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TBRA APPLICANT INTAKE (Completed by Participating Agency (PHA) DATE : NAME of PHA : I. Applicant Information Name of Head of Household: Contact Phone # : # of persons in household : Gross Annual Household Income: Is gross annual household income less than 80% of area median income based on household size? Yes or No If No, STOP. Applicant does not qualify. Proof of displacement: FEMA certification (Obtain copy) or Other (Explain) Previous Address : If displaced by hurricane and no FEMA certification exists, PHA must verify (visual inspection) that the residence is no longer habitable Verified? (circle one) Yes No Not Applicable (FEMA certification attached) II, Landlord Information Name : Contact Phone # : Mailing Address : Payment Method Preferred by Landlord : Direct Deposit Mail Check III. Rental Unit Information Address : County : # of Bedrooms : Monthly TBRA Rent: Monthly Tenant Rent: Move In Date: Security Deposit Paid by PHA : Prorated First Months Rent Paid by PHA : IV, Particivatine Agency Certification As a representative of the Participating Agency, I hereby certify that: 1 . An inspection of the property referenced in Section III was conducted on by a representative of our agency and that the unit meets HUD Housing Quality Standards (HQS). 2 . Both parties are aware that this is temporary assistance for a period not to exceed 12 months, both parties are aware they are obligated to notify the PHA within 10 days in the event the tenant moves out of the unit. A lease addendum has been executed between the tenant and the landlord. Name of Agency Representative Title Signature Date Attachments : FEMA Certification of Displacement (unless not applicable), Tenant Income Certification (TIC). Florida Housing Finance Corporation Page 1 Attachment A. Exhibit 1 (Rev. 09/06)