Section 3 Individual Certification Form - San Antonio Housing Authority

San Antonio Housing AuthorityCertification for Section 3IndividualProcurementDepartmentCONTACT INFORMATIONFirst Name: Last: M.I:DOB:Street Address:City:State:ZIP:County:Last 4 SSN:Primary Phone:E-mail Address:Driver License / State ID: ( State and Number) Sex: Male ☐ Female ☐INDIVIDUAL INFORMATIONCase Manager’s Name:Do you live in public housing orSection 8?Are you able to pass a drug testfor employment?Have you ever been convicted of acrime (felony or misdemeanor)?Have you ever been convicted forviolations of any traffic laws?Are you committed to working 8hrsa day?Are you a member of Jobs Plus orFamily Self-Sufficiency Program?YES ☐YES ☐YES ☐YES ☐YES ☐YES ☐NO ☐ Property Name?NO ☐NO ☐ If yes, explain?NO ☐ If yes, explain?NO ☐ If no, explain?NO ☐ Which program?EDUCATION( Check one) Have a High School Diploma or GED ☐ Enrolled in a GED program ☐ No GED ☐DESIRED INDUSTRY( Check all that apply) Administrative/ Office-Clerical ☐ Landscaping ☐ Construction ☐Maintenance ☐ Warehouse/Distribution ☐ Production/Assembly Line ☐ Customer Service ☐List any skills that pertain to the industry desired: (ex. answer phones, bricklaying etc.)WORK EXPERIENCE(Check one): Some Work Experience Limited Work Experience No Work Experience(2-5 years) (6 months- 1 year) ☐☐☐Field of Experience: (ex. Landscaping )Page 1 of 2

San Antonio Housing AuthorityCertification for Section 3IndividualProcurementDepartmentANNUAL INCOMEIn order to be a Section 3 Certified Individual, your household income must meet the income criteria by household size.(Check one of the following if your family income is at or below the listed amount)FY 2012 80% Area Median Income Limits (Household Size)1 2 3 4 5 6At or below$34,100At or below$38,950At or below$43,800At or below$48,650At or below$52,550At or below$56,450☐☐☐☐☐☐DOCUMENTATION REQUIRED FOR NON-SAHA RESIDENTSPlease provide the required documentation to proceed with the Section 3 Individual Certification:(Attach a copy of one (1) of the following to the application)☐ Last 2 pay stubs☐ Public Assistance letter(s) (ex. SNAP, TANF, WIA)DISCLAIMER AND SIGNATURE☐ By checking this box, I swear or affirm that the information on this form is to the best of my knowledge and belief true, correct,and complete.I hereby authorize San Antonio Housing Authority (SAHA) to display my contact information, experience, work history, andavailability in a database that contractors/vendors and community partners will have access, for employment, training andeducation purposes.My signature or printed name below signifies that I understand and authorize San Antonio Housing Authority and U.S. Departmentof Housing and Urban Development (HUD) officials to verify all the information I provide regarding Section 3 Certification.SignatureDatePlease complete the forms and PrintDrop form off at: 818 S. Flores St. San Antonio TX, 78204 or,E-mail form to: Section3@saha.org or,Fax form to: (210) 477-6333Page 2 of 2