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AFFORDABLE HOUSING LOTTERY APPLICATION CATALYST HOUSING – LYNN, MA APPLICATION DEADLINE: JANUARY 15, 2025 Applicant Legal Name Phone # E-mail Address City IMPORTANT! This application is not complete if not filled out completely, signed, and submitted with ONE COPY EACH of the applicable documents as described below. Applicants must verify all income and assets as part of the lottery application process per EOHLC regulations. Additional documents may be required depending on an applicant’s specific circumstances. Failure to provide a complete application with supporting documents can delay the approval process and your ability to participate in the lottery. Please be advised that lottery applications submitted within 1-week of the lottery deadline cannot be guaranteed for processing and review. We encourage you to submit your application early to ensure acceptance, completion, and eligibility status. REQUIRED INCOME VERIFICATION DOCUMENTS (CHECK IF INCLUDED): ALL APPLICANTS: Last year's Federal tax return (NO STATE RETURNS), including 1099s and W2s, for every person living in the household over the age of 18. If you are not required to file taxes, please write N/A. ALL APPLICANTS: Three most recent and complete statement(s) (include all pages) for all bank accounts, investment accounts, retirement accounts, CDs, real property, cash value of whole life policies, etc. If you do not have any accounts or assets of this kind, please write N/A. IF WORKING: Five most current, consecutive pay stubs, for all salaried employed household members over the age of 18. Six months of income documentation for hourly and seasonal workers. For unemployment, disability, worker's compensation, and/or severance pay, copies of checks or DOR verification stating benefits received. IF SELF-EMPLOYED: Provide a detailed expense and income statement for the five months prior to submission of your application, and the three most recently statement(s) for all business checking and savings accounts. IF RECEIVED: Most recent and complete statement(s) (include all pages) received from Social Security, annuities, insurance policies, retirement funds, pensions, DTA benefits, disability or death benefits, etc. IF YOU HAVE NO INCOME SOURCES: You must submit a notarized statement of zero income. ADDITIONAL DOCUMENTS THAT MAY APPLY BASED ON YOUR SPECIFIC CIRCUMSTANCES (CHECK IF INCLUDED): IF RECEIVING CHILD SUPPORT and/or ALIMONY: Legal documentation indicating the payment amount. If no court document(s) exist, provide a written statement indicating the amount(s) received. IF APPLICABLE: Interest, dividends, and other income from real or personal property. IF PREGNANT: Proof of pregnancy; unborn children may be counted as household members. IF APPLICABLE: School registration documenting full-time student status for any household member(s) over age 18. IF IN THE PROCESS OF DIVORCE or SEPARATION: Legal documentation the process has begun or been finalized. MAIL APPLICATION TO: SEND AS PDF OR FAX: Harborlight Homes P.O. Box 507 [PHONE REDACTED] (fax) Beverly, MA 01915 ---PAGE BREAK--- 2 HOUSEHOLD INFORMATION Name of Persons to Reside in Dwelling (First Name, Middle Initial, Last Name) Relationship to Applicant Age Date of Birth 1 Applicant Are you a full-time student? ☐ Yes ☐ No (Full-time students are typically not eligible for Catalyst Housing due to current LIHTC program regulations; some exceptions apply) Do you live, work, or attend public school in the City of Lynn? ☐ Yes ☐ No IF YES, DOCUMENTATION TO VERIFY LOCAL PREFERENCE MUST BE PROVIDED IN ORDER TO RECEIVE LOCAL PREFERENCE IN THE INITIAL LOTTERY MARK ☒ IF YES LOCAL PREFERENCE DOCUMENTATION INCLUDED: ☐ Lease agreement and/or rent receipt(s) ☐ Current utility or property tax bill ☐ Employment records ☐ Voter registration ☐ Local school registration for non-local applicants (e.g. School Choice or METCO students) Do you require a Mobility Accessible (ADA Type 2) unit? ☐ Yes ☐ No Do you require a unit to support Hearing-Impairment? ☐ Yes ☐ No Would you benefit from the Supportive Services offered at Catalyst Housing by The Haven Project? ☐ Yes ☐ No MARK ☒ IF YES SECTOR EXAMPLE(S) OF SUPPORTIVE SERVICES ☐ Basic Needs Assistance with food, clothing, hygiene products, cellphone, and household goods ☐ Employment Job readiness coaching, resume assistance, interview preparation, employment search assistance ☐ Housing Household budgeting, financial planning, creation of long-term housing goals and plan ☐ Education Application assistance, GED and ESL programs, financial aid counseling ☐ Health Health insurance support, workshops on drug/alcohol use, nutrition, reproduction, and mental health ☐ Community Social skills coaching, advocacy training, community engagement opportunities, conflict resolution classes ---PAGE BREAK--- 3 Are you Homeless as defined under 24 CFR 91.5? ☐ Yes ☐ No IF YES, APPLICANTS MUST SELECT THE APPLICABLE CATEGORY 1-4 (MARK ☒ TO SELECT) AND PROVIDE DOCUMENTATION REQUIRED IN ORDER TO RECEIVE HOMELESS PREFERENCE. MARK ☒ IF YES HOMELESS CATEGORY DESCRIPTION/CRITERIA DOCUMENTATION REQUIRED ☐ Category 1: Literally Homeless Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning: Has a primary nighttime residence that is a public or private place not meant for human habitation; (ii) Is living in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state and local government programs); or (iii) Is exiting an institution where (s)he has resided for 90 days or less and who resided in an emergency shelter or place not meant for human habitation immediately before entering that institution. • Written observation by the outreach worker; or • Written referral by another housing or service provider; or For individuals exiting an institution: One of the forms of evidence above and • Discharge paperwork or written/oral referral, or • Written record of intake worker’s due diligence to obtain above evidence and certification by individual that they exited institution. ☐ Category 2: Imminent Risk of Homelessness Individual or family who will imminently lose their primary nighttime residence, provided that: Residence will be lost within 14 days of the date of application for homeless assistance; (ii) No subsequent residence has been identified; and (iii) The individual or family lacks the resources or support networks needed to obtain other permanent housing. • A court order resulting from an eviction action notifying the individual or family that they must leave; or • For individual and families leaving a hotel or motel—evidence that they lack the financial resources to stay; or • A documented and verified oral statement; and • Certification that no subsequent residence has been identified. ☐ Category 3: Homeless under other Federal statutes Unaccompanied youth under 25 years of age, or families with children and youth, who do not otherwise qualify as homeless under this definition, but who: Are defined as homeless under the other listed federal statutes; (ii) Have not had a lease, ownership interest, or occupancy agreement in permanent housing during the 60 days prior to the homeless assistance application; (iii) Have experienced persistent instability as measured by two moves or more during in the preceding 60 days; and (iv) Can be expected to continue in such status for an extended period of time due to special needs or barriers. • Certification by the nonprofit or state or local government that the individual or head of household seeking assistance met the criteria of homelessness under another federal statute; and • Certification of no PH (Permanent Housing) in last 60 days; and • Certification by the individual or head of household, and any available supporting documentation, that (s)he has moved two or more times in the past 60 days; and • Documentation of special needs or 2 or more barriers. ---PAGE BREAK--- 4 MARK ☒ IF YES HOMELESS CATEGORY DESCRIPTION/CRITERIA DOCUMENTATION REQUIRED ☐ Category 4: Fleeing/ Attempting to Flee Domestic Violence (DV) Any individual or family who: Is fleeing, or is attempting to flee, domestic violence; (ii) Has no other residence; and (iii) Lacks the resources or support networks to obtain other permanent housing. For victim service providers: • An oral statement by the individual or head of household seeking assistance which states: they are fleeing; they have no subsequent residence; and they lack resources. Statement must be documented by a certification by the intake worker. For non-victim service providers: • Oral statement by the individual or head of household seeking assistance that they are fleeing. This statement is documented by a self-certification or by the caseworker. Where the safety of the individual or family is not jeopardized, the oral statement must be verified; and • Certification by the individual or head of household that no subsequent residence has been identified. ---PAGE BREAK--- 5 RACE AND ETHNIC DATA REPORTING FORM (OPTIONAL) Minority reporting categories include only American Indian or Alaska Native, Black or African American, Asian, Native Hawaiian or Pacific Islander; or Other (not White); and the ethnic classification Hispanic or Latino. Please see the Instructions and category definitions on the next page of this application. There is no penalty for persons who do not complete this section of the application. INSTRUCTIONS FOR THE RACE AND ETHNIC DATA REPORTING FORM Owner and agents are required to offer the applicant/tenant the option to complete the form. The form is to be completed at initial application or at lease signing. In-place tenants must also be offered the opportunity to complete the form as part of the next interim or annual recertification. Once the form is completed it need not be completed again unless the head of household or household composition changes. There is no penalty for persons who do not complete the form. However, the owner or agent may place a note in the tenant file stating the applicant/tenant refused to complete the form. Parents or guardians are to complete the form for children under the age of 18. 1. The two ethnic categories you should choose from are defined below. You should check one of the two categories: 1. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term "Spanish origin" can be used in addition to "Hispanic" or "Latino." 2. Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. 2. The five racial categories to choose from are defined below: You should check as many as apply to you: 1. American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. 2. Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam 3. Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" can be used in addition to "Black" or "African American." 4. Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. 5. White. A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Ethnic Categories (Select One) Applicant Hispanic or Latino Not Hispanic or Latino Racial Categories (Select All that Apply) Applicant American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other (not White) ---PAGE BREAK--- 6 INCOME List all income sources such as (but not limited to) wages, child support, Social Security benefits, all types of pensions, Unemployment Compensation, Workman's Compensation, alimony, disability or death benefits, interest/dividends, regular gifts or periodic income, and any other form of income. Applicants with zero income are required to submit a notarized statement. If additional space is needed, please attach another sheet. Type of Income Sources of Income GROSS Amount per Year 1 2 3 4 5 6 TOTAL ASSETS List all bank accounts (checking and savings), CDs, stocks, bonds, retirement accounts, life insurance policies, real property, and/or any other investments below. If additional space is needed, please attach another sheet. Household assets do not include essential personal property. Asset limits for non-retirement accounts apply for 30% AMI subsidized units based on subsidy program requirements (currently $25,000 for MRVP units). If given an opportunity to lease, the affordable unit must be your principal, full-time residence. Type(s) of Asset Bank/Credit Union Name Account # Value or Balance 1 Checking account 2 Savings account 3 Retirement account 4 Other: 5 Other: 6 Other: TOTAL ---PAGE BREAK--- 7 EMPLOYMENT STATUS(ES) Please provide information for any job(s) that provide regular, occasional, temporary, or seasonal income. All employment income must be documented as described on Page 1 of this application. Name of Employed: Occupation: Present Employer: Employer Address: Name & Title of Supervisor: Date of Hire: Annual Gross Salary: Name of Employed: Occupation: Present Employer: Employer Address: Name & Title of Supervisor: Date of Hire: Annual Gross Salary: Name of Employed: Occupation: Present Employer: Employer Address: Name & Title of Supervisor: Date of Hire: Annual Gross Salary: Name of Employed: Occupation: Present Employer: Employer Address: Name & Title of Supervisor: Date of Hire: Annual Gross Salary: ---PAGE BREAK--- 8 APPLICANT CERTIFICATION 1. I/We certify that my household size is persons, as documented herein. 2. I/We certify that my total household income equals as documented herein. 3. I/We certify that my total household assets equal as documented herein. 4. I/We certify that the information in this application and in support of this application is true and correct to the best of my knowledge and belief under full penalty of perjury. I understand that false or incomplete information may result in disqualification from further consideration. 5. I/We certify that no member of my family has a financial interest in the project. 6. I/We understand that being selected in the lottery does not guarantee that I will be able to lease a unit. I understand that all application data will be verified, and additional financial information may be required, verified, and reviewed prior to leasing a unit. I also understand that the project's owner will perform screening, including criminal background and credit checks, to determine eligibility. 7. I/We I understand that Harborlight Homes operates smoke-free communities, which means that smoking of any kind is prohibited in the individual apartments, interior and exterior common areas, and all locations on the properties. 8. I/We authorize Harborlight Homes to verify all financial and household information and direct any employer, landlord or financial institution to release any information to Harborlight Homes and the project owner to determine eligibility. 9. I/We understand that income and asset limits may be reviewed annually and subject to change in accordance with state and/or federal law. I further understand that some units at this property are subject to additional income and asset restrictions in accordance with subsidy program requirements and/or regulatory agreements. 10. I/we understand that it is my responsibility to keep Harborlight Homes informed of any changes in my income, assets, household composition, and/or contact information. I have completed an application and have reviewed and understand the process that will be utilized to distribute the available units. I am qualified based on the program guidelines and agree to comply with applicable regulations. Applicant Signature Date Catalyst Housing LLC and/or Harborlight Community Partners, Inc. dba Harborlight Homes do not discriminate in the selection of applicants on the basis of race, color, national origin, disability, age, ancestry, children, familial status, genetic information, marital status, public assistance recipient, religion, sex, sexual orientation, gender identity, veteran/military status, or any other basis prohibited by law. Applicants with disabilities may request modifications to the apartments or development, or (ii) accommodations to our rules, policies, practices, or services if such modifications and accommodations are necessary to afford an equal opportunity to use and enjoy the housing. THIS IS APPLICATION IS ONLY FOR THIS SPECIFIC DEVELOPMENT