NSP Purchase Assistance Application - City of Deltona, Florida

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Page 13 of 15 Purchase Assistance Program Application Cont. STATEMENT OF NON‐EMPLOYMENT Previous Employer: ________________________________________________________________________ I have been unemployed since _______________________________________________________________ Please indicate by checking which applies to you: __________ __________ (a) I am not presently employed, but anticipated becoming employed within the next 12 months. (b) I am not presently employed and do not anticipate becoming employed within the next 12 months for the following reasons: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ (c) I am receiving unemployment compensation. If this blank is checked, please attach a copy of __________ your approval letter with the stated income amount. __________ (d) I am not receiving unemployment compensation. If this blank is checked, please explain why you are not: __________________________________________________________________________________________ __________________________________________________________________________________________ NOTE: All eligible persons shall seek unemployment benefits when applying for Deltona’s Housing assistance. ___________________________________________ Signature ______________________________________ Date ___________________________________________ Print Name ______________________________________ Date City of Deltona - Department of Planning and Development Services - Community Development Division 2345 Providence Boulevard, Deltona, FL 32725 Phone (386) 878-8614; No faxed copies accepted www.deltonafl.gov
Page 14 of 15 Purchase Assistance Program Application Cont. VERIFICATION OF STUDENT STATUS We are required by State and/or Federal regulations to verify employment history and income information for the applicant in order to determine their eligibility for program assistance. Your cooperation in providing the requested information below is most appreciated. You may mail or fax it to the City of Deltona at (386) 878‐8601. Authorization: An “Authorization for the Release of Information” form has been signed by the applicant who indicates they are in agreement with the release of information requested for the sole purpose of determining eligibility for program assistance. Please return information to: Community Development 2345 Providence Blvd. Deltona, FL 32725 Complete the (applicable) sections below: NAME OF APPLICANT _____________________________________________________________________________ NAME OF STUDENT _______________________________ Social Security No: ________________________ ADDRESS OF STUDENT ______________________________________________________________________ I hereby authorize the release of the information requested below. ____________________________________________ Signature of Applicant/ Student (if over the age of 18) ______________________________________ Date TO BE COMPLETED BY SCHOOL OFFICIAL Student’s Home Address: _____________________________________________________________________ Parent/Guardian responsible for student: ________________________________________________________ Date of Enrollment _____________________________ Full Time ____________ Part Time ______________ This is to certify that the above listed student is enrolled at this school. Name of Educational Institution: _______________________________________________________________ Address of Educational Institution: _____________________________________________________________ Signature _______________________________________ Date: __________________________________________ Title: ___________________________________ Telephone: ______________________________ WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States Government as to any matter within its jurisdiction. City of Deltona - Department of Planning and Development Services - Community Development Division 2345 Providence Boulevard, Deltona, FL 32725 Phone (386) 878-8614; No faxed copies accepted www.deltonafl.gov
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NSP Purchase Assistance Application - City of Deltona, Florida

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