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Page ID	12
Staff Assigned	KC
Status	04
Closed for Editing by Client	No
Original Application ID	0
Mark as Duplicate	No
Do you represent an agency?	No
Tenant Information	Tenant Contact and Income Information Prior to submitting your application, you should gather the documents mentioned above to ensure your application is complete. Applications missing information may delay the award of services. In order for your application to be processed, please fully complete the application. Please enter the contact information below for the person seeking services of the Housing Stability Services Program (this person must be on the lease).

How did you hear about this program?	Waco housing authority
Are you currently working with an agency in your area?	No
Applicant Information
Name	Jhon Brinegar
Address	915 speight
Apartment Number	114
City	waco
State	Texas
Zip	76706
County	McLennan
Phone (Main)	(254) 218-8895
Type	Cell
Phone (Second)	(254) 218-8895
Type	Cell
Email Address	Email hidden; Javascript is required.
Head of Household
First Name	Jhon
Last Name	Brinegar
Unique Identifier	16170604742
Household & Income Information
Are there children in the household under age 18?	No
Are there adults in the household over age 62?	Yes
Is anyone in the household a person with a disability?	Yes
Is anyone in the household a veteran?	No
First time recipient of HSS Services?	Yes
Gender of applicant?	Male
Self-identified race of household?	White
Self-identified ethnicity of household?	Not Hispanic or Latino
Line
Household Size	1
Household Member 1 (Head of Household)
First Name	Jhon
Last Name	Brinegar
Birthdate	06/10/1962
Gross Monthly Income	$1,754.00
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 Gross Monthly Income	$1,754.00
AMI Table
Average Median Income	AMI 50% - 31%
Are you able to provide the required income documentation?	Yes
Household Income Attestation	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.
I certify that the income provided is accurate. (Initials)
Services Requested
SHELTER SERVICES	Temporary Housing
OTHER FINANCIAL ASSISTANCE	Security Deposits, Pet Deposits and App Fees Utility Deposits and Utility Reconnection Fees Short-Term Hotel/Motel Stays
Do you plan to move soon?	No
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.

Are you an apartment or property manager?	No
Required Documentation	Required Documentation To Apply As part of the Program application, all applicants will be required to submit the following documentation required to perform the eligibility review: Government- or other personal ID for at least one household member Copy of rent or lease agreement, if applicable Evidence of unemployment benefits, if applicable Notices of eviction, if applicable Copies of past due utility bills, if utility assistance is being requested Income Documentation for all household members
Landlord Information
Housing Information
Utility Information
Eviction Diversion
Are you undergoing eviction proceedings?	No
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.
Legal	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.
Have you applied for and/or received any services from the TDHCA Housing Stability Services Program?	No
Service 1
Service 2
Service 3

Applicant Signature
Date	03/19/2025
RELEASE OF CLIENT INFORMATION
Agreement Items	I certify that the information provided on this application is true and correct to the best of my knowledge and belief. If granted assistance and fraud is proved, I will repay any funds spent on my behalf. I authorize utility companies, landlords and other sources to release information to Waco Housing Authority and Affiliates for the purpose of certification under this program. I authorize Waco Housing Authority to use the information I provide to screen me for any additional services available throughWHA and its partner agencies. This certification is being made with the full knowledge and understanding that this statement and all applicable documents deemed necessary to substantiate my eligibility is subject to full disclosure and verification by authorized Waco Housing Authority officials. I understand that I may be responsible for making a co-payment and/or paying the balance on my utility bill and/or lease agreement. I will not hold Waco Housing Authority responsible or liable if my services are shut off and/or an eviction notice is received, as a result of non-payment. My signature below will certify I fully understand the above statement and I agree to the terms of assistance as stated in the Assistance Guidelines included in this application.
Applicant Signature
Date	03/19/2025
Acknowledgement of Housing Instability	Self-Declaration of Homelessness
Initials
COVID- 19 SELF-ATTESTATION FORM	Acknowledgement of Being Financially Impacted by the Pandemic
Applicant Name	Jhon Brinegar
Address	Texas Map It
I hereby certify under penalty of perjury that the following information is true	I am physically unable to work
Briefly explain how Covid-19 has impacted your ability to make rent and/or utility payments.	None
Certification
Applicant Signature
Date	03/19/2025
Upload Documents	Please provide any documents that may be needed to verify your application.
Document Type(s)	Picture ID (required) Other
Do not upload Social Security Card	Important: Please do not upload Social Security Card(s).
Upload ID (required)
Upload Other Files
Services Requested by Staff
Services	Security Deposits, Pet Deposits and App Fees Utility Deposits and Utility Reconnection Fees Short-Term Hotel/Motel Stays
Amount Requested
Security Deposits, Pet Deposits and App Fees	$600.00
Short-Term Hotel/Motel Stays	$2,000.00
Utility Deposits and Utility Reconnection Fees	$200.00
HTML Block

Signature Blurb	By signing below, I (the applicant and/or staff) certify that this information is correct to the best of my knowledge.
Must be signature not initials	Please sign with your full signature, not just your initials.
Applicant Signature
Date	03/19/2025

Housing Stability Services Program

Available 24/7

Housing Stability Services Program

Available 24/7

Tenant Contact and Income Information

Household Income Attestation

Required Documentation To Apply

Important: Please do not upload Social Security Card(s).

Please sign with your full signature, not just your initials.