Disaster Housing Assistance Program
DHAP HARDSHIP REQUEST FORM The U.S. Department of Housing and Urban Development’s Disaster Housing Assistance Program (DHAP) allows for clients to request an exception to the implementation of the incremental rent transition payments which go into effect May 1, 2009. A family may request an exception based on economic hardship. The Rosenberg Housing Authority (RHA) must approve this request by verifying income and participation in all required case management services. Section I: Family Request Date:___________________________________________________________________ Client Name:_____________________________________________________________ Social Security Number:____________________________________________________ Gross Monthly Income Amount:_____________________________________________ Address:________________________________________________________________ Phone Number:___________________________________________________________ Reason for Request:
You must provide proof of gross monthly income. Gross monthly income means all sources of income that go to a family member or sources of income paid on behalf of family members (including, but not limited to, the following: wages, interest, annuities, pensions, Social Security Retirement, alimony, child support, Unemployment Benefits, Workers’ Compensation, and any other indirect income). Possible proof: last three paycheck stubs; unemployment compensation statements; benefit letters; retirement checks or statements. If you have no income, please describe below how you are paying utility bills and basic living expenses, such as food and clothing. If asked by the RHA or GMC, you must supply documentation of the source of these monies.
1
Disaster Housing Assistance Program
A. Income and Expenses Worksheet
My Income: Wages (Head of Household)_____________ Child Support/Alimony _____________ TANF ______________ Food Stamps ______________ SS/SSI ______________ Unemployment ______________ Pension ______________ Contributions ______________ Retirement ______________ Veterans ______________ Wages (other members) ______________ Other ______________ My Expenses: Rent Car Payment Other Loan Payments Rentals Car Insurance Health Insurance Child Care Flexible Expenses Credit Cards Electricity Water Gas Telephone Cable Food Transportation/Gas Car Maintenance Personal Expenses Health/Beauty Entertainment Other ______________ ______________ ______________ ______________ ______________ ______________ ______________
_____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________
TOTAL INCOME ______________
TOTAL EXPENSES _______________
I do hereby certify that all of the information above me is true and correct. I also certify that I will promptly report any future increase in income to GMC. I understand that failure to report an increase is grounds for termination of DHAP. Signature of Head of Household_____________________________________ Date ________________
B. Verification of Case Management Participation RHA has verified that the client _________ Has _________ Has not
met all requirements of their on-going case management criteria. ______________________________ Assigned Case Manager Signature _____________________________ Date
In order to be approved for this hardship, both criteria listed above must be confirmed and the client must meet both requirements.
Completed forms and supporting documentation should be delivered, mailed, or faxed to your Case Manager.
2