Applicant Information
Head of Household
Household & Income Information
Household Member 1 (Head of Household)
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
Household Member 9
Household Member 10
Gross Income
Household Income Attestation
Administrator: Waco Housing Authority and Affiliates
If you cannot provide the required documentation, please use this form to document your income. If you have the required documentation and plan to provide it as a part of your application, you can skip to this section.
Note that the self-attestation of household income will require that you re-certify income every three months in
order to receive future funding.Client Initials
I attest that the information stated above is true and accurate, and understand that any intentional or negligent misrepresentation(s) of the information contained in this form may result in civil liability and/or criminal penalties including, but not limited to fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. and liability for monetary damages to McLennan County, and any other person who may suffer any loss due to reliance upon my misrepresentation.
Services Requested
Instructions
If you are transitioning from one household to another, please fill out as much as you can. If we can gather this information now, it will allow us to speed up the payment process.
Landlord Information
Housing Information
Utility Information
Eviction Diversion
Eviction Diversion Program Participation
A portion of the HSS funds have been set aside specifically for households whose landlords have already sued for eviction in their local court. The application process is the same, however, please complete this section if you are undergoing eviction proceedings. If your landlord has not started eviction proceedings, then you may skip this section.
Please provide the information related to your eviction lawsuit.
DUPLICATION OF BENEFITS CERTIFICATION
This document must be completed and signed by any person who has applied for and/or received any services from the TDHCA Housing Stability Services Program.
This section identifies any sources of funds that you have received or applied for as a result of the COVID-19 crisis. Sources of funds include, but are not limited to: Federal, State and Local loan/grant programs, insurance, private or bank loans, nonprofit donations, or loans. Receipt of or pending receipt of any benefit amounts must be disclosed to Waco Housing Authority and Affiliates. By submitting this application, you certify that the benefits disclosed above have been accurately reported. You hereby authorize HUD, the County and each of their respective designees to verify this information and if requested, you agree to provide any information required.
If the information you provided is incorrect, or if your financial circumstances change after the date of your application such that the information disclosed above has become incorrect, you are required to provide written notification to WHA and provide corrected information within five (5) business days. Upon receipt of the updated or corrected information,WHA will determine if there has been a duplication of benefits under Section 312 of the Stafford Act. Written notification should be sent to: Waco Housing Authority and Affiliates, Attention:
HSS Program Management, 4400 Cobbs Drive, Waco, TX 76712.
You agree to repay any assistance that is determined by WHA to be a duplication of benefits under the Stafford Act and you further hereby assign to WHA all of your future rights to reimbursement and all payments received from any grant, subsidized loan, or insurance policies of any type or coverage or under any reimbursement or relief program related to or administered by the Federal Emergency Management Agency or the Small Business Administration or any other program, but only to the extent the proceeds are determined by WHA to be a duplication of benefits under the Stafford Act.
Service 1
Service 2
Service 3
RELEASE OF CLIENT INFORMATION
I certify that I (and my household) am/are at risk of experiencing homelessness or housing instability, or will need to move to an unsafe environment if I do not receive housing stability assistance.
I certify that I (and my household) am/are currently experiencing homelessness, or are survivors of domestic violence fleeing from abuse.
COVID- 19 SELF-ATTESTATION FORM
Acknowledgement of Being Financially Impacted by the Pandemic
Certification
I attest that the information stated above is true and accurate, and understand that any intentional or negligent misrepresentation of the information obtained in this form may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq and liability for monetary damages to McLennan County, and any other person who may suffer any loss due to reliance upon my misrepresentation which I have made on this form. I attest that the information stated above is true and accurate, and understand that any intentional or negligent misrepresentation of the information obtained in this form may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq and liability for monetary damages to McLennan County, and any other person who may suffer any loss due to reliance upon my misrepresentation which I have made on this form.
Upload Documents
Please provide any documents that may be needed to verify your application.
Important: Please do not upload Social Security Card(s).
By signing below, I (the applicant and/or staff) certify that this information is correct to the best of my knowledge.
Please sign with your full signature, not just your initials.
I certify that by signing/submitting this application, I am income-eligible to receive any of the services offered above through the TDHCA Housing Stability Services Program.
I also certify that all the information I am submitting with this application is true and correct.