Public Housing Application

Applicant Information

Name(Required)

First Middle Last

Address(Required)

Street Address City State ZIP Code

Email(Required)

Phone(Required)

All applications must include copies of social security cards for ALL members of the family

How many people will be/are living in the home?(Required)

Family Member #1

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #2

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #3

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #4

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #5

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #6

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #7

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Family Member #8

Name(Required)

First Middle Last

Social Security Number(Required)

Place of Birth (City, State)(Required)

Date Of Birth(Required)

Age(Required)

Sex(Required)

Race(Required)

Relationship(Required)

Please describe relationship:(Required)

Changes to Family

Are there any anticipated changes in family composition?(Required)

Yes

If yes, please explain(Required)

Income

List all sources of income for each person. (Wages, FIP, child support, SS, SSI, pensions, annuities, alimony, etc.) We require verification of income with the application. (Check stub, letter of decision, etc.)

List(Required)

Family Member

Description

Income Amount

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Assets

List the value of property owned by the family. Including houses, land, businesses, etc. Also include checking accounts, savings accounts, certificates of deposit.

List

Family Member

Description

Value

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Deductions & Allowances

List medical and/or dental expenses paid by the family if head of household is disabled or elderly include co-pays

List

Description

Cost

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Childcare

If head of household is in school or employed, list childcare costs

List

Description

Cost

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Family Characteristics

Ethnicity of head of household:(Required)

Hispanic

Non-hispanic

Is the head of household, spouse or co-head disabled?(Required)

Yes

If yes, list any special housing needs required as result of the disability(Required)

Have you been displaced due to domestic violence within the past 90 days?(Required)

Yes

Has the head of household or spouse ever gone by a name different than what is listed on the application?(Required)

Yes

If yes, please explain and list past names used.(Required)

Has any family member every been charged with a drug-related or violent crime?(Required)

Yes

If yes, please provide details:(Required)

When?

Where?

Have you been charged with or convicted of a felony?(Required)

Yes

If yes, please explain:(Required)

Are you currently participating in, or have you ever participated in a Public Housing or Section 8 Program anywhere?(Required)

Yes

Which program?(Required)

Public Housing

Section 8

Address(es) while in program:(Required)

Name & Address of PHA(Required)

Your name, if different, when on program:

Do you owe any money to our agency or any other PHA?(Required)

Yes

If yes, list name and address of PHA(Required)

Waiting Lists

Each town listed below represents a waiting list. Please choose the town(s) you wish to live in. You may choose as many as you wish. The numbers behind the towns represent the number of bedrooms available in that town.

Towns(Required)

Landlord/Rental History

Starting with the most recent, please list the name and complete address of each landlord you have rented from in the past 5 years. Also include the address of the property and the dates you rented from each landlord.

Explain any periods of time when you did not rent (example: lived with relatives, out of the country, in college, buying home, etc.):

List

Name Of Renter

Landlord Name & Address

Rental Property Address

Dates Rented

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Applicant Certification

Please read carefully before agreeing and signing application

Each adult person that is 18 or older MUST sign this application.

How many adults will be signing this agreement?(Required)

Name(Required)

Signature(Required)

Name(Required)

Signature

Name(Required)

Signature

Name(Required)

Signature