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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_______________