INITIAL APPLICATION FOR HOUSING
List all persons who will be living in the home, beginning with the head of household. Each box must be completed for each member. No one except those listed on this form may live in the unit. Applications with missing Social Security Numbers or Date of Birth will be rejected.
| Name | Relation to Head |
U.S. Citizen |
Disabled | Sex | Date of Birth | Social Security or Registration # |
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| List all children who will be living in the home, oldest to youngest. | |||||||
| Name | Relation to Head |
U.S. Citizen |
Disabled | Sex | Date of Birth | Social Security or Registration # |
School Name |
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RACE AND ETHNICITY OF HEAD OF HOUSEHOLD
| Race |
Ethnicity |
Income includes money or contributions from any and all sources paid to or on behalf of a family member.
List the sources and amounts of all income (money) expected for the coming 12 months for all family members from any and all sources.
| Family Member Name | Income Source | Amount $ | Frequency |
Do you claim any of the following preferences?
Working, Elderly, Handicapped, or Disabled
YOU ARE REQUIRED TO NOTIFY THE HOUSING AUTHORITY (IN WRITING) OF ANY CHANGES. IF WE CANNOT CONTACT YOU AT THE ABOVE ADDRESS, YOUR NAME WILL BE REMOVED FROM THE WAITING LIST, AND YOU WILL HAVE TO RE-APPLY. YOU ARE RESPONSIBLE FOR KEEPING YOUR APPLICATION UPDATED. IF YOU FAIL TO DO SO YOUR APPLICATION WILL BE REJECTED.WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AND SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISONED FOR NOT MORE THAN FIVE YEARS OR BOTH.