BRHA Annual Recertification

1
Head of Household Name* This field is required.
First Name
Last Name
2
Housing Specialist * This field is required.You can find your housing specialist's name on the letter your received.
Please Select
Please Select
Dixie Manor Intake
Jahlisa Robinson
Schemida Sylvain
Nelsy Andros
3
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number for Head of Household* This field is required.
Please enter a valid phone number.
5
Email for Head of Household* This field is required.
example@example.com
6
Marital Status* This field is required.
Single
Divorced
Married
Other
7
Explain Marital Status* This field is required.
8
Emergency Contact Name* This field is required.
First Name
Last Name
9
Emergency Contact Relationship to You: * This field is required.
10
Emergency Contact Telephone Number * This field is required.
Please enter a valid phone number.
11
Are There Other Adults In Your Household? * This field is required.
YESNO
12
Other Adult Household Member #2* This field is required.
First Name
Last Name
13
Phone Number for Other Adult Household Member #2* This field is required.
Please enter a valid phone number.
14
Email for Other Adult Household Member #2* This field is required.
example@example.com
15
Other Adult Household Member #3Please proceed to the next question if you have listed all adult household members
First Name
Last Name
16
Phone Number for for Other Adult Household Member #3* This field is required.
Please enter a valid phone number.
17
Email for Other Adult Household Member #3* This field is required.
example@example.com
18
Other Adult Household Member #4Please proceed to the next question if you have listed all adult household members
First Name
Last Name
19
Phone Number for Other Adult Household Member #4* This field is required.
Please enter a valid phone number.
20
Email for Other Adult Household Member #4* This field is required.
example@example.com
21
Other Adult Household Member #5Please proceed to the next question if you have listed all adult household members
First Name
Last Name
22
Phone Number for Other Adult Household Member #5* This field is required.
Please enter a valid phone number.
23
Email for Other Adult Household Member #5* This field is required.
example@example.com
24
Do you have minor children in your household? * This field is required.
YESNO
25
Minor Household Member #1* This field is required.
First Name
Last Name
26
Minor Household Member #2Please proceed to the next question if you have listed all minor household members
First Name
Last Name
27
Minor Household Member #3Please proceed to the next question if you have listed all minor household members
First Name
Last Name
28
Minor Household Member #4Please proceed to the next question if you have listed all minor household members
First Name
Last Name
29
Minor Household Member #5Please proceed to the next question if you have listed all minor household members
First Name
Last Name
30
Minor Household Member #6Please proceed to the next question if you have listed all minor household members
First Name
Last Name
31
Minor Household Member #7Please proceed to the next question if you have listed all minor household members
First Name
Last Name
32
Minor Household Member #8Please proceed to the next question if you have listed all minor household members
First Name
Last Name
33
Minor Household Member #9Please proceed to the next question if you have listed all minor household members
First Name
Last Name
34
Minor Household Member #10Please proceed to the next question if you have listed all minor household members
First Name
Last Name
35
Please upload Proof of Address for ALL Minors * This field is required.For example, this can be a school document with the child's name and home address or a medical insurance document.
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Max. file size: 10.6MB
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36
Has anyone moved out of your household during the past 12 months? * This field is required.Including deaths, marriages, jail, permanent placement in nursing homes, etc)
YESNO
37
If yes, who? * This field is required.Who moved out of your
First Name
Last Name
38
Certification* This field is required. I understand that additional family members may not be added to the lease until I have submitted a request and the request has been formally approved by the Housing Authority. I certify that this Family Composition information given to Boca Raton Housing Authority is TRUE, ACCURATE and COMPLETE. I understand that I must report immediately in writing any changes in the household size. I/We understand the rules and regulations regarding guests/visitors and when I/We must report anyone staying with me.
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39
Has any member of your household, including adults and minors, ever engaged in, been arrested, indicted, convicted or placed on probation for, or had a adjudication withheld, or had charges dropped or nolle prossed in connection with drug related (including manufacturing or producing methamphetamine) or violent criminal activity in the last 5 years?* This field is required.
YESNO
40
If yes, who?* This field is required.
First Name
Last Name
41
When? * This field is required.
Date
Year
Month
Day
42
Where - City and State? * This field is required.
43
What was the outcome? * This field is required.
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Ok
Ok
44
Anyone else?* This field is required.
YESNO
45
If yes, who?* This field is required.
First Name
Last Name
46
When? * This field is required.
Date
Year
Month
Day
47
Where - City and State? * This field is required.
48
What was the outcome? * This field is required.
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Ok
Ok
49
Has any member of your household, including adults and minors, ever engaged in, been arrested, indicted, convicted or placed on probation for, or had a adjudication withheld, or had charges dropped or nolle prossed in connection with any felony charge in the last 5 years?* This field is required.
YESNO
50
If yes, who?* This field is required.
First Name
Last Name
51
When* This field is required.
Date
Year
Month
Day
52
Where - City and State?* This field is required.
53
What was the outcome? * This field is required.
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Ok
54
Anyone Else?* This field is required.
YESNO
55
If yes, who?* This field is required.
First Name
Last Name
56
When* This field is required.
Date
Year
Month
Day
57
Where - City and State?* This field is required.
58
What was the outcome? * This field is required.
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Ok
59
Is any member of your household required to register as a sex offender in the last 5 years?* This field is required.
YESNO
60
If yes, who?* This field is required.
First Name
Last Name
61
When* This field is required.
Date
Year
Month
Day
62
Where - City and State? * This field is required.
63
What was the outcome? * This field is required.
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Ok
64
Anyone Else?* This field is required.
YESNO
65
If yes, who?* This field is required.
First Name
Last Name
66
When* This field is required.
Date
Year
Month
Day
67
Where - City and State? * This field is required.
68
What was the outcome? * This field is required.
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Ok
69
Certification* This field is required.I certify that this Criminal Background information given to the Boca Raton Housing Authority is TRUE and ACCURATE. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing assistance or termination of tenancy.
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70
Have you disposed of, sold, or given away any assets for less than Fair Market Value during the past 2 years?* This field is required.
YESNO
71
If yes, what type of asset? * This field is required.
72
Date of disposal or sale?* This field is required.
Date
Year
Month
Day
73
Amount Received $? * This field is required.
74
Market Value when disposed/sold $?* This field is required.
75
Did you inherit any property in the last 12 months?* This field is required.
YESNO
76
Do you own or are you purchasing a house, mobile home or any other form of real estate?* This field is required.
YESNO
77
Certification* This field is required.I certify that the Property Disposition information given to the Boca Raton Housing Authority is TRUE and ACCURATE. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing assistance or termination of tenancy.
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78
Is Head of Household Disabled or 62 Years of Age or Older?* This field is required.
YESNO
79
Does Head of Household have any unreimbursed medical expenses?* This field is required.HUD regulations define medical expenses at 24 CFR 5.603(b) to mean “medical expenses, including medical insurance premiums, that are anticipated during the period for which annual income is computed, and that are not covered by insurance.
YESNO
80
Please upload supporting documents for unreimbursed medical expenses? * This field is required.
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Max. file size: 10.6MB
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81
Do you pay child care for a family member under the age of 13* This field is required.
YESNO
82
If yes, Children's Name(s) * This field is required.Please list all children.
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Ok
83
Childcare Provider Name * This field is required.
84
Childcare Provider Phone Number* This field is required.
Please enter a valid phone number.
85
Monthly Cost* This field is required.
86
Proof of Payment to Child Care Provider* This field is required.
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Max. file size: 10.6MB
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87
Recent FPL Bill* This field is required.Please upload an FPL Bill Statement dated within the last 60 Days. Documents older than 60 days will NOT be accepted.
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Max. file size: 10.6MB
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88
Recent Water Bill
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Max. file size: 10.6MB
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89
Did any household member file a Tax Return last year?* This field is required.
YESNO
90
Please upload most recent Tax Return - All Pages.* This field is required.Tax return must be signed and include all pages.
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Max. file size: 10.6MB
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91
Does Household receive Food Stamps/TANF?* This field is required.
YESNO
92
Please upload Food Stamp/TANF letter?* This field is required.
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Max. file size: 10.6MB
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93
Does any household member receive Unemployment Compensation?* This field is required.
YESNO
94
Please upload proof of unemployment payments for the last 2 months.* This field is required.
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Max. file size: 10.6MB
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95
Does any household member receive Social Security?* This field is required.
YESNO
96
Please Upload Social Security Award Letter(s) for ALL family members who receive Social Security.* This field is required.
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Max. file size: 10.6MB
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97
Does any household member receive SSI, SSDI or SSA?* This field is required.
YESNO
98
Please Upload SSI, SSDI, or SSA Award Letter(s) * This field is required.
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Max. file size: 10.6MB
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99
Does any family member receive Child Support?* This field is required.
YESNO
100
Please Upload Statement of child Support Payments for the last 2 months?* This field is required.
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Max. file size: 10.6MB
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101
Does any family member receive Worker's Compensation Payments? * This field is required.
YESNO
102
Please upload proof of worker's compensation payments for the last 2 months.* This field is required.
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Max. file size: 10.6MB
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103
Does any family member receive annuity payments? * This field is required.
YESNO
104
Please upload proof of annuity payments.* This field is required.
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Max. file size: 10.6MB
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105
Does any family member receive Veteran's Benefits? * This field is required.
YESNO
106
Please upload proof of Veteran's benefit payments. * This field is required.
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Max. file size: 10.6MB
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107
Does any family member receive alimony payments? * This field is required.
YESNO
108
Please upload proof of alimony payments. * This field is required.
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Max. file size: 10.6MB
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109
Is any family member self employed? * This field is required.
YESNO
110
Please list self employment occupation and monthly income earned.* This field is required.
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Ok
111
Please upload proof of self employment income* This field is required.
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Max. file size: 10.6MB
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112
Does anyone outside of your household pay any of your bills or give you or any household member money?* This field is required.
YESNO
113
If yes, who? * This field is required.Please list the person outside of your household who pays any of your bills or gives you or any household member money?
First Name
Last Name
114
How much and how often?* This field is required.Please list how much the person gives and how often they give it - Weekly, Monthly, etc?
115
Is any family member employed? This included minors. * This field is required.
YESNO
116
Name and Phone Number of each Employer* This field is required.Please list each household member and their employer's information. For example: John Doe, Walmart 954-123-4567 Jane Doe, Boca Reginal Hospital 561-123-4567
117
Please upload 6 weeks of recent and consecutive paystubs for EACH employed family member* This field is required.Documents must be no older than 60 days.
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Max. file size: 10.6MB
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118
Signature* This field is required.I/we certify that this Family Income information given to the Boca Raton Housing Authority is TRUE and ACCURATE and COMPLETE. I KNOW I am required to report immediately in writing any changes in income within 10 days. I/we understand that any misrepresentation on my/our part will result in my/our assistance being terminated, and the possibly of criminal charges on the basis of fraud.
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119
Do any household members own a vehicle?* This field is required.
YESNO
120
If yes, please list - Make/Model, Year and Color of each vehicle. * This field is required.
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Ok
121
Does any household member have a Bank Account?* This field is required.
YESNO
122
Please upload 3 recent and consecutive bank statements for all bank accounts.* This field is required.This includes : Checking, Savings, CD, Money Market, RA’s; Stocks; Bonds and Annuities. Statements must be consecutive for example Jan/Feb/Mar or Oct/Nov/Dec.
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Max. file size: 10.6MB
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123
Did any household member close any Bank Accounts since your last annual recertification?
YESNO
124
Please upload proof of account closure for any accounts that were closed since your last annual recertification.Proof of account closure would be a letter from the banking institution indicating the account was closed.
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Max. file size: 10.6MB
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125
Do any household member have Life Insurance/Trusts?
YESNO
126
If Yes, Please list who, Account #, Name, Phone and Address of Bank, Brokerage, or company, and Value/Balance* This field is required.
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Ok
127
Do any household member have Lottery/Gambling Winnings?* This field is required.
YESNO
128
If Yes, Please list who, Account #, Name, Phone and Address of Bank, Brokerage, or company, and Value/Balance* This field is required.
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Ok
129
Do any household member have stocks, bonds, annuities or IRAs?* This field is required.
YESNO
130
If Yes, Please list who, Account #, Name, Phone and Address of Bank, Brokerage, or company, and Value/Balance* This field is required.
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Ok
131
Are your family asset less than $5,000?
YESNO
132
Signature* This field is required.I certify that the net family assets are less than $ 5,000.
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133
Do any household members 18 or older attend school or college?
YESNO
134
If yes, please list below. * This field is required.
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135
For each student, please supply proof of current registration (a transcript of classes and credits taken)* This field is required.
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Max. file size: 10.6MB
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136
CertificationI/we certify that I/we understand that I/we must report all changes of criminal status, income or family size within ten (10) days of the change. I/we understand that all changes must be reported in writing. I/we understand that no person other than those listed on the housing application may occupy an assisted unit. I/we understand that the Housing Authority is authorized to obtain criminal arrest records from law enforcement agencies through the use of background checks on all adults (anyone in the household over 18 years of age). This assists them in screening applicants and family members to be admitted or to remain in the program. This action assists the Housing Authority in complying with HUD requirements to deny or terminate assistance to applicants or participants in the program who are engaging in or have engaged in violent criminal or drug related activities. In signing this document I/we confirm that I/we fully comprehend and I/we do hereby swear and attest that all of the above information about me/us and all members living within my/our Subsidized Housing Unit is true and correct. I/we also understand that any false statements made in an attempt to receive or continue to receive public assistance benefits is a crime under Florida Statute 414.39. WARNING! Title 18, Section 1001 of the United States Code states that a person is guilty of a felony for knowingly making false or fraudulent statements to any department or agency of the United States. BY MY SIGNATURE BELOW, I HEREBY SWEAR AND ATTEST THAT ALL OF THE INFORMATION ON THIS FORM ABOUT ME AND MY HOUSEHOLD IS TRUE AND CORRECT, AND I HAVE READ AND AGREE TO THE CERTIFICATIONS CONTAINED ON THIS FORM.
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137
How would to rate this recertification process * This field is required.
1
2
3
4
5
138
Please provide the main reason for your rating- Thank you! * This field is required.
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