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Duke Barrington Rental Application Page 3

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Michigan State Housing Development Authority

CHECKLIST MSHDA PROGRAMS

(Issued under P.A. of 1966 as amended and Section 8 f the U.S. Housing (program) Act of 1937.)

Complete a separate form for each household member who is age 18 or older.

Name:

Unit Number:

Yes

COMPLETE EACH ITEM:

I am a citizen of the United States or a permanent legal resident.

□

I am presently a student.

Check one:

Full-time

Part-time

Other ____________

□

I (check one only if it applies)

was a student sometime during the past twelve-month period or

□

anticipate becoming a student at sometime during the upcoming twelve-month period.

INCOME

I have a job and receive money/wages, tips or bonuses. (List the businesses or companies that pay you.)

________________________________________________

___________________________

I am self-employed. (List the types of jobs you do.)

I receive Social Security or Rail Road Retirement Act income.

I receive Supplemental Security Income (SSI).

I receive quarterly payments from FIA for the State-paid portion of an SSI Grant

I receive unearned income for a family member(s) age 17 or under (e.g.: Social Security).

I receive periodic payments from retirement funds or pensions. If yes, how many funds or pensions?

______ List name(s) of fund or pension provider. ________________________

I receive disability or death benefits other than Social Security.

I receive Veteran's Administration benefits.

I receive Public Assistance.

I receive cash contributions or gifts including rent or utility payments, on an ongoing basis from persons

not living with me.

I receive unemployment benefits.

I receive periodic payments from Workers' Compensation.

I receive periodic payments from trust, annuity or inheritance. If yes, from how many sources? __

I receive income from rental of real estate or personal property.

I receive periodic payments from lottery winnings.

I receive adoption assistance payments.

I receive alimony.

I receive GI Bill benefits.

I receive military active duty allotments.

I am a member of an Indian Tribe receiving gaming payments.

REV6/24/2014

Duke Barrington Rental Application Page 3

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