Page 6 - TBRA_Intake

D. HOUSEHOLD COMPOSITION INFORMATION (Continued)

1. Was any household member a full‐time student within the last calendar year? No Yes, who?

2. Is any household member listed above a foster child? No Yes, who?

3. Is any household member listed above a live‐in attendant? No Yes, who?

4. Is any household member temporarily absent from the home? No Yes, who?

If Yes, Indicate reason for temporary absence:

5. Do you anticipate other members will join your household within the next 12 months? No Yes, explain:

E. HOUSING ASSISTANCE RECEIVED PREVIOUSLY

(List any other housing assistance provided to or received by any household member)

Source Amount Date Received Reason

1. FEMA: Federal Emergency Management Agency $
No Yes

2. SBA: Small Business Administration $
No Yes

3. Section 8: Housing and Urban Development $
No Yes

4. TBRA: Tenant Based Rental Assistance $
No Yes

5. Homeowner Insurance $
No Yes

6. Other Describe: $
No Yes

F. CONFLICT OF INTEREST INFORMATION

1. Is anyone in the household currently serving or has anyone served within the last 12 months as an employee, agent,

consultant, officer, or elected or appointed official of TDHCA, Administrator, or Development Owner? No Yes

If Yes, identify who, organization name, and role:

Is this a current role? No Yes If No, identify date role ceased:

2. Is anyone in the household related to anyone who is currently serving or who has served within the last 12 months as an
employee, agent, consultant, officer, or elected or appointed official of TDHCA, Administrator, or Development Owner (either
through familial or business ties)? No Yes

If YES, identify who, organization and role:

Is this a current role? No Yes If No, identify date role ceased:

G. DISPOSAL OF ASSETS INFORMATION

1. Has anyone in the household given away anything of value within the last two years? (if a home was released due to
foreclosure, bankruptcy, or divorce, answer No): No Yes, who?

Provide explanation (including the type of asset, estimated value of asset, amount disposed for, and date of disposal):

2. Has anyone in the household owned a home in the last two years? No Yes, who?

Do they currently own it? No

If No: When was it disposed of?

Yes If Yes: Is it being rented? No Yes

Is it sitting vacant? No Yes

Is it in the process of being sold? No Yes

TDHCA HOME Investment Partnerships Program March 2015

HOME Program Intake Application Page 2