The Housing Authority
OF THE CITY OF
NEW SMYRNA BEACH, FLORIDA 32168
BRIAN CLARK 1101 SOUTH DIXIE FREEWAY
EXECUTIVE DIRECTOR New Smyrna Beach, FL 32168
www.newsmyrnahousing.com TEL. 386/428-8171 FAX.386/427-3429
PUBLIC HOUSING APPLICATION
Thank you for choosing The Housing Authority of the City of New Smyrna Beach to provide your housing needs. We would like to make your application
process as pleasant as possible and would like to give you information to help you understand the process.
To submit an application, you must complete the attached application and provide the following:
1. Birth Certificates
2. Social Security cards for all family members
3. Picture Identification for all adults living in the household.
4. Proof of Income (Employer’s info, Required: Company name, address, phone & fax number, supervisors name, pay stubs, child support, SS and/ or SSI,
unemployment, AFDC/TANF benefits, pensions, etc.)
5. Most recent federal income tax return.
6. Landlord Verification (lease)
7. Bank Statements 3 months.
8. Green Card, proof of Citizenship or Passport, if you are not a natural born U.S. citizen, INS paperwork.
9. If pregnant, proof of pregnancy.
10. Verification of 6 months of continued employment and 3 months of paystubs.
11. Verification of current address if different than on Picture ID. (2 forms)
Your application will be processed and when your name appears to the top of the waiting list, you will be sent a letter to the address you provided on the
application to schedule an appointment for your interview with the office staff. Our application process includes verification of all information you provided on
the application, eviction records, and nationwide criminal background checks for all applicants.
Please keep in mind there are many more applicants then available apartments and depending upon your circumstances and which preference(s) you may qualify
for. You may check the waiting list that is posted on the bulletin board in the lobby; no waiting list information will be given out over the telephone.
We hope these suggestions will help. If you have any additional questions, do not hesitate to contact the Management Office at (386)428-8171.
APPLICATION FOR ADMISSION
5/11/16
Date: _________________________________________________________________ 4:13pm
Time:________________________________________________
APPLICATION FOR ADMISSION x NO
HAVE YOU BEEN / ARE YOU IN SUBSIDIZED HOUSING? YES
2
UNIT BR SIZE: ___________ Greenlawn Terr.
WHERE? _____________________________________________ 2011
WHEN?_______________________________________
ETHNICITY: HISPANIC NONHISPANIC RACE: WHITE x BLACK ASIAN / PACIFIC ISLANDER INDIAN / NATIVE ALASKAN
APPLICANT NAME
Peterkin Jason M.D. (786)975-5936 P367-433-77-362-0
Last Name First Middle Telephone # Drivers License #
CURRENT ADDRESS
1732 n.w. 3rd Terr. #205 Florida City Fl./33034 1 year
Street City St/Zip Years
PREVIOUSE ADDRESS
1235 Sharar Ave. Opa-locka Fl./33054 1 year
Street City St/Zip Years
MAILING ADDRESS
1732 n.w. 3rd Terr. #205 Florida City Fl./33034
Street City St/Zip Years
Sharica Peterkin
EMERGENCY CONTACT ________________________________________ (786)234-8826
TELEPHONE #__________________________ Wife
RELATION________________
(For statistical purposes only) (Check one box each in “a” and “b”)
A. Is the head of your household? White x Black American Indian / Alaskan Native Asian / Pacific Islander
B. Ethnicity of the Head of Household: Hispanic x Non-Hispanic
I. HOUSEHOLD COMPOSITION: List the correct LEGAL name of all household members who will reside in the unit, as they appear on Social Security
cards. Begin with Head of Household, spouse, older children, etc., and then list any additional adults.
Family Members Social Security Relation Sex Age Birth Birth Occupation/
Legal Names Numbers to Head Date Place School
1.
Jason Peterkin 267-85-8146 Head M 38 10/07/77 NY SSI
2.
Sharica Peterkin 591-18-7128 Wife F 34 12/31/82 FL N/A
3.
Tedrick Eliis Jr. 772-18-1977 Son M 13 03/03/03 FL SSI
4.
Jason Peterkin Jr. 884-03-1709 Son M 2 11/19/13 FL N/A
5.
6.
7.
Do you anticipate changes in household composition within the next 12 months? Yes X No
Why?___________________________________________________________________________________________________________________________
Does anyone live with you now who is not listed above? Yes X No.
If yes please explain? ______________________________________________________________________________________________________________
II. CURRENT HOUSING STATUS
4
How many people live in your unit now? ____________________________ 1
How many bedrooms do you have? __________________________________
Do you wish to move? X Yes No To small, it is not enough room for all 4 of us.
If yes why? ___________________________________________________________________________
Are you being evicted? Yes x No If yes why? ___________________________________________________________________________
$750
What is your current rent? ______________ Yes
Are you current on your rent? ____________________ N/A
What do you pay for utilities?_______________________
III. OTHER INFORMATION REQUIRED:
Do you have Medicare? Yes XNo If yes, what is your Medicare premium? _____________________________________________________
Do you have any other medical insurance? X Yes No
05079-148408711 Bermudez M.D. Roberto 3100 s.w. 145th Ave. Miramar,Fl.33027 St#201
If yes, give policy number and name and address of agent __________________________________________________________________________________
Do you receive medical assistance through the Welfare Department? Yes X No
Do you have any outstanding medical bills on which you are paying? Yes X No
Do you expect to have any medical expenses during the next 12 months? Yes X No
If yes, you will need to submit proof of the amount of these expenses to get the credit.
Do you pay for an attendant or for any equipment for the handicapped member(s) that permit them or someone
else in the family to be able to work? Yes X No
Is your family in need of an accessible unit pursuant to Section 504? Yes X No
IV. INCOME INFORMATION: Please answer each of the following questions. For each “yes” answer, provide the detail in the chart below.
Is any member of your household employed, full time, part-time or seasonally? Yes X No
Does any member of your household expect to for any period during the next (12) months? Yes X No
Does any member of your household work for someone who pays them cash? Yes X No
Is any member of your household on leave of absence from work due to lay-off, medical maternity or military? Yes X No
Does any member of your household now receive, or expect to receive unemployment benefits? Yes X No
Does any member of your family now receive or expect to receive child support? Yes X No
Is any member of your household entitled to child support that he/she is not now receiving? Yes X No
Does any member of your household now receive or expect to receive alimony payments? Yes X No
Is any member of your household entitled to alimony payments that he/she is not now receiving? Yes X No
Does any member of your household receive or expect to receive TANIF assistance? Yes X No
Does any member of your family receive or expect to receive Social Security benefits? X Yes No
Does any member of your household receive or expect to receive income from pension or annuity? Yes X No
Does any member of your household receive regular case contributions from individuals not living in the unit or
from agencies? Yes X No
Does any member of your household receive income from assets including interest on checking or saving accounts,
interest and dividends from certificates of deposit, stocks or bonds or income from rental property? Yes X No
Do you pay for child care which entitles you or another family member to work or go to school? Yes X No
If yes, give name and address of child care provider, weekly amount that you pay and name of family member enabled to work:
_________________________________________________________________________________________________________________________________
Jason Peterkin: SSI, Tedrick Ellis: SSI
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
V. TOTAL HOUSEHOLD INCOME: List below all money earned or received by everyone living in the household. This includes all money from wages, self-
employment, child support, contributions, Social Security, retirement, disability, Workmen’s Compensation, AFDC, TANF, SSI, veteran’s benefits, rental
property income, stock dividends, interest, alimony annuities, direct contributions and all other sources of income.
HOUSEHOLD MEMBER NAME SOURCE OF INCOME (include complete address) Income per wk /
month
Jason Peterkin SSI $ 733 wk / mo
Tedrick Eliis SSI $ 733 wk / mo
$ wk / mo
$ wk / mo
VI. WORK HISTORY FOR ALL ADULT HOUSEHOLD MEMBERS FOR THE PAST TWO (2) YEARS:
FAMILY MEMBERS NAME EMPLOYERS NAME EMPLOYERS ADDRESS PHONE # FROM / TO
Jason Peterkin N/A N/A
Sharica Peterkin N/A N/A
VII. ASSETS: List all assets of all household members. Examples: house, property, boat mobile home, savings accounts, stocks, bonds, certificates of deposit,
land, lots and acreage, inheritances, promissory notes from selling property, cash in safety box, etc.
Value $________________________________ Asset: ________________________________________________________________________________
Value $________________________________ Asset: ________________________________________________________________________________
In the last two (2) years have any one in the household disposed of an asset valued at $1,000.00 or more? Yes No
If yes, List the Asset(s) ______________________________________________________________________________________________________________
Value of Asset(s) ___________________________________________________________________________________________________________________
Amount received for the Asset(s) ______________________________________________________________________________________________________
VII. ADDITIONAL INFORMATION ON HOUSEHOLD
Current Monthly Household Expenditures:
Theresa Jenkins & 1732 n.w. 3rd Terr. apt.#205 Florida cityy,Fl. 33034
Present Landlord & Address __________________________________________________________________________________________________________
750
Rent $______ 60
Phone $______ Insurance $______ Furn Payment $______ Rentals $______ Electric $______ TV/Cable $______
Auto Pmt $______ Life/Health $______ TV/ Appliance $______ 150
Gas $______ Food $______ 80
Auto Ins $______ Medical Exp $______
Loan $______ Water $______ Child Care $______ Other $______
IX. BANKING INFORMATION
BANK NAME ADDRESS ACCT # ACCT TYPE JOINT / BALANCE
INDIVIDUAL
N/A
$
$
$
$
X. MARITAL STATUS / HISTORY
What is your marital status? Single X Married Separated Divorced Widowed
SSN of Deceased Spouse ____________________________________________________________________________________________________________
Have you ever been known by another name? Yes X No What was the name? ______________________________________________________
XI. ABSENT PARENT INFORMATION
FAMILY MEMBER FATHER / MOTHER STREET ADDRESS CITY STATE LAST CONTACT
DATE
N/A
Comments:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
XI. POLICE CHECK: Have you or anyone in your household ever been arrested or convicted of any crime other than traffic violations? Please note that if you
were arrested and not convicted you still have to check the yes block.
Yes X No If yes, explain:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
XIII. VEHICLE(S): N/A
HH Mem. #______________ Make _______________________ Year ________________________ Tag# ________________
N/A
HH Mem # ______________ Make _______________________ Year ________________________ Tag # _______________
Vehicle driven regularly (but not owned) by HH/Member?
N/A
Owner________________________________________________ Make _________________________ Year___________________ Tag #________________
HOUSING FRAUD IS A VIOLATION OF STATE AND FEDERAL LAWS
Any person who obtains, or who established eligibility for, and any person who knowing/ intentionally aids or abets such person in
obtaining or establishing eligibility for any public housing, or a reduction in public housing rental charges, or any rent subsidy or
assistance, to which such person would not otherwise be entitled, by means of a false statement, failure to disclose information,
impersonation, other fraudulent scheme or device shall be guilty of a felony. As used in this act “public housing” shall mean housing
which is constructed, operated, maintained, administered by the state, a county, a municipal corporation, a housing authority, or by
any other political subdivision or public corporation of the state or its subdivision or pc corporation of the state of its subdivisions.
WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A
FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANYH
DEPARTMENT OR AGENCY OF THE UNITED STATES OR THE DEPARTMENT OF HOUSING AND URBAN
DEVELOPMENT.
I/We understand that this is not a contract and does not bind either party. I/We further certify that the information given to the Housing Authority of the City of
New Smyrna Beach representing household composition, income, assets, criminal history, and allowances and deductions is accurate and complete to the best of
my / our knowledge and belief. I/We also understand that furnishing false information and /or making false statements is grounds for termination of housing
assistance/ occupancy, and I am responsible to repay any underpaid rent or overpaid rental assistance.
I/We have no objection to inquires being made for the purpose of verifying the statements made herein.
I/We understand that any verification required by the Housing Authority of the City of New Smyrna Beach must be returned within seven (7) days. Failure to do
so will result in a delay in processing of my / our application, withdrawal of this application, or termination of my / our tenancy or assistance.
After verification by The Housing Authority of the City of New Smyrna Beach, the information will be submitted to the Department of Housing and Urban
Development on Form HUD-50058 via (PIC), a computer generated system. See the Federal Privacy Act Statement for more information about its use.
5/11/2016 5/11/2016
Signature of Head of Household Date Spouse or Other Adult Signature Date
________________________________________________________________
HANSB Representative’s Signature / Date
