Download Eligibility revised - Rosenberg Housing Authority

DHAP RE-ELIGIBLITY FORM
The Disaster Housing Assistance program (DHAP) is entering the second portion of the
program. The U.S. Department of Housing and Urban Development’s Disaster Housing
Assistance Program requires clients to re-qualify for continued assistance within six
months of the lease-up date or July 31st, whichever comes first.
Section I: Family Eligibility
Date:___________________________________________________________________
Client Name:_____________________________________________________________
Social Security Number:____________________________________________________
Gross Monthly Income Amount:_____________________________________________
Current address:__________________________________________________________
Pre-Disaster address:______________________________________________________
Phone Number:___________________________________________________________
You must provide proof of gross monthly income. Gross monthly income means all
sources of income that go to a family member or sources of income paid on behalf of
family members (including, but not limited to, the following: wages, interest, annuities,
pensions, Social Security Retirement, alimony, child support, Unemployment Benefits,
Workers’ Compensation, and any other indirect income).
Possible proof: last three paycheck stubs; unemployment compensation statements;
benefit letters; retirement checks or statements, mortgage statement, Tax statement,
utility bills for pre-disaster house.
You must provide proof of housing expenses, if any. This will include Proof of
Ownership, mortgage statement, real estate tax statement, home owners insurance, utility
bills for pre-disaster house, rent for Dhap unit and utilities for Dhap unit.
If you have no income, please describe below how you are paying utility bills and basic
living expenses, such as food and clothing. If asked by the RHA or GMC, you must
supply documentation of the source of these monies.
A. Income and Expenses Worksheet
My Income:
My Expenses:
Wages (Head of Household)_____________
Child Support/Alimony
______________
TANF
______________
Food Stamps
______________
SS/SSI
______________
Unemployment
______________
Pension
______________
Contributions
______________
Retirement
______________
Veterans
______________
Wages (other members)
______________
Other
______________
Rent (Dhap Unit)
______________
Mortgage Payment (pre-dis) ______________
Proof of Ownership (pre-dis) ______________
Real Estate Taxes (pre-dis) ______________
Home Owners Insurance
______________
TOTAL INCOME
______________
Flexible Expenses:
Electricity (Dhap unit)
Water (Dhap unit)
Gas (Dhap Unit)
Electricity (pre-dis)
Water (Pre-dis)
Gas (Pre-dis)
______________
______________
______________
______________
______________
______________
TOTAL EXPENSES
______________
Check list:
() All Income documents (Bills and Statements)
() All Housing documents (Bills and Statements)
() Case management is good standing
I do hereby certify that all of the information above me is true and correct. I also certify that I will promptly
report any future increase in income to GMC. I understand that failure to report an increase is grounds for
termination of DHAP.
Signature of Head of Household______________________________________ Date ____________
Signature of GMC Representative______________________________________Date____________
______________________________________________________________________________
______________________________________________________________________________
Approval () Denial ()
Signature of RHA DHAP Coordinator _________________________________Date_______________