Household Information

Income Information

List below all sources of income for all household members. Include both earned income (from business or employment) and unearned income (alimony, social security, retirement, disability and unemployment benefits, lease rental payments, child support, alimony)

Application is incomplete unless we have proof of income for each family member living in the household. Examples for proof of income are 1040 income tax return, W-2 statement from employer, check stubs, social security letters or checks, retirement pension letters or checks, etc.

Please submit documentation proving you own your home

Please submit documentation such as a bank statement or utility billing at the address.

If yes, you must be current in your payments to be eligible to receive rehabilitation assistance.

If yes, you are NOT eligible to receive further assistance until three years has passed since you received services.

Please describe briefly the problem in the following areas. If none, leave blank or put “N/A”. (If you need additional space, you may attach another sheet to this application.)

Certifications and Signature

I understand that this application is not a contract and is not binding in any manner. I hereby authorize SIHA to obtain any and all information necessary to verify the statements made above.

I certify that all the answers given are true, complete and correct to the best of my knowledge and belief, and they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive financial assistance, and that false information or misleading statements may constitute a violation of 18 U.S.C. 1001. This application contains material covered by the Privacy Act. No record will be communicated to anyone or any agency unless request in writing, either by the applicant or an officer or employee of the housing program or other federal agency requiring it in the performance of their duties.