| APPLICATION FOR
PUBLIC HOUSING HOUSING AUTHORITY OF THE CITY OF MUSKOGEE 220 North 40th Street, Muskogee, OK 74401 Honor Heights Towers (918) 687-6301 ext. Green Country Village (918) 687-5631 24 Port City Acres (918) 682-3672 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 IPlease
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 IIHousehold
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 IIITotal
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:
Section IVAssets: 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 VRental
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 VIPERSONAL
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 COMPOSITIONI
know I am required to report immediately in writing any changes in income
and any changes in household composition. REPORTING ON PRIOR HOUSING ASSISTANCEI
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 ASSISTANCEI
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. COOPERATIONThis
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.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||