Department of Health and Human Services
521 E. Fourth Street
Long Beach, CA 90802
Tel 562 570-6985
Fax 562 499-1052
Cabrillo Gateway
PERSONAL DECLARATION FOR RENTAL ASSISTANCE BENEFITS
COMPLETE ALL SECTIONS OF THIS FORM AND ANSWER ALL QUESTIONS. DO NOT LEAVE ANY QUESTIONS BLANK.
If a question does not apply, write “N/A.” If you do not understand a question, you may ask for an explanation during your interview.
***WARNING: Making false statements on this document is considered FRAUD and may result in TERMINATION from the program***
HEAD OF HOUSEHOLD NAME:
HEAD OF HOUSEHOLD EMAIL:
HEAD OF HOUSEHOLD ADDRESS:
PHONE #:
EMERGENCY CONTACT NAME:
EMERGENCY CONTACT RELATIONSHIP:
EMERGENCY CONTACT ADDRESS:
PHONE #:
CITY/ STATE/ZIP:
CITY/ STATE/ZIP:
SECTION I – HOUSEHOLD COMPOSITION
List ALL people living in your home. List the Head of Household first followed by spouse/co-head
A. FAMILY HOUSEHOLD COMPOSITION
*RACE= (1) White (2) Black/African American (3) American Indian (4) Asian (5) Native Hawaiian/Other Pacific Islander
(list all that apply)
FULL NAME ON
SOCIAL
SECURITY CARD
RELATIONSHIP
TO HEAD OF
HOUSEHOLD
DATE OF
BIRTH
AGE
SEX
VETERAN
*RACE
(1-5)
ETHNICITY
DISABLED
Hispanic
Not Hispanic
Hispanic
Not Hispanic
Yes
No
1.
HEAD
M
F
2.
Relation
M
F
Yes
No
Yes
No
3.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
4.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
5.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
6.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
7.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
8.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
9.
Relation
M
F
Yes
No
Hispanic
Not Hispanic
Yes
No
ARE ALL MEMBERS OF HOUSEHOLD US CITIZENS OR LEGAL RESIDENTS?
Yes
SOCIAL SECURITY
NUMBER
Yes
No
No
B. SEPARATED / DIVORCE
List spouse or ex-spouse information if they do not live with you.
Spouse / Ex-spouse
(Full Name)
Last Known Address
(if unknown write city and/or state)
Divorced?
Yes
No
Yes
No
Yes
No
Yes
No
Year
Separated
C. NON-CUSTODIAL PARENT(S)
List other parent(s) information for any of the children listed in Section A.
Child(ren) Name(s)
Non-Custodial Parent
(Absent Parent Name)
Last Known Address
Contact with absent parent?
Yes
No
Yes
No
Yes
No
D. STUDENT STATUS*
List all family members who are attending College or Adult School
*UNOFFICIAL SCHOOL TRANSCRIPTS WILL BE ACCEPTED
Student Name
Part-time or
Full-time
Status
School Name and Address
Financial Aid
Type
Financial Aid
Amount
Student ID
$
$
$
$
$
$
$
Section II – Household Income
Answer each question below.
If you answered “YES”, fill out information below for the household member(s) who receive this income.
A. EMPLOYMENT
YES/NO
1. Do you or any other household member(s) receive full/part-time job earnings or severance pay?
Yes
No
2. Do you or any other household member(s) receive cash, tips, or bonuses?
Yes
No
3. Do you or any other household member(s) receive military or reserve pay?
Yes
No
4. Are you or any other household member(s) self-employed?
Yes
No
5. Do you or any other household member(s) receive Crystal Stairs pay?
Yes
No
6. Do you or any other household member(s)receive In-Home Supportive Services pay to care for another person?
Yes
No
Gross Earnings (before taxes)
(Include Frequency – wkly, bi-wkly, monthly)
Name & Address of Employer
Page
2
Name of Household Member
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
B. PUBLIC ASSISTANCE BENEFITS
YES/NO
1. Do you or any other household member(s) receive CALWORKS, cash aid, GR,, welfare, or food stamps?
Yes
No
2. Do you or any other household member(s) receive adoption or foster care payments?
Yes
No
3. Do you or any other household member(s) receive transportation reimbursement?
Yes
No
4. Do you or any other household member(s) receive services from Crystal Stairs ?
Yes
No
Name of Household Member
Monthly Amount
Type of Benefit
$
$
$
$
$
C. SSI / PENSION / OTHER BENEFITS
YES/NO
1. Do you or any other household member(s) receive Social Security/SSI benefits?
Yes
No
2. Do you or any other household member(s) receive a pension, retirement benefits, or an annuity?
Yes
No
3. Do you or any other household member(s) receive unemployment benefits or disability benefits?
Yes
No
4. Do you or any other household member(s) receive temporary disability benefits?
(i.e. State, Worker’s Comp, AFLAC, Colonial)
Yes
No
$
per
$
per
$
per
Name & Address of Source
D. CHILD SUPPORT OR ALIMONY BENEFIT(S)
YES/NO
1. Do you or any other household member(s) receive child support payments?
Yes
No
2. Do you or any other household member(s) receive alimony directly from an absent parent/spouse?
Yes
No
3. Does the parent purchase items for child(ren) such as clothing, food, formula, diapers, etc.?
Yes
No
Name of Child
Non-Custodial Parent /Absent Parent
/Spouse Name & Address
Amount
Cash Value of Purchase
(clothing, food, formula, etc)
$
per
$
$
per
$
$
per
$
E. CONTRIBUTIONS
1. Does anyone outside your household give you money or pay your bill(s) for you? If yes,
Who:
How Much:
How often:
2. Does anyone outside your household give or buy you supplies, such as groceries, etc? If yes,
Who:
How Much:
How often:
3. Does anyone outside your household pay auto insurance or a car note for you? If yes,
Who:
How Much:
How often:
4. Are your utility bills in your name? If you answered no, explain:
YES/NO
Yes
No
Yes
No
Yes
No
Yes
No
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
3
Monthly/Weekly amount
Page
Name of Household Member
F. FEDERAL INCOME TAX
YES/NO
1. Did you or any household member(s) file a federal income tax return in the last 12 months?
2. Did you or any household member(s) receive W-2 and/or 1099 income form(s) in the last 12 months; but did NOT
file a tax return? If yes, explain.
3. Were you or any household member(s) claimed as a dependent on someone else’s taxes?
Name of Household Member
Tax Year
Yes
No
Yes
No
Yes
No
Name of Person claiming family
member as dependent
Reasons Taxes not filed
G. ADDITIONAL HOUSEHOLD INCOME
List all that may apply, if the information does not apply write “none”
Social Security (self)
$
/month
Cal Works (cash assistance)
$
/month
Social Security (other)
$
/month
Food Stamps (EBT)
$
/month
SSI
$
/month
Unemployment
$
/month
VA Pension
$
/month
Educational Grant
$
/month
$
/month
Other Pension (from:
)
$
/month
Self-Employment
Child Support (case #
)
$
/month
Other (describe:
)
$
/month
Paid by:
State of
Other:
Other (describe:
)
$
/month
Other (describe:
)
$
/month
Other (describe:
)
$
/month
Other (describe:
)
$
/month
Other (describe:
)
$
/month
Other (describe:
)
$
/month
Other (describe:
)
$
/month
Other (describe:
)
$
/month
$
/month
Total Monthly Gross Income:
Yes
No
Page
4
Does any household member have an income source that is currently being garnished?
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
SECTION III – ASSETS
Answer each question below. If you answer “YES” fill out information below for your family member(s) with that asset(s).
A. ACCOUNT INFORMATION
YES/NO
1. Do you or any household member(s) have a savings or checking account?
Yes
No
2. Do you or any household member(s) have stocks, bonds, or certificates of deposit (CD)?
Yes
No
3. Do you or any household member(s) have a money market fund/trust fund?
Yes
No
4. Do you or any household member(s) have a retirement, 401(k), federal Thrift Savings Plan, or IRA acct?
Yes
No
Name of Household Member
Company / Bank Name
Type of Account
Account Number
B. PROPERTY
YES/NO
1. Do you or any household member own or have an interest in commercial or residential real estate or mobile home?
Yes
No
2. Has anyone in your household sold any real estate in the last 2 years?
Yes
No
Name of Household Member
Type of Asset
Value
$
$
C. DISPOSAL OF ASSETS
HUD requires Public Housing Agencies to verify whether recipients of rental assistance have disposed of any assets within the past 24 months.
“Dispose” means to get rid of, sell, or give away. Assets include, but are not limited to: stocks, bonds, savings certificates, money market funds,
equity in real property or other capital investments, cash value of trust accounts, IRAs, Keogh accounts, contributions to company retirement or
pension funds, lump sum receipts such as inheritances, capital gains, lottery winnings, insurance settlements, personal property held for
investment such as gems, jewelry, coin collections, cars, cash value life insurance policies, etc.
1. In the past 24 months (2 years), have you or any member of your household disposed of
any assets for less than their market value?
Yes, I/We have disposed of asset(s).
No, I/We have not disposed of any asset(s).
If you answered “Yes, I/We have disposed of asset(s),” complete the following:
2. What was the asset?
3. What date was the asset disposed of?
4. What was the value of the asset at the time it was disposed of?
5. List the actual amount received for the asset: $
D. LUMP SUM INCOME
Did you or any member of your household receive a large sum of money from ANY source including settlements or law suits
within the last 12 months? If yes, explain below.
Value
$
$
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
5
Type of Asset
Page
Name of Household Member
SECTION IV – VEHICLES AND CREDIT CARDS
Answer each question below. If you answer “YES” fill out information below for the household member(s).
A. VEHICLES BEING USED BY YOUR HOUSEHOLD
YES/NO
1. Do you or any other household member(s) have a vehicle(s) registered to him/her? If yes, who?
2. Does anyone outside your household pay auto insurance for you? If yes, who and how much?
3. Does anyone outside your household pay car payments for you? If yes, who and how much?
4. Do you or any other household member(s) have use of any vehicle(s) that is not registered to him/her?
If yes, complete information below.
Name of Registered Member
Make and Model of Vehicle
Year
Yes
No
Yes
No
Yes
No
Yes
No
Monthly
Payment
License Plate Number
$
$
B. CREDIT CARD AND LOANS
YES/NO
1. Do you or any other household member(s) have a Visa, Master Card, Discover, or American Express?
Yes
No
2. Do you or any other household member(s) have department store, furniture store, or jewelry store accounts?
Yes
No
3. Do you or any other household member(s) have credit union loans, bank loans, payday loans, or personal loans?
Yes
No
Name of Household Member
Creditor/
Bank Name
Account
Balance
Delinquent or in Collections?
Monthly
Payment
$
Delinquent/late
Collections
$
$
Delinquent/late
Collections
$
SECTION V – EXPENSES
Answer each question below. If you answer “YES” fill out the information below for the household member(s) with that expense(s).
A. CHILD CARE EXPENSES
YES/NO
Do you pay childcare for a child 12 and under to go to work or to school?
Yes
No
Do you pay for care equipment for a household member with a disability for you to go to work?
Yes
No
If Yes, is the childcare expense paid for by an agency or by another person outside of our household?
Yes
No
Name of Child or Disabled Member
Child Care Providers Name
Name of Agency
Amount Paid
$
Page
6
$
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
B. MEDICAL EXPENSES
List all Health Care Providers whom you have *PAID* out of pocket in the past year and you would like Housing to contact to verify your
household’s medical expenses. Do not list health care providers whose services are covered entirely by insurance. If you have more health care
providers than you can list here, make a copy of this sheet, or contact the Housing Authority of the City of Long Beach for additional copies.
Medical Expenses – To Qualify:
If the head of the household or spouse is 62 years of age or older, or a person with disabilities, you may complete this sheet to have your
household medical expenses considered in the determination of your housing benefits. All members of the household age 18 and over who
have medical expenses should sign this form if their medical expenses are to be considered.
HIPPA Compliant Authorization to Disclose Health Information
By signing this form, I authorize the health care providers listed below to disclose any information requested concerning the cost of my
medical treatment to the Housing Authority of the City of Long Beach (HACLB). The HACLB may use this information only for the purpose of
verifying my eligibility for and/or the amount of my housing assistance.
I understand that I have the right to revoke this authorization at any time by notifying HACLB in writing at 521 E. Fourth Street, Long Beach, CA
90802. I understand that the revocation is only effective after it is received and logged by HACLB. I understand that any use or disclosure made
prior to the revocation under this authorization will not be affected by a revocation.
Unless revoked in writing by me, this Authorization will expire six (6) months from the date of my signature below.
I understand that my health care providers cannot disclose the requested information without my signature on this Authorization, and that my
signing or refusal to sign this authorization will not affect my ability to receive treatment from my health care providers.
I understand that I am entitled to receive a copy of this authorization.
I have the right to refuse to sign this authorization. I understand the potential exists for the information used or disclosed pursuant to this
Authorization to be re-disclosed by the recipient and no longer be protected by federal law.
I have reviewed and understand this Authorization.
Signature of Head of Household
Printed Name
Date Signed
Signature of Other Adult
Printed Name
Date Signed
Signature of Other Adult
Printed Name
Date Signed
Signature of Other Adult
Printed Name
Date Signed
Select Expense
Household Member
with this expense
Provider Name & Address
Provider Name
Provider Address
Phone
Number
Amount
*YOU* Paid
On-going
Co-Pay?
$
Yes
No
Provider Name
Provider Address
$
Yes
No
Select Expense
Provider Name
Provider Address
$
Yes
No
Select Expense
Provider Name
Provider Address
$
Yes
No
Page
Select Expense
7
Type of Expense:
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
C. UTILITIES
WHICH UTILITIES
DO YOU PAY:
WHAT APPLIANCES
DID YOU PAY FOR:
ELECTRIC
GAS
REFRIGERATOR
STOVE
TRASH
WATER SEWER
AIR CONDITIONER
D. HOUSEHOLD EXPENSES
Rent
List the MONTHLY average amount ALL household members pay for each of the following; If the expense does not apply to
you, write NO or N/A. Do not leave any spaces blank.
$
Car Payment
$
Loan Payment
$
Gas
$
Gas for car
$
Credit Cards
$
Electricity
$
Car Insurance
$
Life Insurance
$
Water
$
Car Maintenance
$
Medical Bills
$
Trash & Sewer
$
Public Transportation
$
Medical Insurance
$
Cable/Internet
$
Childcare
$
Groceries/Food
$
Telephone
$
Disability Expenses
$
Other/Personal Spending
$
Cell Phone
$
Household Supplies
$
Clothing
$
Gardener
$
Furniture Payments
$
Other:
$
Page
8
Total Expenses:
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
SECTION VI – Household Information
Answer each question below. If you answer “YES” fill out the information below for the household member(s).
A. HOUSEHOLD INFORMATION
1.
2.
3.
YES/NO
Is there a family member(s): with a disability that started a new job or got a raise in the last 12 months?
If yes, explain:
Yes
No
Is any household member temporarily absent from the home? Away at school, military service, incarcerated, etc. If
yes, explain in detail (including length of absence):
Yes
No
Does any household member have any minor children that do not live in the home?
If yes, explain:
Yes
No
Yes
No
4.
Are you or anyone in your household CURRENTLY or ever been on Parole or Probation? If yes, explain:
5.
Are you or any household member CURRENTLY BEING CHARGED with a crime, felony, or misdemeanor,
including traffic violations, in ANY state within the United States? If yes explain:
Yes
No
Are you or anyone in your household subject to registration as sex offender or a registered sex offender in ANY
state within the United Sates? If yes, explain:
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
6.
7.
8.
9.
Have you or anyone in your household ever been ARRESTED charged and/or CONVICTED of ANY type of CRIME
(misdemeanor or felony) other than traffic violations in ANY State in the United States? If yes, list in detail,
regardless of date of offense:
Do ANY of the above crimes include drug-related, alcohol–related or violent/criminal offenses? If yes, explain:
Have you or anyone in your household ever used any name(s) or Social Security number(s) other than the one you
currently used or issued by the Social Security Administration? If yes, list other names(s) and/or Social Security
number(s) used:
10. In the last 5 years, have you or any household member’s criminal record been EXPUNGED (erased/eliminated) for
any crime? If yes, explain:
11. Are you or any household member a fugitive from justice in ANY State within the United States? If yes, explain:
12. In the last 5 years, have you ever received or lived in any other assisted-housing (Section 8/affordable
housing/public housing) elsewhere? If yes, list in detail date(s) and location(s):
13. Have you or any household member ever failed to report income while receiving assisted-housing (Section
8/affordable housing/public housing)? And, as a result, were required to repay money for misrepresenting
information on such program? If yes, list date and all details:
14. In the last 5 years, have you or any household member committed program-violations in connection with a federally
funded program, such as Social Security, Veterans Affairs, Welfare, Medicaid/Medicare/Medical, WIC, general
relief/assistance, Cal-Works, food stamps/Cal-Fresh, etc? And, as a result, was repayment or a decrease in your
allotment required? If yes, list date and all details:
Page
9
15. In the last 3 years, have you been evicted or asked to vacate a Section 8 unit due to: (a) non-payment of rent (b)
drug activity (c) alcohol abuse (d) criminal activity (e) housekeeping issues or (f) interfering with the health, safety, or
the right to a peaceful enjoyment of the premises by other residents or been court ordered to pay for damages to a
unit? If yes, explain:
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.
SECTION VII – CERTIFICATION OF THE FAMILY
I/We hereby certify under penalty of perjury under the laws of the state of California that all the information contained in this document is true and correct. I
understand that ALL changes in the income of ANY member of the household must be reported to the Housing Authority within 30 days of
occurrence. The Housing Authority MUST APPROVE ANY additional household members. The head of household must request in writing to add or to
remove any member. Failure to comply with the rules and regulations may result in termination from the program.
I/We have received, have read, and understand a copy of the attached Statement of Family Obligations. I/We hereby certify that I/we understand
my/our responsibilities to the Housing Authority and I/we further acknowledge that my/our housing assistance may be terminated if I/we violate them.
I/We hereby certify that that above-referenced statement has been explained and/or translated to me by a reliable source.
Certification. All adult members in the household must sign this declaration to certify accuracy of the information reported.
Giving True and Complete Information: I certify that all the information provided on household composition, income, family assets and items for allowances
and deductions is accurate and complete to the best of my knowledge.
Reporting Changes in Income or Household Composition: I know I am required to report within 30 days in writing any changes in income and household
size. I understand the rules and regulations regarding guests/ visitors and when I must report anyone who is staying with me.
Reporting on Prior Housing Assistance: I certify that I have disclosed where I received any previous Federal housing assistance and whether or not any
money is owed. I certify that if I have received previous assistance, I did not commit any fraud, knowingly misrepresent any information, or vacate the unit in
violation of the lease.
No Duplicate Residence or Assistance: I certify that the dwelling unit will be my principal residence and I will not obtain duplicate Federal housing assistance
while I am in this current program. I will not live anywhere else without notifying the Department of Housing Services in writing. I will not sub-lease my assisted
residence.
Cooperation: I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true
circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I understand failure or refusal to do so may
result in delays, termination of assistance, or eviction.
Criminal and Administrative Actions for False Information: I understand that knowingly supplying false, incomplete, or inaccurate information is punishable
under Federal or State criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing
assistance or termination of tenancy.
I understand that by applying for assistance through the Housing Authority of the City of Long Beach, a criminal background check and sex
offender check will be conducted on all adults. Signatures below authorize the background check.
X
Signature of Head of Household
Date
X
Signature of Spouse/Co-Head or Other Adult
Date
X
Signature of Other Adult
Date
X
Signature of Other Adult
Date
Page
WARNING:
Title 18, Section 1001 of the United States Code states that a person is Guilty Of A FELONY FOR KNOWINGLY AND
WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS to any department or agency of the United States. MAKING
FALSE STATEMENTS IS ALSO A FELONY UNDER CALIFORNA STATE LAW (Penal Code Sections: 115, 118, 487, 532) and
may result in criminal charges including perjury, grand theft, filing false documents with a public office, and obtaining money
under false pretenses.
10
By my signature below, I do hereby swear and attest that all of the information reported on this form about me and my household is true and correct, and I
have read and agree to the certifications contained in this form. I also understand that all changes in household members or income must be reported to the
Housing Authority of the City of Long Beach in writing, immediately.
IF YOU NEED ADDITIONAL SPACE TO ANSWER ANY OF THESE QUESTIONS, USE AN ADDITIONAL SHEET OF PAPER AND
ATTACH IT TO THIS FORM.