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For Statistical Purposes Only

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).

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

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

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 relase 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.

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.