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Head of Household

Name*

First Middle Last

Maiden Name

Other Names Used

Date of Birth*

Social Security Number*

Name of Co-Head of Household

Date of Birth

Social Security Number

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Message Phone

Work Phone

Household Details

Family/Elderly
Handicapped/Disabled

Apartment Size

Area Preference

Affirmative Action Information

For Statistical Purposes Only

Race

Ethnicity

Previous Housing

Family Members

List all family members who will be living with you, including foster children, live-in aides (if needed for the care of a family member). No one except those listed on this form may live in the unit. (Begin with the Head of Household - HOH).

Use the + button to add additional family members.

First and Last Names	Relation To You	Sex	Social Security Number	Birth Date	Disabled Person	Birthplace	Full-Time Student

Rental History

When applying for Low-income housing, list your current and previous landlords.

Current Landlord's Name

First Last

Current Landlord's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Landlord's Phone Number

Your Previous Rental Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Landlord's Name

First Last

Previous Landlord's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous Landlord's Phone Number

Income

Does anyone, including children, receive or expect to receive money from any source listed below?

Employment*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Job Training Program*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Work Study*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Educational Loans*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Grants, Scholarships*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

TANF*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

General Assistance

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Unemployment Comp.*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Workmen's Comp.*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Military Allotment*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Veteran's Benefit*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Child Support*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Alimony*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Spousal Support*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Social Security*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

SSI*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Pension/Retirement*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Insurance Policy*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Annuities*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Interest/Asset*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Income from Rental Property*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Second Job*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Self-Employment*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Lottery Winnings*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Gifts*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Payment Non-Household Member*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Monetary Contributions*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

Other, Explain*

Yes
No

Income Details

Who	Gross Income	Per Week, Per Month, or Bi-monthly?

None at this Time

Yes

Certification

I/we certify that the statements on this application are true and to the best of my/our knowledge and belief and understand that they will be verified. I/we authorize the release of information to the Housing Authority by my/our employer(s), the Department of Public Assistance, the Social Security Administration, credit reporting agencies, and/or other business or government agencies. I/we understand that any false statement made on this application will cause me/us to be disqualified for admission.

Applicant Siganture*

First Middle Last

Date*

Co-Applicant Signature

First Middle Last

Date

Upon completion of this application you will receive additional forms to sign and return. We will also need a copy of every family members social security card, birth certificate and photo ID for family members over the age of 18.

Warning: 18 U.S.C. 1001 provides among other things that whoever knowingly and willfully makes or uses a document or writing containing false, fictitious, or fradulent statement or entry in any matter within the jurisdiction of any department or agency of the United States shall be fined not more than $10,000 or imprisoned for not more than five years or both.

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