Supplement To Application For Federally Assisted Housing Template
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10BHA Office Use Only
Bloomington Housing Authority
1007 N Summitt Street
Date: __________
Bloomington, IN 47404
Number of Adults in Household: __________
Phone: 812-339-3491
Number of Minors in Household: __________
Fax: 812-339-7177
Staff Initials: __________
Public Housing Applicant:
Now that you submitted your online application, there are certain verification documents, legal documents and proof
of income statements to be submitted to the BHA Main Office. This letter is to serve as a guide for what those
verifications are. Please note this helpful guide may not include all the verifications needed by the BHA for your
family. The BHA will notify you by mail or email if other documents are needed. Please submit all verifications and
documents within 10 days of online application submittal.
Applicant / Head of Household Name:
Confirmation Number for Online Application
Did you receive a confirmation number for your online application? If so, write it down here:
Sign the Attached Documents
Attached to this letter are the following documents that must be signed by the Head of Household and all other adult
⎕ HUD Form 92006 “Supplement to Application for Federally Assisted Housing”
members of the household:
⎕ “Authorization for Release of Information”
⎕ HUD Form 9886 “Authorization for Release of Information/Privacy Act Notice”
⎕ HUD Form 52675 “Debts Owed to PHAs and Terminations”
⎕ “Consent for Criminal Background Check”
⎕ Original Social Security Card of each member of the household (Copies can be mailed, however an original
Verifications for Adults
⎕ Birth Certificate
⎕ Driver’s License, Military ID, Employment Card or Passport
MUST be shown to BHA Intake before a unit is offered.)
⎕ Original Social Security Card (Copies can be mailed, however an original MUST be shown to BHA Intake before
Verifications for Children
⎕ Birth Certificate
⎕ Adoption papers (if applicable)
a unit is offered.)
⎕ Custody agreement (if applicable)
⎕ Health and Human Services ID (if applicable)
⎕ Certified school records (if applicable)
Preference Point Verifications
Did you select any preference points on the application? If so, submit the proper documentation to prove you
qualify for those preference points.
(OVER)
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