Western Regional Housing Authority

Revised 01/2023

Main Office Deming Office Pyramid Village

P.O. Box 3015 112 W. Ash Street 1001 Avenida Del Sol

2545 N. Silver Street Deming, NM 88030 Lordsburg, NM 88045

Silver City, NM 88062 (575) 546-6544 (575) 542-8111

(575) 388-1974

DOCUMENTS REQUIRED

In order to be determined eligible for assistance, you must provide this agency with adequate/required

documentation/information. The following items will be required to be submitted to this office at the time

the application is accepted. Western Regional Housing Authority will not accept an application for any

type of assistance that they may administer without these documents being presented. The Western

Regional Housing Authority reserves the right to request any other information or documents that it deems

necessary in the course of determining applicant eligibility in administration of all of its programs.

The list of documents includes but is not limited to the following:

1. Original Birth Certificates

A. State Birth Certificate

B. Hospital Birth Certificate

C. Foreign Nationality-Any documentation provided and acceptable by INS proving

family/household place of birth.

D. Application for Birth Certificate with a thirty (30) day grace period to provide birth certificate.

1. At the end of the thirty (30) day grace period the applicant will be given an additional ten

(10) days in which to submit birth certificate documentation to the Western Regional

Housing Authority office.

2. If the birth certificate/documentation is not provided within the ten (10) day period the

applicant will be canceled.

E. US Passport

2. Social Security Cards of all family members. If not applicable, a certification stating that no social

security number has been assigned or applied for. If applicant has been assigned a number, but does not

have proper documentation, an application for a social security card replacement will be accepted. A

ninety (90) day period will be allowed to provide social security cards. If not provided within ninety (90)

days, applicant will be canceled

3. Divorce Decree (If less than 5 Yrs).

4. Current Driver’s License or Government Issued Picture ID for all adult family members.

5. Checking and/or Savings Account. Current Statement

6. Income Verification. The information you provide will be computer matched using the Employment

Income Verification Database. Examples of Income: A statement of financial assistance from friends

and/or relatives, Social Security, SSI, TANF/SNAP, Child Support, Unemployment Benefits.

College Students: Financial Award Statement/ Statement from the Business Office.

Employment: 2 most recent Paystubs or Employment Verification Form (for New Employment)

7. Income Tax Return. (Federal, State and W-2's)

ALL ITEMS LISTED ABOVE MUST BE RETURNED WITH A COMPLETED APPLICATION

TO BE ACCEPTED

If you or anyone in your family is a person with disabilities, and you require specific accommodation in

order to fully utilize our programs and services, please contact the housing authority

What is the difference between Section 8 and public

housing?

This Housing Authority (PHA) administers 2 (two) programs.

1. Low Rent Public Housing Program

2. Section 8 Housing Program (Voucher Program)

The Housing Developments owned, managed and maintained by the PHA are

referred to as Low Rent Public Housing (The rent subsidy is tied to the unit and is

not transferrable). There are 154 Public Housing Units, 54 Units in Silver City, NM,

and 100 Units in Lordsburg, NM, ranging in size from 1 bedroom to 4 bedrooms. The

established rent is approximately 30% of residents adjusted income.

The Section 8 Housing Voucher Program is a rental subsidy program administered by

this agency. Qualified families in this program are selected from the waiting list,

certified, briefed on the requirements of the program and allowed to locate their

own decent safe and sanitary housing. Rents are controlled by Fair Market Rents as

established by HUD. The tenant’s portion of the rent payable to the owner is based

on 30% of the family’s adjusted gross income. The Housing Authority subsidizes the

difference between the tenant’s portion and the actual rent. The Fair Housing Act

prohibits discrimination in housing because of race, color, national origin, religion,

sex or handicap.

Revised 06/2022

_________________________________________________________________________

WESTERN REGIONAL HOUSING AUTHORITY

Main Office Deming Office Pyramid Village

P.O. Box 3015 112 W. Ash Street 1001 Avenida Del Sol

2545 N. Silver Street Deming, NM 88030 Lordsburg, NM 88045

Silver City, NM 88062 (575) 546-6544 (575) 542-8111

(575) 388-1974

APPLICATION FOR RENTAL ASSISTANCE

Application No.:________________Date:__________________Time:___________Rec’d by:___________

PLEASE COMPLETE APPLICATION IN INK

Indicate the program(s) you are applying for:

Voucher Program

(Select Only One)

_____Grant County- Silver City, Cliff, & surrounding areas

_____Catron County – Reserve & surrounding areas

_____Luna County – Deming & surrounding areas

_____Hidalgo County- Lordsburg & surrounding areas

AND

Public Housing

(Select Only One)

______Hillside/Valley Vista (Silver City)

______Pyramid Village (Lordsburg)

A. APPLICANT:

Name:____________________________________________________________________________________

Mailing Address:___________________________________________________________________________

City State Zip Code

Street Address:_____________________________________________________________________________

City State Zip Code

Home phone:______________________________Work phone:______________________________________

Cell Phone:________________________________Email Address:____________________________________

List the names, addresses, and phone numbers of relatives or friends:

1. Name:_________________________________ 2. Name: __________________________________

Address:_______________________________ Address:_________________________________

______________________________________ ________________________________________

Phone:________________________________ Phone:__________________________________

B. HOUSING STATUS (Circle One)

What is your current monthly rent? $________________

Do you pay utilities? Yes No

List utilities paid: __________________________________________________________________________

Are you now living in or have you ever applied for a government subsidized unit (HUD) before ? Yes No

If yes, where and when? ____________________________________________________________________

Present landlord is ____________________________________Phone number_________________________

Former landlord was __________________________________Phone number_________________________

C. HOUSEHOLD COMPOSITION AND CHARACTERISTICS

NO. MEMBER FULL NAMES RELATIONSHIP BIRTH DATE AGE SOCIAL SECURITY NO.

1 SELF

Are you: (Circle One)

1. Married 2. Single - If single, have you ever been married? Yes No

3. Divorced 4. Separated 5. Widowed - If yes, do you receive social security? Yes No

Race: White Black Indian Asian Other:______________

Ethnicity: Hispanic Non-Hispanic

D. INCOME INFORMATION (Circle One)

Is any member of your household employed full-time, part-time, or seasonally? Yes No

Does any member of your household work for someone who pays them in cash? Yes No

Is any member of your household on leave of absence from work due to lay-off, medical, maternity or military

leave? Yes No

Is any family member actively seeking work? Yes No

Does any member in the household receive unemployment benefits or severance pay? Yes No

If yes, explain: ________________________________________________________________________

Does any member of your household receive child support from an absent parent or from a child support

recovery unit? Yes No

List the last known address of the absentee parent: ___________________________________________

Does any member of your household receive alimony payments? Yes No

Does any member of your household receive welfare assistance (SNAP, TANF, General Assistance)? Yes No

Does any member of you household receive any monies/payments from an employer for disability or workmen’s

comp? Yes No

Do any members of your household own a business or self-employed? Yes No

Does any household member participate in a job training program? Yes No

Does any household member receive any type of military pay (including Coast Guard and National Guard

Reserve units)? Yes No

Does anyone outside of your household pay for any of your household bills or living expenses? Yes No

Did any household members file an income tax return last year? Yes No

If No, did anyone else claim you or any other household member on their income tax return? Yes No

Explain:_____________________________________________________________________________

Are there any family members who are temporarily absent from the home? Yes No

If yes, explain:___________________________________________________________________________

Does any member of your family receive Social Security or SSI benefits? Yes No

Does any member of your household receive income from a pension/retirement or annuity? Yes No

Does any household member have any type of retirement account (Company, IRA, 401(K), etc.) ? Yes No

If yes, explain:___________________________________________________________________________

Does any member of your household receive regular cash contributions for your household bills or living

expenses from individuals not living in the unit or from any agencies? Yes No

Is any adult in your household a full-time student? Yes No

If yes, explain:___________________________________________________________________________

Does any member of your household receive scholarships or grants? Yes No

For each type of income that your household receives, give the source of the income and the amount of

the income that can be expected from the source during the next 12 months. This includes, but is not

limited to, full and/or part-time employment, all income from welfare agencies (SNAP, TANF, general

assistance), social security, pension, SSI disability, armed forces reserves, unemployment compensation,

child care, alimony, child support, scholarships and grants, contract for deed, interest on assets,

dividends, annuities, regular contributions from people not residing with you.

MBR

SOURCE & TYPE OF INCOME

ANNUAL

INCOME

E. ASSETS (Circle One)

List all cars in your name or your household members’ names:

Make__________________Model___________________Year__________Plate No.______________

Does any household member have a checking or savings account? Yes No

Does any household member own any home or property? Yes No

Does any member of your household receive income from assets including interest on checking or savings

accounts, interest and/or dividends from certificates of deposit, stock or bonds, or income from the rental of

property? Yes No

If yes, explain:___________________________________________________________________________

Does any household member have any inheritances, lottery winnings, or lump-sum payments from any other

source? Yes No

Does any household member have any life insurance policies? Yes No

Has any household member sold or given away any asset in the past two years? (This includes real estate, stocks,

bonds, property, jewelry, stamp collections held as an investment, etc.) Yes No

F. EXPENSES (Circle One)

Do you pay for a care attendant or for any equipment, for any household member with disabilities, that is

necessary to permit that person or someone else in the household to work? Yes No

If yes, weekly amount $___________

If yes, are any of these expenses reimbursed by any person or agency? Yes No

Do you pay child care for children 12 or under that is not reimbursed by AFDC or any other person or

agency? Yes No If yes, weekly cost: $______________________

QUESTIONS FOR HOUSEHOLDS WHOSE HEAD OR SPOUSE IS 62 YEARS OF AGE OR OLDER OR

IS A PERSON WITH A DISABILITY: (Circle One)

Do you require any special amenities? Yes No

If yes, please list____________________________________________________________________

Does any household member pay for Medicare? Yes No

Does any household member pay for any type of medical insurance? Yes No

Is any household member paying on past medical expenses and/or anticipate any medical expenses during the

next 12 months that will not be reimbursed by any source outside the household? (This includes prescription and

non-prescription drugs and any other medical costs.) Yes No

G. PROGRAM INFORMATION

Do you owe money to any housing authority? Yes No

If yes, name of agency____________________________________________________________________

Do any of your children under the age of seven (7) have an elevated lead blood level? Yes No

Has any member of the household been convicted of any criminal and/or drug-related activities in the last three

(3) years? Yes No

Is any member of the household subject to a lifetime sex offender registration? Yes No

This application is made with the understanding that the Housing Authority will conduct a criminal background

check and verify rental history. I have no objection to inquiries for the purpose of verification of the above

information and statements.

APPLICANT CERTIFICATION: I/we certify that the information given to Western Regional Housing

Authority on household composition, income, net family assets, and allowances and deductions are accurate and

complete to the best of my/our knowledge and belief. I/we understand that false statements or misinformation

are grounds for termination of housing assistance and termination of tenancy.

APPLICANT___________________________________ DATE:________________________

OTHER ADULT________________________________ DATE:________________________

*WARNING:

Section 1001 of the Title 18 U.S.C. provides: “Whoever in any matter within the jurisdiction of any

department or agency of the United States knowingly and willfully falsifies... a material fact, or makes any

false, fictitious or fraudulent statements or representations, or makes or uses any false writing or

document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined

not more than $10, 000 or imprisoned for no more than five (5) years or both.”

____________________________________________________________________________________________

**FOR OFFICE USE ONLY**

THIS SECTION OF THE APPLICATION IS TO BE COMPLETED ONLY AT THE

TIME OF APPLICATION UPDATE IN THE PRESENCE OF PHA REPRESENTATIVE

I/we the applicant(s) have reviewed this application and have made changes to reflect current status of applicant.

APPLICANT____________________________________ DATE:________________________

OTHER ADULT_______________________________ DATE:________________________

APPLICATION STATUS - MISSING OR INCOMPLETE DOCUMENTS

Does this applicant qualify for the Residency Preference? Yes No

If Yes, Explain:_____________________________________________________________________________

OMB Control # 2502-0581

Exp. (07/31/2012)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

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.

Applicant Name:

Mailing Address:

Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:

E-Mail Address (if applicable):

Relationship to Applicant:

Reason for Contact: (Check all that apply)

mergency

Unable to contact you

Termination of rental assistance

Eviction from unit

Late payment of rent

Assist with Recertification Process

Change in lease terms

Change in house rules

Other: ______________________________

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.

Check this box if you choose not to provide the contact information.

Signature of Applicant

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.

Form HUD- 92006 (05/09)

Original is retained by the requesting organization.

form HUD-9886

(07/14)

ref. Handbooks 7420.7, 7420.8, & 7465.1

Authorization for the Release of Information/

Privacy Act Notice

to the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014

and the Housing Agency/Authority (HA) exp. 07/31/2017

Persons who apply for or receive assistance under the following

programs are required to sign this consent form:

PHA-owned rental public housing

Turnkey III Homeownership Opportunities

Mutual Help Homeownership Opportunity

Section 23 and 19(c) leased housing

Section 23 Housing Assistance Payments

HA-owned rental Indian housing

Section 8 Rental Certificate

Section 8 Rental Voucher

Section 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consent

form may result in the denial of eligibility or termination of

assisted housing benefits, or both. Denial of eligibility or termi-

nation of benefits is subject to the HA’s grievance procedures and

Section 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies. (This consent is

limited to wages and unemployment compensation I have re-

ceived during period(s) within the last 5 years when I have

received assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent is

limited to the wage and self employment information and pay-

ments of retirement income as referenced at Section 6103(l)(7)(A)

of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent is

limited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current and

former employers concerning salary and wages and (b) financial

institutions concerning unearned income (i.e., interest and divi-

dends). I understand that income information obtained from these

sources will be used to verify information that I provide in

determining eligibility for assisted housing programs and the level

of benefits. Therefore, this consent form only authorizes release

directly from employers and financial institutions of information

regarding any period(s) within the last 5 years when I have

received assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney Homeless

Assistance Amendments Act of 1988, as amended by Section 903

of the Housing and Community Development Act of 1992 and

Section 3003 of the Omnibus Budget Reconciliation Act of 1993.

This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: (1)

HUD and the Housing Agency/Authority (HA) to request verifi-

cation of salary and wages from current or previous employers; (2)

HUD and the HA to request wage and unemployment compensa-

tion claim information from the state agency responsible for

keeping that information; (3) HUD to request certain tax return

information from the U.S. Social Security Administration and the

U.S. Internal Revenue Service. The law also requires independent

verification of income information. Therefore, HUD or the HA

may request information from financial institutions to verify your

eligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUD

and the above-named HA to request income information from the

sources listed on the form. HUD and the HA need this information

to verify your household’s income, in order to ensure that you are

eligible for assisted housing benefits and that these benefits are set

at the correct level. HUD and the HA may participate in computer

matching programs with these sources in order to verify your

eligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protect

the income information it obtains in accordance with the Privacy

Act of 1974, 5 U.S.C. 552a. HUD may disclose information

(other than tax return information) for certain routine uses, such as

to other government agencies for law enforcement purposes, to

Federal agencies for employment suitability purposes and to HAs

for the purpose of determining housing assistance. The HA is also

required to protect the income information it obtains in accordance

with any applicable State privacy law. HUD and HA employees

may be subject to penalties for unauthorized disclosures or im-

proper uses of the income information that is obtained based on the

consent form. Private owners may not request or receive

information authorized by this form.

Who Must Sign the Consent Form: Each member of your

household who is 18 years of age or older must sign the consent

form. Additional signatures must be obtained from new adult

members joining the household or whenever members of the

household become 18 years of age.

PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)

(Full address, name of contact person, and date) (Full address, name of contact person, and date)

U.S. Department of Housing

and Urban Development

Office of Public and Indian Housing

Western Regional Housing Authority

Original is retained by the requesting organization.

form HUD-9886

(07/14)

ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________

Head of Household Date

___________________________________________

Social Security Number (if any) of Head of Household

__________________________________________________ _______________

Spouse Date

__________________________________________________ _______________

Other Family Member over age 18 Date

__________________________________________________ _______________

Other Family Member over age 18 Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for

the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that

receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first

independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In

addition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

__________________________________________________ ________________

Other Family Member over age 18 Date

__________________________________________________ ________________

Other Family Member over age 18 Date

__________________________________________________ ________________

Other Family Member over age 18 Date

__________________________________________________ ________________

Other Family Member over age 18 Date

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of

information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully

requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more

than $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against

the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information

by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair

Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and

participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and

other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family

will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring

HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.

This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory

investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted

or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,

and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members

six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide

any of the requested information may result in a delay or rejection of your eligibility approval.

Paperwork Reduction Notice: The information collection requirements contained in this notice have been approved by the

Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3520) and assigned OMB

control number 2577-0266. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and a

person is not required to respond to a collection of information unless the collection displays a current valid OMB control

number.

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:

1. 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

2. Whether or not you have entered into a repayment agreement for the amount that you owe the PHA; and

3. Whether or not you have defaulted on a repayment agreement; and

4. Whether or not the PHA has obtained a judgment against you; and

5. Whether or not you have filed for bankruptcy; and

6. 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.

U.S. Department of Housing and Urban Development

Office of Public and Indian Housing

DEBTS OWED TO PUBLIC HOUSING AGENCIES AND TERMINATIONS

OMB No. 2577-0266 Expires 04/30/2013

April 26, 2010

Form HUD-52675

* Every Adult Household Member needs to sign this form.

_______________________________________________

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, your current rental assistance may be terminated and your future request for HUD rental assistance may be

denied for a period of up to ten years from the date you moved out of an assisted unit or were terminated from a HUD

rental assistance program.

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:

1. To have access to your records maintained by HUD.

2. To have an administrative review of HUD’s initial denial of your request to have access to your records maintained

by HUD.

3. To have incorrect information in your record corrected upon written request.

4. 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.

5. 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?

You should contact the PHA, who has reported this information about you, in writing, if you disagree with the reported

information. 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. Disputes must be made within three years

from the end of participation date. Otherwise the debt and termination information is 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.

This Notice was provided by the below-listed PHA:

I hereby acknowledge that the PHA provided me with the

Debts Owed to PHAs & Termination Notice:

Signature Date

Printed Name

OMB No. 2577-0266 Expires 04/30/2013

April 26, 2010

Form HUD-52675

Western Regional Housing Authority

Revised 06/2022

*Fill out ONE form for EVERY household member*

WESTERN REGIONAL HOUSING AUTHORITY

DECLARATION OF U.S. CITIZENSHIP OR NON CITIZEN WITH

ELIGIBLE IMMIGRATION STATUS

I , hereby declare under

penalty of perjury, that I, to the best of my knowledge, am lawfully within the United States

because:

I am a citizen, naturalized citizen or national of the United States; or

I have eligible immigration status as check below (see attachment for

explanations). Attach INS document(s) evidencing eligible immigration status

and signed verification consent form.

Immigrant status under 101(a)(15) or 101(a)(20) of the INA

Permanent residence under 249 of the INA

Refugee, asylum, or conditional entry status under 207, 208, or 203

of the INA

Parole status under 212(d)(5) of the INA

Threat to life or freedom under Section 243(h) of the INA

Amnesty under 245A of the INA.

Signature of Adult or Legal Guardian Date

WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and

willfully makes or uses a document or writing containing any false, fictitious, or fraudulent

statement or entry in any matter within the jurisdiction of any department or agency of the

United States, shall be fined not more than $10,000 or imprisoned for not more than five years,

or both.

*For each adult, the declaration must be signed by the adult. For each child under 18 years of

age, the declaration must be signed by an adult residing in the assisted dwelling unit who is

responsible for the child.

NOTICE OF OCCUPANCY RIGHTS UNDER

THE VIOLENCE AGAINST WOMEN ACT

U.S. Department of Housing and Urban Development

OMB Approval No. 2577-0286

Expires 06/30/2017

Form HUD-5380

(12/2016)

Western Regional Housing Authority

Notice of Occupancy Rights under the Violence Against Women Act

To all Tenants and Applicants

The Violence Against Women Act (VAWA) provides protections for victims of domestic

violence, dating violence, sexual assault, or stalking. VAWA protections are not only available

to women, but are available equally to all individuals regardless of sex, gender identity, or sexual

orientation.

The U.S. Department of Housing and Urban Development (HUD) is the Federal

agency that oversees that the Housing Choice Voucher Program and Low Rent Public Housing

Program is in compliance with VAWA. This notice explains your rights under VAWA. A

HUD-approved certification form is attached to this notice. You can fill out this form to show

that you are or have been a victim of domestic violence, dating violence, sexual assault, or

stalking, and that you wish to use your rights under VAWA.”

Protections for Applicants

If you otherwise qualify for assistance under the Housing Choice Voucher Program and Low

Rent Public Housing Program, you cannot be denied admission or denied assistance because you

are or have been a victim of domestic violence, dating violence, sexual assault, or stalking.

Protections for Tenants

If you are receiving assistance under the Housing Choice Voucher Program and Low Rent Public

Housing Program, you may not be denied assistance, terminated from participation, or be evicted

Despite the name of this law, VAWA protection is available regardless of sex, gender identity, or sexual

orientation.

Housing providers cannot discriminate on the basis of any protected characteristic, including race, color, national

origin, religion, sex, familial status, disability, or age. HUD-assisted and HUD-insured housing must be made

available to all otherwise eligible individuals regardless of actual or perceived sexual orientation, gender identity, or

marital status.

***This form is for your records only, DO NOT RETURN THIS FORM (HUD-5380) with your application packet.***

Form HUD-5380

(12/2016)

from your rental housing because you are or have been a victim of domestic violence, dating

violence, sexual assault, or stalking.

Also, if you or an affiliated individual of yours is or has been the victim of domestic violence,

dating violence, sexual assault, or stalking by a member of your household or any guest, you

may not be denied rental assistance or occupancy rights under the Housing Choice Voucher

Program and Low Rent Public Housing Program solely on the basis of criminal activity directly

relating to that domestic violence, dating violence, sexual assault, or stalking.

Affiliated individual means your spouse, parent, brother, sister, or child, or a person to whom

you stand in the place of a parent or guardian (for example, the affiliated individual is in your

care, custody, or control); or any individual, tenant, or lawful occupant living in your household.

Removing the Abuser or Perpetrator from the Household

HP may divide (bifurcate) your lease in order to evict the individual or terminate the assistance

of the individual who has engaged in criminal activity (the abuser or perpetrator) directly relating

to domestic violence, dating violence, sexual assault, or stalking.

If HP chooses to remove the abuser or perpetrator, HP may not take away the rights of eligible

tenants to the unit or otherwise punish the remaining tenants. If the evicted abuser or perpetrator

was the sole tenant to have established eligibility for assistance under the program, HP must

allow the tenant who is or has been a victim and other household members to remain in the unit

for a period of time, in order to establish eligibility under the program or under another HUD

housing program covered by VAWA, or, find alternative housing.

In removing the abuser or perpetrator from the household, HP must follow Federal, State, and

local eviction procedures. In order to divide a lease, HP may, but is not required to, ask you for

Form HUD-5380

(12/2016)

documentation or certification of the incidences of domestic violence, dating violence, sexual

assault, or stalking.

Moving to Another Unit

Upon your request, HP may permit you to move to another unit, subject to the availability of

other units, and still keep your assistance. In order to approve a request, HP may ask you to

provide documentation that you are requesting to move because of an incidence of domestic

violence, dating violence, sexual assault, or stalking. If the request is a request for emergency

transfer, the housing provider may ask you to submit a written request or fill out a form where

you certify that you meet the criteria for an emergency transfer under VAWA. The criteria are:

(1) You are a victim of domestic violence, dating violence, sexual assault, or

stalking. If your housing provider does not already have documentation that you

are a victim of domestic violence, dating violence, sexual assault, or stalking, your

housing provider may ask you for such documentation, as described in the

documentation section below.

(2) You expressly request the emergency transfer. Your housing provider may

choose to require that you submit a form, or may accept another written or oral

request.

(3) You reasonably believe you are threatened with imminent harm from

further violence if you remain in your current unit. This means you have a

reason to fear that if you do not receive a transfer you would suffer violence in the

very near future.

Form HUD-5380

(12/2016)

You are a victim of sexual assault and the assault occurred on the premises

during the 90-calendar-day period before you request a transfer. If you are a

victim of sexual assault, then in addition to qualifying for an emergency transfer

because you reasonably believe you are threatened with imminent harm from

further violence if you remain in your unit, you may qualify for an emergency

transfer if the sexual assault occurred on the premises of the property from which

you are seeking your transfer, and that assault happened within the 90-calendar-day

period before you expressly request the transfer.

HP will keep confidential requests for emergency transfers by victims of domestic violence,

dating violence, sexual assault, or stalking, and the location of any move by such victims and

their families.

HP’s emergency transfer plan provides further information on emergency transfers, and HP must

make a copy of its emergency transfer plan available to you if you ask to see it.

Documenting You Are or Have Been a Victim of Domestic Violence, Dating Violence,

Sexual Assault or Stalking

HP can, but is not required to, ask you to provide documentation to “certify” that you are or have

been a victim of domestic violence, dating violence, sexual assault, or stalking. Such request

from HP must be in writing, and HP must give you at least 14 business days (Saturdays,

Sundays, and Federal holidays do not count) from the day you receive the request to provide the

documentation. HP may, but does not have to, extend the deadline for the submission of

documentation upon your request.

Form HUD-5380

(12/2016)

You can provide one of the following to HP as documentation. It is your choice which of the

following to submit if HP asks you to provide documentation that you are or have been a victim

of domestic violence, dating violence, sexual assault, or stalking.

• A complete HUD-approved certification form given to you by HP with this notice, that

documents an incident of domestic violence, dating violence, sexual assault, or stalking.

The form will ask for your name, the date, time, and location of the incident of domestic

violence, dating violence, sexual assault, or stalking, and a description of the incident.

The certification form provides for including the name of the abuser or perpetrator if the

name of the abuser or perpetrator is known and is safe to provide.

• A record of a Federal, State, tribal, territorial, or local law enforcement agency, court, or

administrative agency that documents the incident of domestic violence, dating violence,

sexual assault, or stalking. Examples of such records include police reports, protective

orders, and restraining orders, among others.

• A statement, which you must sign, along with the signature of an employee, agent, or

volunteer of a victim service provider, an attorney, a medical professional or a mental

health professional (collectively, “professional”) from whom you sought assistance in

addressing domestic violence, dating violence, sexual assault, or stalking, or the effects of

abuse, and with the professional selected by you attesting under penalty of perjury that he

or she believes that the incident or incidents of domestic violence, dating violence, sexual

assault, or stalking are grounds for protection.

• Any other statement or evidence that HP has agreed to accept.

If you fail or refuse to provide one of these documents within the 14 business days, HP does not

have to provide you with the protections contained in this notice.

Form HUD-5380

(12/2016)

If HP receives conflicting evidence that an incident of domestic violence, dating violence, sexual

assault, or stalking has been committed (such as certification forms from two or more members

of a household each claiming to be a victim and naming one or more of the other petitioning

household members as the abuser or perpetrator), HP has the right to request that you provide

third-party documentation within thirty 30 calendar days in order to resolve the conflict. If you

fail or refuse to provide third-party documentation where there is conflicting evidence, HP does

not have to provide you with the protections contained in this notice.

Confidentiality

HP must keep confidential any information you provide related to the exercise of your rights

under VAWA, including the fact that you are exercising your rights under VAWA.

HP must not allow any individual administering assistance or other services on behalf of HP (for

example, employees and contractors) to have access to confidential information unless for

reasons that specifically call for these individuals to have access to this information under

applicable Federal, State, or local law.

HP must not enter your information into any shared database or disclose your information to any

other entity or individual. HP, however, may disclose the information provided if:

• You give written permission to HP to release the information on a time limited basis.

• HP needs to use the information in an eviction or termination proceeding, such as to evict

your abuser or perpetrator or terminate your abuser or perpetrator from assistance under

this program.

• A law requires HP or your landlord to release the information.

Form HUD-5380

(12/2016)

VAWA does not limit HP’s duty to honor court orders about access to or control of the property.

This includes orders issued to protect a victim and orders dividing property among household

members in cases where a family breaks up.

Reasons a Tenant Eligible for Occupancy Rights under VAWA May Be Evicted or

Assistance May Be Terminated

You can be evicted and your assistance can be terminated for serious or repeated lease violations

that are not related to domestic violence, dating violence, sexual assault, or stalking committed

against you. However, HP cannot hold tenants who have been victims of domestic violence,

dating violence, sexual assault, or stalking to a more demanding set of rules than it applies to

tenants who have not been victims of domestic violence, dating violence, sexual assault, or

stalking.

The protections described in this notice might not apply, and you could be evicted and your

assistance terminated, if HP can demonstrate that not evicting you or terminating your assistance

would present a real physical danger that:

1) Would occur within an immediate time frame, and

2) Could result in death or serious bodily harm to other tenants or those who work on the

property.

If HP can demonstrate the above, HP should only terminate your assistance or evict you if there

are no other actions that could be taken to reduce or eliminate the threat.

Other Laws

VAWA does not replace any Federal, State, or local law that provides greater protection for

victims of domestic violence, dating violence, sexual assault, or stalking. You may be entitled to

Form HUD-5380

(12/2016)

additional housing protections for victims of domestic violence, dating violence, sexual assault,

or stalking under other Federal laws, as well as under State and local laws.

Non-Compliance with The Requirements of This Notice

You may report a covered housing provider’s violations of these rights and seek additional

assistance, if needed, by contacting or filing a complaint with Albuquerque HUD field office.

For Additional Information

You may view a copy of HUD’s final VAWA rule at https://www.gpo.gov/fdsys/pkg/FR-2016-

11-16/pdf/2016-25888.pdf.

Additionally, HP must make a copy of HUD’s VAWA regulations available to you if you ask to

see them.

For questions regarding VAWA, please contact Western Regional Housing Authority

Executive Director.

For help regarding an abusive relationship, you may call the National Domestic Violence Hotline

at 1-800-799-7233 or, for persons with hearing impairments, 1-800-787-3224 (TTY). You may

also contact El Refugio 575-538-2135.

For tenants who are or have been victims of stalking seeking help may visit the National Center

for Victims of Crime’s Stalking Resource Center at https://www.victimsofcrime.org/our-

programs/stalking-resource-center.

For help regarding sexual assault, you may contact El Refugio 575-538-2135. Victims of

stalking seeking help may contact El Refugio 575-538-2135.

Attachment: Certification form HUD-5382

Form HUD-5382

(12/2016)

CERTIFICATION OF U.S. Department of Housing OMB Approval No. 2577-0286

DOMESTIC VIOLENCE, and Urban Development

Exp. 06/30/2017

DATING VIOLENCE,

SEXUAL ASSAULT, OR STALKING,

AND ALTERNATE DOCUMENTATION

Purpose of Form: The Violence Against Women Act (“VAWA”) protects applicants, tenants, and

program participants in certain HUD programs from being evicted, denied housing assistance, or

terminated from housing assistance based on acts of domestic violence, dating violence, sexual assault, or

stalking against them. Despite the name of this law, VAWA protection is available to victims of domestic

violence, dating violence, sexual assault, and stalking, regardless of sex, gender identity, or sexual

orientation.

Use of This Optional Form: If you are seeking VAWA protections from your housing provider, your

housing provider may give you a written request that asks you to submit documentation about the incident

or incidents of domestic violence, dating violence, sexual assault, or stalking.

In response to this request, you or someone on your behalf may complete this optional form and submit it

to your housing provider, or you may submit one of the following types of third-party documentation:

(1) A document signed by you and an employee, agent, or volunteer of a victim service provider, an

attorney, or medical professional, or a mental health professional (collectively, “professional”) from

whom you have sought assistance relating to domestic violence, dating violence, sexual assault, or

stalking, or the effects of abuse. The document must specify, under penalty of perjury, that the

professional believes the incident or incidents of domestic violence, dating violence, sexual assault, or

stalking occurred and meet the definition of “domestic violence,” “dating violence,” “sexual assault,” or

“stalking” in HUD’s regulations at 24 CFR 5.2003.

(2) A record of a Federal, State, tribal, territorial or local law enforcement agency, court, or

administrative agency; or

(3) At the discretion of the housing provider, a statement or other evidence provided by the applicant or

tenant.

Submission of Documentation: The time period to submit documentation is 14 business days from the

date that you receive a written request from your housing provider asking that you provide documentation

of the occurrence of domestic violence, dating violence, sexual assault, or stalking. Your housing

provider may, but is not required to, extend the time period to submit the documentation, if you request an

extension of the time period. If the requested information is not received within 14 business days of when

you received the request for the documentation, or any extension of the date provided by your housing

provider, your housing provider does not need to grant you any of the VAWA protections. Distribution or

issuance of this form does not serve as a written request for certification.

Confidentiality: All information provided to your housing provider concerning the incident(s) of

domestic violence, dating violence, sexual assault, or stalking shall be kept confidential and such details

shall not be entered into any shared database. Employees of your housing provider are not to have access

to these details unless to grant or deny VAWA protections to you, and such employees may not disclose

this information to any other entity or individual, except to the extent that disclosure is: (i) consented to

by you in writing in a time-limited release; (ii) required for use in an eviction proceeding or hearing

regarding termination of assistance; or (iii) otherwise required by applicable law.

***This form is for your records only, DO NOT RETURN THIS FORM (HUD-5382) with your application packet.***

Form HUD-5382

(12/2016)

TO BE COMPLETED BY OR ON BEHALF OF THE VICTIM OF DOMESTIC VIOLENCE,

DATING VIOLENCE, SEXUAL ASSAULT, OR STALKING

1. Date the written request is received by victim: _________________________________________

2. Name of victim: ___________________________________________________________________

3. Your name (if different from victim’s):________________________________________________

4. Name(s) of other family member(s) listed on the lease:___________________________________

___________________________________________________________________________________

5. Residence of victim: ________________________________________________________________

6. Name of the accused perpetrator (if known and can be safely disclosed):____________________

__________________________________________________________________________________

7. Relationship of the accused perpetrator to the victim:___________________________________

8. Date(s) and times(s) of incident(s) (if known):___________________________________________

_________________________________________________________________

10. Location of incident(s):_____________________________________________________________

This is to certify that the information provided on this form is true and correct to the best of my knowledge

and recollection, and that the individual named above in Item 2 is or has been a victim of domestic violence,

dating violence, sexual assault, or stalking. I acknowledge that submission of false information could

jeopardize program eligibility and could be the basis for denial of admission, termination of assistance, or

eviction.

Signature __________________________________Signed on (Date) ___________________________

Public Reporting Burden: The public reporting burden for this collection of information is estimated to

average 1 hour per response. This includes the time for collecting, reviewing, and reporting the data. The

information provided is to be used by the housing provider to request certification that the applicant or

tenant is a victim of domestic violence, dating violence, sexual assault, or stalking. The information is

subject to the confidentiality requirements of VAWA. This agency may not collect this information, and

you are not required to complete this form, unless it displays a currently valid Office of Management and

Budget control number.

In your own words, briefly describe the incident(s):

______________________________________________________________________________________

***This form is for your records only, DO NOT RETURN THIS FORM (HUD-5382) with your application packet.***