FOR OFFICE USE ONLY. DO NOT MARK IN THIS BOX

APPLICATION NUMBER                                                                  PRIORITY NUMBER                             (  ) Disabled                                                                                                           Req’d Bedroom Size                                            (  ) Handicapped                                                                   (  ) Elderly (  ) Family                                                                                                               Case Worker                                                                                                                                                                            Date Received                                            (  ) Eligible (  ) Ineligible                                                                                                          Monthly Rent $                                    (  ) Incomplete                                                                                                       Utility Allowance

 

Section I

Please fill out this portion of the application accurately and completely.  Do not leave anything blank.  If the question does not apply to you, mark it with a NO, N/A, or Zero.  You must fill in a current address or an address where you can be reached by mail.  It is your responsibility to reply to correspondence and to report any changes of address or living conditions.  If you do not respond to correspondence (mail) within the time allocated, your case will be inactivated for failure to reply and you will have to begin the application procedure again.

Name of Applicant: (Last)                                                                  (First)                                                     (MI)                       

Name of Spouse: (Last)                                                                       (First)                                                     (MI)                       

Present Address:                                                                                                                                                                                                

City:                                                                          State:                                    Zip Code:                                                              

Home Phone:(       )                                                               Work Phone: (      )                                                                              

Spouse Phone (if different from above):                                                          Work Phone: (      )                                              

Section II

Household Composition:  List all persons who will be living in your home, listing head of household first.

Are there any anticipated changes in family composition?                                                                                                         

For Statistical Purposes Only:

Race:  (  ) White   (  ) Black   (  ) American Indian   (  ) Indian/Alaskan Native   (  ) Asian/Pacific Islander

Ethnicity:  (  ) Hispanic   (  ) Non-Hispanic

Name, Address and Telephone Number of someone else who can be notified in case of emergency or relay messages in case you cannot be reached at the address and telephone number listed previously:

Name of Applicant: (Last)                                                                  (First)                                                     (MI)                       

Present Address:                                                                                                                                                                                                

City:                                                                          State:                                    Zip Code:                                                              

Home Phone:(       )                                                               Business Phone: (       )                                                                       

Section III

Total Household Income:  List all money earned or received by everyone living in your household.  This includes money from wages, self-employment, child support, contributions, Social Security, disability payments, unemployment, Workers Compensation, retirement benefits, TANF, Veteran’s benefits, rental property income, stock dividends, alimony, and all other sources.

For the elderly, handicapped, or disabled:

• Medical Insurance which is paid for by you.  Monthly Amount: $                                                                            
• Type:                                                                                                     
• Other medical expenses not paid by insurance or family members:                                                                                                                                                                                                                                                                            
• Pharmacy Name & Address:                                                                                                                                             
• Are you a handicapped person?  (   ) Yes        (  )  No
• Do you require special accommodations as a handicapped person?  (   ) Yes       (  ) No

Section IV

Assets:  Please fill out Section IV honestly and to the best of your knowledge.  Do not leave anything blank.  If the question does not apply to you then mark it with a NO, N/A, or Zero.  If you do not fill in this section completely, your application will be marked “Incomplete” and this will delay the intake process until you have completed each question.

1.  Do you or any other household member own or have a savings and/or checking account?  (  ) Yes     (  ) No

If yes, list bank and account number and amount held in accounts:  (  ) Checking     (  ) Savings     (  ) Both

2.  Do you or any other household member own or have an interest in any real estate and/or mobile home and/or boat?  (  ) Yes     (  ) No                                                                                                                                                                                 

3.  Have you sold any real estate in the last two years?  (  ) Yes     (  ) No                                                                                

Date Sold:                                                  Amount Received:                                                                                                          

4. Do you own any stocks or bonds?  (   ) Yes       (   ) No                                                                                                           

5.  Do you or any other household member own a motor vehicle?  (   ) Yes     (   ) No   Year                                 

Make                                                      Model                                                     Tag Number                                                       

6.  Are you or any other household member financing a motor vehicle?  (   ) Yes     (   ) No   Amount $                             

7.  Does anyone outside your household pay for any of your bills or give you money?  (   ) Yes   (   ) No

Section V

Rental History: Please fill out this section of your application completely.  Start with your present address and landlord and go backwards for the past five years.  Keep them in order as you lived there.  Also include any addresses where you lived with a friend or relative and list their name and relation.  If you do not fill out this section completely, your application will be marked “Incomplete” and this will delay the intake process until you have completed each section.

1.  Have you or any other household member lived in any Assisted Housing before?  (   ) Yes      (   ) No

If yes, explain:                                                                                                                                                                                      

2.  Have you or any other household member ever been convicted of a crime, other than traffic violations?  (   ) Yes     (   ) No  If yes, explain:                                                                                                                                                                               

3.  Have you or any other household member ever committed fraud in an Assisted Housing program or been required to repay money for knowingly misrepresenting information for such programs?  (   ) Yes     (   ) No

If yes, explain:                                                                                                                                                                                      

4.  Have you ever been evicted or violated your rental agreement or lease?  (   ) Yes      (   ) No

If yes, explain:                                                                                                                                                                                      

5.  Have you ever left any Assisted Housing program owing money?  (   ) Yes      (   ) No

If yes, how much?                                                Please explain:                                                                                                     

Section VI

PERSONAL OR CHARACTER REFERENCES: Please fill out this section with at least two personal or character references.  If you do not fill in at least two names, your application will be marked “Incomplete” and this will delay the intake process until you have answered each question.  Please use references not related by kinship.

APPLICANT/TENANT CERTIFICATION

GIVING TRUE AND COMPLETE INFORMATION

I certify that all the information provided on household composition, income, family assets, and items for allowances and deductions is accurate and complete to the best of my knowledge.  I understand that false statements or information are punishable under Federal and State laws.  I also understand that false statements or information are grounds for denial of housing or assistance, termination of housing assistance and termination of tenancy.  I have reviewed the application form and certify that the information shown is true and correct.

REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION

I know I am required to report immediately in writing any changes in income and any changes in household composition.

REPORTING ON PRIOR HOUSING ASSISTANCE

I certify that I have disclosed where I received any previous Federal Housing Assistance and whether or not any money is owed.  I certify that for this previous assistance I did not commit and fraud, knowingly misrepresent any information, or vacate the unit in violation of the lease.

NO DUPLICATE RESIDENCE OR ASSISTANCE

I certify that the house or apartment will be my principal residence and that I will not obtain duplicate Federal Housing Assistance while I am in this current program.  I will not live anywhere else without notifying the Housing Authority immediately in writing.  I will not sublease my assisted residence.

COOPERATION

This application is made with the understanding that it is to be processed for both credit, landlord, and character references.  I have no objection to inquiries for the purpose of verification of the above statement.  This includes a Police (Criminal Background) check.  It is understood that the above information will be held in strict confidence.  I must renew this application each six (6) months thereafter if I desire my application to remain active.  I know that I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true circumstances.  Cooperation includes attending prescheduled meetings, responding to correspondence (mail) within the time allocated, notifying any changes in address and completing and signing needed forms.  I understand failure or refusal to do so may result in my application being inactivated, delayed, termination of assistance, or eviction.

Signatures of all household adults:

                                                                                                                                Date                                                                       

                                                                                                                                Date                                                                       

************************************FOR OFFICE USE ONLY***********************************

1.  Does the applicant require assistance from a family member or provider?                                                                           

2.  Does the applicant require special accommodations as a handicapped person?                                                                

3.  Is the applicant’s income within eligibility guidelines?                                                                                                           

4.  Is the applicant ELIGIBLE/INELIGBLE/INCOMPLETE?                                                                                                         

APPLICATION STATUS:

Date Cancelled:                                                                                    Reason:                                                                                 

Date Renewed:                                                                                     Date Renewed:                                                                    

Date Renewed:                                                                                     Date Renewed:                                                                    

Signature of MHA Representative                                                                   Date

Please explain in your own words what your current living situation is, and why you are applying for housing assistance and any other information you feel is important for consideration on your application.