request for early release - San Antonio Housing Authority

request for early release - San Antonio Housing Authority

818 South Flores Street | San Antonio, Texas 78204 | 210-477-6262 | www.saha.org
REQUEST FOR EARLY RELEASE
Date:
SSN:
Participant Name:
Address:
City, State, Zip:
Home Phone:
Cell Phone:
Email Address:
PLEASE COMPLETE THE FOLLOWING INFORMATION AND RETURN TO
THE CUSTOMER SERVICE REPRESENTATIVE.
Write a brief explanation of your reason for requesting an Early Release:
Check the box that indicates your request:
Early Release Request (stop here and go to SECTION ONE)
Violence Against Women (VAWA) Request (stop here and go to SECTION TWO)
HQS Inspection Failed or Complaint (stop here and go to SECTION THREE)
SECTION ONE: Early Release Request
Indicate the documentation you have to support your request by checking the appropriate box.
Police report
A copy of the letter from the landlord agreeing to your release
Copy if a Judgment
Letter Statement (s) from a medical professional
A copy of the letter to the landlord stating your concerns and requesting to be released from your
agreement
Any individual with a disability or other medical need who requires an accommodation should contact the San Antonio Housing
Authority at (210) 477-6262. Si usted no comprende este documento porque está escrito en inglés, por favor llame al (210)
477-6262 para asistencia.
Page 1 of 3
Rev. 2/19/2013
AHP-2315
818 South Flores Street | San Antonio, Texas 78204 | 210-477-6262 | www.saha.org
Have you informed the landlord of your intention to request an Early Release from SAHA?
Yes
No
Is the landlord in agreement?
Yes
No
Have you completed the full first (initial) year of your lease agreement with the landlord at your unit?
Yes
No
Early Release appointments will be granted for those who quality.
 Requests for Early Release will not be granted for individuals in the initial (first) year of their lease
agreements, unless under VAWA or SAHA HQS (landlord) terminations.
 Must have valid supporting documentation for your request.
 If the landlord has approvers, the landlord must be informed in writing of your intention and reason
for seeking an Early Release.
SECTION TWO: VAWA Request
Indicate the documentation you have to support your request by checking the appropriate box.
A police report stating or indicating domestic violence
Other agency documentation stating a present danger to the individual
A copy of the letter to the landlord stating your concerns and requesting to be released from your
agreement
Restraining order
Protective order
Certification of Domestic Violence, Dating Violence, or Stalking (HUD-50066 form)
A statement from a victim service provider, attorney, or medical professional who helped address
incidents of domestic violence, dating violence or stalking. The professional must state that he or she
believes the incidents are real abuse. NOTE: Signatures of both participant and professional are
required on the statement. The statement must include the phrase “under penalty of perjury”.
Have you informed the landlord of your intention to request an Early Release from SAHA?
Yes
No
Has the landlord been informed of your circumstance?
Yes
No
Any individual with a disability or other medical need who requires an accommodation should contact the San Antonio Housing
Authority at (210) 477-6262. Si usted no comprende este documento porque está escrito en inglés, por favor llame al (210)
477-6262 para asistencia.
Page 2 of 3
Rev. 2/19/2013
AHP-2315
818 South Flores Street | San Antonio, Texas 78204 | 210-477-6262 | www.saha.org
Did you submit a Certification of Domestic Violence, Dating Violence, or Stalking (HUD-50066 form)?
Yes
No
(If you are in need of one, request it from your customer service representative).
Did you attach all supporting documentation to the form?
Yes
No
SECTION THREE: HQS Inspection Failed or Complaint
Indicate the documentation you have to support your request by checking the appropriate box.
Received a letter, or was informed of termination for a failed HQS inspection.
Did your inspection fail?
Yes
No
If Yes, was it:
Owner Responsibility? (CSR will schedule your appointment to receive a new voucher)
Owner / Tenant Responsibility? (Please complete and turn in an informal hearing request form)
Tenant Responsibility? (Please complete and turn in an informal hearing request form)
Are you reporting and HQS complaint?
Yes
No
If Yes, the CSR will forward your complaint to the Inspections department.
Note to CSR: Please fax this complaint / concern to the Inspections department at (210) 477-6157.
I hereby certify that all information provided in this document is true and correct to the best of my
knowledge.
Participant Signature
Date
Please attach copies of documentation supporting your request.
Accepted By:
Date Accepted:
Any individual with a disability or other medical need who requires an accommodation should contact the San Antonio Housing
Authority at (210) 477-6262. Si usted no comprende este documento porque está escrito en inglés, por favor llame al (210)
477-6262 para asistencia.
Page 3 of 3
Rev. 2/19/2013
AHP-2315