. Below is a list that highlights the HACSM eligibility criteria. Detailed information on HACSM’s eligibility, waitlist, and preference policy can be found in the Administrative Plan located on the HACSM website: www.smchousing.org. Once you’ve accessed the HACSM website, click on Resources link at the top of the page and continue by the following path; >Plans and Reports>HACSM Admin Plan. (http://housing.smcgov.org/document/hacsm-admin-plan)

Accommodations for persons with disabilities will be provided, but must be requested in advance by calling 650-466-7098 or emailing [email protected]. Please put “Sweeney Lane Apartments – RA Request” on the subject line of the email.

Income Limits: Gross Annual Income May Not Exceed

Family Size

1 2 3 4 5 6 7 8

$43,050 $49,200 $55,350 $61,500 $66,450 $71,350 $76,300 $81,200

Asset Limits

Total assets may not exceed $100,000. Assets include and are not limited to: savings, checking, stocks, and bonds. Retirement accounts are excluded from asset limits. Example of retirement accounts are: IRAs, Roth IRAs, 401(k), 403(b), and 457 plans. Also, an applicant family may not have ownership of real property, including mobile and manufactured homes, in which the family has a legal right to reside.

Criminal History

HACSM will deny an applicant for: 1. Conviction of producing or manufacturing methamphetamine on federally assisted property; 2. Lifetime registered sex offender; 3. Violent or drug-related criminal activity within the past three (3) years.

Citizen-ship/

Immigra-tion

At least one family member must be a citizen, national, or non-citizen with eligible immigration status.

Page 9: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

COMPLETE BOTH SIDES OF THIS FORM

Pre-Application for Housing 6/2016

COMPLETE BOTH SIDES OF THIS FORM

Sweeney Lane Apartments

PRE-APPLICATION FOR HOUSING

FILL IN ALL SECTIONS AND FIELDS; IF NOT APPLICABLE INSERT ‘N/A’. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.

A. Household Contact Information Name:

Last First MI Relationship to Household

Address:

Email Address:

Contact Phone #:

( ) -

Preferred Apartment Sizes(can list more than 1, contact management for unit sizes

specific to the property you are applying)

1BR 2BR 3BR

Alternate Phone #:

( ) -

B. Household Composition Please see Resident Selection Criteria for Occupancy Standards

Please be sure to include your HOH information (from above) if applicable in this section, Member #1 - HOH

All persons who

will reside in unit

Relationship to

Head of

Household

Name

Last, First MI Social Security Number

Date of Birth

(mm/dd/yyyy)

Full-Time Student

Y/N

Member #1

Head of Household

Member #2

Member #3

Member #4

Member #5

Member #6

Member #7

Member #8

Member #9

Do you anticipate any household changes within the next twelve months? YES NO

If Yes, Expected # of: Additions:___________ or Reductions:___________

Anticipated changes may not qualify you at move-in.

C. Community Resident Selection Preferences This community may participate in programs requiring residency preferences; please check with management prior to completing this section. Preference eligibility will be verified prior to housing being offered.

Do you have a transferrable Housing Choice Voucher?

YES

NO

N/A

Do you or any member qualify for any local live/work preference (confirm with management)?

YES

NO

N/A

Are you or any member of your household certified as “Homeless” by a services program?

YES

NO

N/A

Do you or any member qualify for other property preferences (confirm with management)?

YES

NO

N/A

Were you or any member of your household above displaced by Redevelopment?

YES

NO

N/A

Are you currently homeless? YES

NO

N/A

Does any member of your household require a unit accessible to those living with specific disabilities? Please check if applies: Mobility Vision Hearing

YES

NO

N/A

Are any household members military veterans?

YES

NO

N/A

YES

NO

N/A

Does any household member require a live-in attendant? YES

NO

N/A

Page 10: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

COMPLETE BOTH SIDES OF THIS FORM

Pre-Application for Housing 6/2016

To be completed if the Federal Funding box is checked. If not, please check N/A. Federal Funding: YES NO

Are you a National Citizen of the United States of America?

YES

NO

N/A

Are you not contending eligible immigration status? YES

NO

N/A

Are you a Non-Citizen with eligible immigration status with one of the following: Form I-551, I-94, I-688, 688B, I-151 or receipt issued by DHS

YES

NO

N/A

Are you subject to a lifetime Sex Offender registration program in any State?

YES

NO

N/A

D. Income & Assets

List below total combined gross income received from all sources by all members of the household. Show amount on annual (yearly) basis:

COMBINED HOUSHOLD INCOME FOR ALL HOUSEHOLD MEMBERS

ALL SOURCES (Include all sources of employment (gross) except self-employment (net), Social Security, SSI, pensions, interest and dividends, disability, unemployment, gift income, alimony and child support on an annual (yearly ) basis)

Annual Amount $______________________

COMBINED HOUSHOLD ASSETS FOR ALL HOUSEHOLD MEMBERS

ALL SOURCES (Include NET liquid assets such as Checking and Savings account balances, Life Insurance value, 401K, Real Estate Equity, Stocks, Bonds, Mutual Funds, etc.)

Value or Balance $______________________

E. Signature & Consent

1. To the best of my/our knowledge and belief, I/we certify that the foregoing information is true, complete and correct. 2. I/we certify that if selected to move into this property, the unit I/we occupy will be my/our only residence. 3. I/we understand that the above information is being collected to determine my/our eligibility for an apartment with rent below market

rate. 4. I/we understand that adverse credit reports may disqualify my/our application for occupancy. 5. I/we understand that false statements or information are punishable under federal law. 6. I/we understand we must provide written notification of any changes to the information on this form, especially address changes. 7. I/we understand that this pre-application is solely to obtain a place on the waiting list for Sweeney Lane Apartments and does not

guarantee the availability or act as an offer of housing. 8. I/we understand that the completion of a full application and participation in an eligibility interview that includes verification of the

information provided must occur prior to an offer of housing.

PLEASE REVIEW THE PRE-APPLICATION TO ENSURE ALL ITEMS HAVE BEEN FILLED OUT.

ALL MEMBERS AGED 18 OR OVER MUST SIGN AND DATE THIS APPLICATION. APPLICANT Signature: DATE: APPLICANT Signature: DATE: APPLICANT Signature: DATE: APPLICANT Signature: DATE: APPLICANT Signature: DATE: APPLICANT Signature: DATE:

The undersigned agent certifies that the information sought herein is for the purpose of evaluation of the applicant’s tenancy and for no other purpose. Community Manager Signature Printed Name

Date

RETURN COMPLETED PRE-APPLICATION TO:

Sweeney Lane Apartments

295 89th

St., Suite 101, Daly City, CA (650)466-7098 MidPen Housing Management Company and its affiliates comply with the Fair Housing Act, the Rehabilitation Act of 1973 and the Fair Housing Act Amendments of 1988 prohibiting discrimination based on race, color, national origin, disability, sex, religion, and familial status and Title VI of the Civil Rights Act of 1964 prohibiting discrimination on the basis of disability in any program or activity receiving federal financial assistance. We do not discriminate and do not deny or limit services, terms, conditions, privileges or facilities based on race, color, creed, religion, sex, sexual orientation, age, disability, medical condition, marital status, familial status, source of income, national origin or gender, in any and all aspects of applicant/ resident relations, including without limitation, accepting and processing applications, selecting residents from eligible applicants on the waiting list; assigning units, certifying and re-certifying eligibility for assistance, granting accommodation, and terminating tenancies.

Page 11: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

Revised 8/18/16

HOUSING AUTHORITY OF THE COUNTY OF SAN MATEO (HACSM)

Application for Project-Based Program

Sweeney Lane Apartments Please print clearly

Last Name First Name Gender

(F/M)

Social Security

Number Birthdate (MM/DD/YYYY)

Relationship to

Head of Household

1 Head of Household

2 Spouse or Co-Head

3

4

5

6

7

8

Race: White Black American Indian/Alaskan Native Asian Native Hawaiian/Other Pacific Islander

Ethnicity: Hispanic Non-Hispanic

A. The ZIP Code of your residence: _____________

B. If you work or have been hired to work, the ZIP Code of the city where you work: ______________

C. If you are currently homeless, the ZIP Code where you are homeless: _____________, and check all that are

applicable to your homelessness below:

An individual or family with a primary nighttime residence that is a public or private place not designed for or

ordinarily used as a regular sleeping accommodation for human beings, including a car, park, abandoned building,

bus or train station, airport, or camping ground; or

An individual or family living in a supervised publicly or privately operated shelter designated to provide

temporary living arrangements (including congregate shelters, transitional housing, or hotels and motels paid for

by charitable organizations or by federal, state, or local government programs for low- income individuals); or

An individual who is exiting an institution where he or she resided for 90 days or less and who resided in an

emergency shelter or place not meant for human habitation immediately before entering that institution; or

An individual or family that is fleeing, or is attempting to flee, domestic violence, dating violence, sexual assault,

stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family

member, including a child, that has either taken place within the individual’s or family’s primary nighttime

residence or has made the individual or family afraid to return to their primary nighttime residence, and has no

other residence and lacks the resources or support networks, for example, family, friends.

D. What is the GROSS ANNUAL household income (before any deductions) from ALL sources? $________________

E. Do you or any family member(s) claim a disability? (Temporary disability does not apply) Yes No

F. Does your family need any of the following special housing accommodations?

Accessible light switches, electrical outlets, thermostats and other environmental controls Grab Bars in bathrooms

Ground floor (no stairs) Modified smoke detectors for hearing impaired Ramps

Wider hallways and doors Other:

Resident or

mailing

address:

Address City State Zip

Daytime Phone No.: ( ) E-mail:

I certify, under penalty of perjury, that the above statements are complete, true and correct.

I understand that this application is not for the Housing Voucher Program and I will not receive a Section 8

Voucher.

I understand it is my responsibility to report changes including my contact information to HACSM.

I authorize HACSM, the property owner, and other funding agencies, if applicable, to share information as

supplied in this application and related to my eligibility. In all other instances, this information is protected by

the Federal Privacy Act.

Signature of Head of Household: Date:

Page 12: NOW LEASING! - smcgov.org · 2016-09-12 · Temporary Leasing Office . 295 89. th. St., Suite 101, Daly City, CA 94015 . Telephone: (650)466-7098 . Applicants will be required to

Rev. 8/10/16

Housing Authority of the County of San Mateo Homeless Preference Certification

The undersigned hereby certifies _______________________________________ (Applicant) meets one

or more of the following Homeless Preference definitions:

Applicant is a member of a household (one or more persons residing together) who lacks a fixed, regular,

and adequate nighttime residence, meaning:

(Check all that are applicable)

An individual or family with a primary nighttime residence that is a public or private place not

designed for or ordinarily used as a regular sleeping accommodation for human beings, including

a car, park, abandoned building, bus or train station, airport, or camping ground; or

An individual or family living in a supervised publicly or privately operated shelter designated to

provide temporary living arrangements (including congregate shelters, transitional housing, and

hotels and motels paid for by charitable organizations or by federal, state, or local government

programs for low-income individuals); or

An individual who is exiting an institution where he or she resided for 90 days or less and who

resided in an emergency shelter or place not meant for human habitation immediately before

entering that institution.

An individual or family that is fleeing, or is attempting to flee, domestic violence, dating

violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to

violence against the individual or a family member, including a child, that has either taken place

within the individual’s or family’s primary nighttime residence or has made the individual or

family afraid to return to their primary nighttime residence, and has no other residence and lacks

the resources or support networks, e.g., family, friends.

The undersigned Certifying Agency further certifies that it will deliver direct service coordination to

Applicant and to assist Applicant throughout Applicant’s tenancy if these services are necessary for

Applicant to maintain stable housing at Sweeney Lane Apartments.

Certifying Agency: _____________________________________________________________________

Address: _____________________________________________________________________________

Certifier Name: ____________________________ Title: __________________________________

Phone No.: ________________________________ Email:_________________________________