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TBRA APPLICANT INTAKE <br /> (Completed by Participating Agency (PHA ) <br /> DATE : NAME of PHA : <br /> I. Applicant Information <br /> Name of Head of Household : Contact Phone # : <br /> # of persons in household : Gross Annual Household Income : <br /> Is gross annual household income less than 80% of area median income based on household size ? Yes or No <br /> If No, STOP. Applicant does not qualify . <br /> Proof of displacement: FEMA certification (Obtain copy) or Other (Explain ) <br /> Previous Address : <br /> If displaced by hurricane and no FEMA certification exists, PHA must verify (visual inspection) that the residence is no longer habitable <br /> Verified? (circle one) Yes No Not Applicable (FEMA certification attached) <br /> II. Landlord Information <br /> Name : Contact Phone # : <br /> Mailing Address : <br /> Payment Method Preferred by Landlord : Direct Deposit Mail Check <br /> HI. Rental Unit Information <br /> Address : <br /> County : # of Bedrooms : <br /> Monthly TBRA Rent : Monthly Tenant Rent : Move In Date : <br /> Security Deposit Paid by PHA : <br /> Prorated First Months Rent Paid by PHA : <br /> IV. Participating Agency Certification <br /> As a representative of the Participating Agency, I hereby certify that : <br /> 1 . An inspection of the property referenced in Section III was conducted on by a <br /> representative of our agency and that the unit meets HUD Housing Quality Standards (HQS ) . <br /> 2 . Both parties are aware that this is temporary assistance for a period not to exceed 12 months , both parties are aware <br /> they are <br /> obligated to notify the PHA within 10 days in the event the tenant moves out of the unit. A lease addendum has been executed <br /> between the tenant and the landlord. <br /> Name of Agency Representative Title <br /> Signature Date <br /> Attachments : FEMA Certification of Displacement (unless not applicable) <br /> Florida Housing Finance Corporation Page I Attachment A , Exhibit 1 (Rev . 09/05 ) <br />