HCV: Housing Choice Voucher Program Statement of Family Obligations

Lee K. Hight Administration Building
326 West 9th Street ' Post Office Box 1428
Rome, Georgia 30162-1428
Tel: 706.291.0780 ' Fax: 706.295.0376

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[{"type":"text","required":true,"label":"I,_________________________ , understand that as a participant in Northwest Georgia Housing Authority's HCV Program, that my household members and I will be required to comply with certain obligations and responsibilities according to HUD and Northwest Georgia Housing Authority. I hereby warrant that I am aware of the following requirements:","placeholder":"Type your name here","name":"I_________________________--understand-that-as-a-participant-in-Northwest-Georgia-Housing-Authoritys-HCV-Program-that-my-household-members-and-I-will-be-required-to-comply-with-certain-obligations-and-responsibilities-according-to-HUD-and-Northwest-Georgia-Housing-Authority-I-hereby-warrant-that-I-am-aware-of-the-following-requirements","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"For all statements below, please review and select the check box to agree.","className":"d-block"},{"type":"checkbox-group","required":true,"label":"1.","name":"1","className":"d-block","values":[{"label":"I must search for my own unit both initially and if I desire to move to a different unit, Iunderstand that NWGHA is not responsible for locating a suitable unit for me. I must locatea unit within the time given.","value":"I must search for my own unit both initially and if I desire to move to a different unit, Iunderstand that NWGHA is not responsible for locating a suitable unit for me. I must locatea unit within the time given."}]},{"type":"checkbox-group","required":true,"label":"2.","name":"2","className":"d-block","values":[{"label":"I understand that NWGHA is NOT responsible for any rental assistance payments untilsuch time as it determines the unit meets all applicable program requirements, includingthe ability to pass the inspection standards set by HUD.","value":"I understand that NWGHA is NOT responsible for any rental assistance payments untilsuch time as it determines the unit meets all applicable program requirements, includingthe ability to pass the inspection standards set by HUD."}]},{"type":"checkbox-group","required":true,"label":"3.","name":"3","className":"d-block","values":[{"label":"To notify my NWGHA representative and owner PRIOR to my vacating the unit bysubmitting a 30-day written notice to NWGHA and the landlord. I must leave the unit ingood condition at the time of moving out.","value":"To notify my NWGHA representative and owner PRIOR to my vacating the unit bysubmitting a 30-day written notice to NWGHA and the landlord. I must leave the unit ingood condition at the time of moving out."}]},{"type":"checkbox-group","required":true,"label":"4.","name":"4","className":"d-block","values":[{"label":"To comply with all interim and annual reporting requirements. All changes must bereported in the office and in writing.","value":"To comply with all interim and annual reporting requirements. All changes must bereported in the office and in writing."}]},{"type":"checkbox-group","required":true,"label":"5.","name":"5","className":"d-block","values":[{"label":"To report any change of income in writing within ten (10) days of the date of the change.If I fail to do so I will be subject to pay all monies owed and maybe be prosecuted for fraud.Sources of income include but are not limited to; wages, government benefits (SocialSecurity, SSI, VA, and TANF), unemployment benefits, pension, child support and regularcontributions and/or gifts from friends and family members. This includes all householdmembers.","value":"To report any change of income in writing within ten (10) days of the date of the change.If I fail to do so I will be subject to pay all monies owed and maybe be prosecuted for fraud.Sources of income include but are not limited to; wages, government benefits (SocialSecurity, SSI, VA, and TANF), unemployment benefits, pension, child support and regularcontributions and/or gifts from friends and family members. This includes all householdmembers."}]},{"type":"checkbox-group","required":true,"label":"6.","name":"6","className":"d-block","values":[{"label":"To report any decrease in household composition within ten (10) days of move-out. Myvoucher size is determined by the members of my household.","value":"To report any decrease in household composition within ten (10) days of move-out. Myvoucher size is determined by the members of my household."}]},{"type":"checkbox-group","required":true,"label":"7.","name":"7","className":"d-block","values":[{"label":"To report and receive written permission for any family members proposed to move inPRIOR to the occupancy of such person(s). All household members must be approved. Allrequired forms must be completed, and all documentation must be turned in.","value":"To report and receive written permission for any family members proposed to move inPRIOR to the occupancy of such person(s). All household members must be approved. Allrequired forms must be completed, and all documentation must be turned in."}]},{"type":"checkbox-group","required":true,"label":"8.","name":"8","className":"d-block","values":[{"label":"To pay my portion of the rent to the landlord in accordance with my lease agreement andNOT to pay any additional rent or extra charges that are not listed on the lease. Failure topay my portion of the rent in a timely matter will result in termination of my assistance.","value":"To pay my portion of the rent to the landlord in accordance with my lease agreement andNOT to pay any additional rent or extra charges that are not listed on the lease. Failure topay my portion of the rent in a timely matter will result in termination of my assistance."}]},{"type":"checkbox-group","required":true,"label":"9.","name":"9","className":"d-block","values":[{"label":"Where applicable, maintain utilities. Failure to maintain utilities will result in a 24-hournotice to restore utilities. If service is not restored my assistance will be terminated.","value":"Where applicable, maintain utilities. Failure to maintain utilities will result in a 24-hournotice to restore utilities. If service is not restored my assistance will be terminated."}]},{"type":"checkbox-group","required":true,"label":"10.","name":"10","className":"d-block","values":[{"label":"To maintain the unit in a good habitable condition and to report any unavoidable orunexpected damages and maintenance problems to my landlord in a timely manner so asnot to increase the cost of repair nor further jeopardize the habitability of the leased unit.This includes housekeeping and in some cases exterminating","value":"To maintain the unit in a good habitable condition and to report any unavoidable orunexpected damages and maintenance problems to my landlord in a timely manner so asnot to increase the cost of repair nor further jeopardize the habitability of the leased unit.This includes housekeeping and in some cases exterminating"}]},{"type":"checkbox-group","required":true,"label":"11.","name":"11","className":"d-block","values":[{"label":"To pay for all damage to the unit caused by my household members and/or guests while inoccupancy or at the time of move out. Failure to pay for damages may result in terminationof my assistance.","value":"To pay for all damage to the unit caused by my household members and/or guests while inoccupancy or at the time of move out. Failure to pay for damages may result in terminationof my assistance."}]},{"type":"checkbox-group","required":true,"label":"12.","name":"12","className":"d-block","values":[{"label":"To allow NWGHA and owner to conduct unit inspections after reasonable notice andduring reasonable hours. Failure to correct tenant-caused NSPIRE violations in the timegiven will result in termination of my assistance.","value":"To allow NWGHA and owner to conduct unit inspections after reasonable notice andduring reasonable hours. Failure to correct tenant-caused NSPIRE violations in the timegiven will result in termination of my assistance."}]},{"type":"checkbox-group","required":true,"label":"13.","name":"13","className":"d-block","values":[{"label":"To comply with all provisions of the lease. Failure to abide by my lease may result intermination of my assistance. Failure to provide owner notices to vacate the unit or ownereviction notices may result in termination of my assistance.","value":"To comply with all provisions of the lease. Failure to abide by my lease may result intermination of my assistance. Failure to provide owner notices to vacate the unit or ownereviction notices may result in termination of my assistance."}]},{"type":"checkbox-group","required":true,"label":"14.","name":"14","className":"d-block","values":[{"label":"Not to sublease the unit nor to use the unit for illegal activities. The family must not engagein drug-related criminal activity or violent criminal activity.","value":"Not to sublease the unit nor to use the unit for illegal activities. The family must not engagein drug-related criminal activity or violent criminal activity."}]},{"type":"checkbox-group","required":true,"label":"15. The family (including all household members) must not:","description":"Please select all four options to agree","name":"15The-family-including-all-household-members-must-not","className":"d-block","values":[{"label":"Commit any serious or repeated violation of the lease.","value":"Commit any serious or repeated violation of the lease."},{"label":"Commit fraud, bribery, or any other corrupt or criminal act in connection with the HCVProgram.","value":"Commit fraud, bribery, or any other corrupt or criminal act in connection with the HCVProgram."},{"label":"Owe any money to the NWGHA or another Housing Agency in connection with HCV orpublic housing programs.","value":"Owe any money to the NWGHA or another Housing Agency in connection with HCV orpublic housing programs."},{"label":"Engaging in or threaten abusive or violent behavior toward housing authority personnel.","value":"Engaging in or threaten abusive or violent behavior toward housing authority personnel."}]},{"type":"header","subtype":"h4","label":"Family Certification:","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I understand that failure to comply with these responsibilities is grounds for denial or termination of my rental assistance. I understand as Head of Household that it is my sole responsibility to provide true and complete information on myself and all household members now or in the future and failure to do so may lead to the denial or termination of my assistance. I also understand that false statements or information are punishable under Federal and/or State Law and NWGHA will pursue accordingly.","name":"I-understand-that-failure-to-comply-with-these-responsibilities-is-grounds-for-denial-or-termination-of-my-rental-assistance-I-understand-as-Head-of-Household-that-it-is-my-sole-responsibility-to-provide-true-and-complete-information-on-myself-and-all-household-members-now-or-in-the-future-and-failure-to-do-somay-lead-to-the-denial-or-termination-of-my-assistance-I-also-understand-that-false-statements-orinformation-are-punishable-under-Federal-andor-State-Law-and-NWGHA-will-pursue-accordingly","className":"d-block","values":[{"label":"I certify","value":"I certify"}]},{"type":"text","required":true,"label":"Signature:","description":"By typing your name you are signing this form.","placeholder":"Type your full legal name","name":"Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature:","name":"Date-of-Signature","className":"col-md-6"}]