STATESVILLE HOUSING AUTHORITY PRELIMINARY APPLICATION

Application Date
Application Date
Application Time
Application Time
PROGRAMS YOUR APPLYING FOR
Summit Village *
Oaktree Village *
Parkwood Village *
Raleigh Hills *
Holly Hills (Mt. Holly, NC) *
Rollins Apts (Mt. Holly, NC) *
Summit Village Apts (62 or older/disabled) *
Brevard Gardens *
Household Information
Name (Head of Household) *
Name (Head of Household)
Birth Date
Birth Date
Additional Household Member 1:
Additional Household Member 1:
Birth Date
Birth Date
Additional Household Member 2:
Additional Household Member 2:
Birth Date
Birth Date
Additional Household Member 3:
Additional Household Member 3:
Birth Date
Birth Date
Additional Household Member 4:
Additional Household Member 4:
Birth Date
Birth Date
Provide full name, source of income, wages, SSI, SSA, child support and total monthly amount.
Please answer ALL of the following questions:
Are you or your spouse currently elderly? (62 or older)
Will you need a Disabled/Handicapped accessible unit?
Are you a Veteran with an Honorable Discharge?
Do you own the home in which you are living in? If yes, list home’s address.
Do you own a home in which you are not living in?
Are you paying rent for the home in which you are currently living in?
Do you have a current Landlord? If yes, list name, address and phone number below:
Did you have a prior Landlord? If yes, list name, address and phone number below:
Have you ever lived in Public Housing or lived under Section 8 Voucher program? If yes, When & Where?
Have you or your family ever been asked to move by any Housing Authority or Landlord? If yes, What Housing Authority or Landlord? When & Why?
Have you ever been evicted from any Housing Authority or HUD assisted housing for a drug related activity? If yes, what housing authority, When & Where?
Do you owe any outstanding balance to any Housing Authority? If yes, to What Housing Authority & What amount?
Are you or any household member banned from any Public Housing Authority or HUD assisted property?
Are you or any household member subject to a lifetime registration requirement under a State sex offender registration program?
List Person(S) Name who will live in the property:
Warning *
Section 1001 of Title 18 of the United States Code makes it a criminal offense to make willful false statements or misrepresentation to any Department or Agency of the United States to any matter within its jurisdiction. I have read the above statement and the above information is correct to the best of my knowledge. I have no objection to inquiries for the purpose of verifying the facts herein stated. I authorize the Statesville Housing Authority to use a third party background checking company to obtain my credit and rental history and perform a criminal record search. I understand that the information obtained is to be used only in the processing of my rental application. I hereby release and hold harmless any third party background checking company who has provided information from any and all liabilities arising out of the use of such information in connection with my credit history and criminal record search.
Date *
Date
Date
Date
Date
Date
Date
Date
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.
Address
Address
Reason for Contact: (Check all that apply)
Date
Date
Check this box if you choose not to provide the contact information.
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you. Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law. Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.
Date *
Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. 

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.


Directions and Information Regarding Public Housing Developments

Name, Address and Phone Number Driving Directions from Statesville Housing Authority Central Office Streets Included In This Development
Summit Village
Development # 21 & S8NC
1353 Pearl Street
704/761-4500
Sr. Property Manager: Thea Sheller
Property Manager: Reggie Imes
Go to corner of W. Allison Street and Shelton Avenue and turn right. Turn right onto Garner Bagnal Blvd. Turn right onto Oakland Avenue. Turn left onto Pearl Street. Office is on the left. Alexander Street, Deaton Street, Gray Street, Pearl Street, Reid Street, Medlin Street
BDRM SZ: 1, 2 & 3
Oak Tree Village
Development #22
1353 Pearl Street
704/761-4500
Sr. Property Manager: Thea Sheller
Property Manager: Reggie Imes
Go to corner of W. Allison Street and Shelton Avenue and turn right. Turn right onto Garner Bagnal Blvd. Turn right onto Oakland Avenue. Turn left onto Pearl Street. Office is on the left. Knox Avenue, Williams Road, Park Drive, Lakeview Drive, Elam Avenue, Woodlawn Drive, Ascending Lane
BDRM SZ: 2, 3, 4 & 5
Parkwood Village
Development #23
234 Dobson Street
704/761-4500
Property Manager: Tammy McNair
Property Manager: Lolita Gordon
Go to corner of W. Allison Street and Shelton Avenue and turn right. Turn left onto Garner Bagnal Blvd. Make right onto Rickert Street. Turn right onto Dobson Street. Office is on the left. Buffalo Shoals Road, Columbia Street, Inglewood Road, Ericson Street, Grove Drive, Wilson Lee Blvd, Seventh Street, Fourth Street, Fifth Street, West Raleigh Avenue
BDRM SZ: ALL
Raleigh Hills
Development #24
234 Dobson Street
704/761-4500
Property Manager: Tammy McNair
Property Manager : Lolita Gordon
Go to corner of W. Allison Street and Shelton Avenue and turn right. Turn left onto Garner Bagnal Blvd. Make right onto Rickert Street. Turn right onto Dobson Street. Office is on the left. Adams Street, E. Raleigh Avenue, McCullough Street, Dobson Street, Rickert Street, Winona Street, Rolling Lane, Crescent Lane, Unity Drive
BDRM SZ: ALL
Holly Hills Rollins
Development #25
635 Noles Drive
704/761-4769
Sr.Property Manager: Destiny Higginbotham
Go to corner of W. Allison Street and Shelton Avenue and turn right. Turn left onto Garner Bagnal Blvd. Merge onto I-77 South towards Charloote. Merge onto I-485 S/Pineville/Outer. Exit 14 NC-27. Continue to follow NC27. Turn right onto Highland St/NC2273. Take 1st left onto main street. Take 1st right onto Woodlawn Ave. Stay straight to go onto Noles Dr. Noles Drive, South Hawthorne
BDRM SZ: 2,3

Eligibility Requirements

  • Qualify as a family-a family may be a single person
  • Annual income plus income from assets does not exceed the HUD income limits
  • Family composition conforms to occupancy standards
  • Rent paying habits are satisfactory
  • No indebtedness to any landlord or Housing Authority
  • No record of disturbances, destruction of property or poor housekeeping habits
  • No history of drug related or violent criminal activity
  • Has not committed fraud, misrepresentation or falsified information
  • Has not been evicted from any assisted housing in the past 3 years
  • Has not been evicted from any assisted housing in the past 5 years for drug related activity
  • Must submit evidence of citizenship or eligible applicant status
  • Must not be or have any household member who is subject to a life time registration requirement under a state sex offender registration program

Eligibility Requirements - To apply for residency at Brevard Gardens the following must apply:

  1.  Must be gainfully employed with a minimum household emplyment income of $15,000 per year and does not include HUD exluded wages; and
  2. Must be employed for a minimum of twelve-(12) consecutive months prior to application and/or admission date; and
  3. Family composition meets the Occupancy standards requirement; and
  4. Must enroll in the Housing Counseling Program.
  5. Non Smoking Community.

Reasonable Accommodation for Applicants with Disabilities

The PHA will make a reasonable accommodation in the application and other policy requirements when requested in writing, by a qualified applicant with a disability.  Reasonable accommodation includes helping an applicant meet application requirements, but does not require lowering or waiving essential requirements for eligibility.  Accommodations are not reasonable if it requires a fundamental alteration in the nature of the program or imposes undue financial and administrative burdens on the PHA

Notice to Applicants

Effective September 14, 2009, PHAs will have the ability to enter the following information into Enterprise Income Verification (EIV):

  • Amount of debt owed by a former tenant to a PHA
  • If applicable, indication of bankruptcy filing
  • If applicable, the reason for any adverse termination of the family from a federally assisted housing program This information will be used by HUD to create a national repository of families that owe a debt to a PHA and/or have been terminated from a federally assisted housing program.  This national repository will be available within the EIV system for all PHAs to access during the time of application for rental assistance.  PHAs will be able to access this information to determine a family’s suitability for rental assistance, and avoid providing limited federal housing assistance to families who either: (1) Owe a debt to a PHA; or (2) have previously been unable to comply with HUD program requirements.

U.S. Department of Housing and Urban Development Office of Public and Indian Housing DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS 

Paperwork Reduction Notice:  Public reporting burden for this collection of information is estimated to average 7 minutes per response. This includes the time for respondents to read the document and certify, and any recordkeeping burden. This information will be used in the processing of a tenancy. Response to this request for information is required to receive benefits. The agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB control number. The OMB Number is 2577‐0266, and expires 08/31/2016. 

NOTICE TO APPLICANTS AND PARTICIPANTS OF THE FOLLOWING HUD RENTAL ASSISTANCE PROGRAMS:  

  • Public Housing (24 CFR 960)  
  • Section 8 Housing Choice Voucher, including the Disaster Housing Assistance Program (24 CFR 982)  
  • Section 8 Moderate Rehabilitation (24 CFR 882)  
  • Project-Based Voucher (24 CFR 983)  

The U.S. Department of Housing and Urban Development maintains a national repository of debts owed to Public Housing Agencies (PHAs) or Section 8 landlords and adverse information of former participants who have voluntarily or involuntarily terminated participation in one of the above-listed HUD rental assistance programs.  This information is maintained within HUD’s Enterprise Income Verification (EIV) system, which is used by Public Housing Agencies (PHAs) and their management agents to verify employment and income information of program participants, as well as, to reduce administrative and rental assistance payment errors.   The EIV system is designed to assist PHAs and HUD in ensuring that  families are eligible to participate in HUD rental assistance programs and determining the correct amount of rental assistance a family is eligible for. All PHAs are required to use this system in accordance with HUD regulations at 24 CFR 5.233.  

HUD requires PHAs, which administers the above-listed rental housing programs, to report certain information at the conclusion of your participation in a HUD rental assistance program.  This notice provides you with information on what information the PHA is required to provide HUD, who will have access to this information, how this information is used and your rights.  PHAs are required to provide this notice to all applicants and program participants and you are required to acknowledge receipt of this notice by signing page 2.  Each adult household member must sign this form. 

What information about you and your tenancy does HUD collect from the PHA?  
The following information is collected about each member of your household (family composition):  full name, date of birth, and Social Security Number. 

The following adverse information is collected once your participation in the housing program has ended, whether you voluntarily or involuntarily move out of an assisted unit: 

  • Amount of any balance you owe the PHA or Section 8 landlord (up to $500,000) and explanation for balance owed (i.e. unpaid rent, retroactive rent (due to unreported income and/ or change in family composition) or other charges such as damages, utility charges, etc.); and
  • Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and
  • Whether or not you have defaulted on a repayment agreement; and
  • Whether or not the PHA has obtained a judgment against you; and
  • Whether or not you have filed for bankruptcy; and
  • The negative reason(s) for your end of participation or any negative status (i.e., abandoned unit, fraud, lease violations, criminal activity, etc.) as of the end of participation date.

Who will have access to the information collected?
This information will be available to HUD employees, PHA employees, and contractors of HUD and PHAs.

How will this information be used?
PHAs will have access to this information during the time of application for rental assistance and reexamination of family income and composition for existing participants.  PHAs will be able to access this information to determine a family’s suitability for initial or continued rental assistance, and avoid providing limited Federal housing assistance to families who have previously been unable to comply with HUD program requirements.  If the reported information is accurate, a PHA may terminate your current rental assistance and deny your future request for HUD rental assistance, subject to PHA policy. 

How long is the debt owed and termination information maintained in EIV?
Debt owed and termination information will be maintained in EIV for a period of up to ten (10) years from the end of participation date. 

What are my rights?
In accordance with the Federal Privacy Act of 1974, as amended (5 USC 552a) and HUD regulations pertaining to its implementation of the Federal Privacy Act of 1974 (24 CFR Part 16), you have the following rights:

  • To have access to your records maintained by HUD, subject to 24 CFR Part 16.
  • To have an administrative review of HUD’s initial denial of your request to have access to your records maintained by HUD.
  • To have incorrect information in your record corrected upon written request.
  • To file an appeal request of an initial adverse determination on correction or amendment of record request within 30 calendar days after the issuance of the written denial.
  • To have your record disclosed to a third party upon receipt of your written and signed request. 

What do I do if I dispute the debt or termination information reported about me?
If you disagree with the reported information, you should contact in writing the PHA who has reported this information about you. The PHA’s name, address, and telephone numbers are listed on the Debts Owed and Termination Report.  You have a right to request and obtain a copy of this report from the PHA. Inform the PHA why you dispute the information and provide any documentation that supports your dispute. HUD's record retention policies at 24 CFR Part 908 and 24 CFR Part 982 provide that the PHA may destroy your records three years from the date your participation in the program ends. To ensure the availability of your records, disputes of the original debt or termination information must be made within three years from the end of participation date; otherwise the debt and termination information will be presumed correct. Only the PHA who reported the adverse information about you can delete or correct your record.  

Your filing of bankruptcy will not result in the removal of debt owed or termination information from HUD’s EIV system.  However, if you have included this debt in your bankruptcy filing and/or this debt has been discharged by the bankruptcy court, your record will be updated to include the bankruptcy indicator, when you provide the PHA with documentation of your bankruptcy status.    The PHA will notify you in writing of its action regarding your dispute within 30 days of receiving your written dispute.  

If the PHA determines that the disputed information is incorrect, the PHA will update or delete the record.  If the PHA determines that the disputed information is correct, the PHA will provide an explanation as to why the information is correct.