waitingListPreApplication

Applicant Information

IP Address: 3.235.25.27

First Name: *

Last Name: *

Social Security Number: *

Applicant Information

Family Members

Reasonable Accommodation

		Needs Accommodation
	Explain:

Applicant Questions

If any of this information is incorrect or needs to be updated, please contact the housing authority.

Waiting Lists To Apply To

Applicant Information

Head of Household

	First Name:
	Middle Initial:
	Last name:
*Required	Birth Date: *	(mm / dd / yyyy)
*Required	Gender: *
		Has Disability
*Required	Primary Race: *
*Required		Hispanic Not Hispanic

Reasonable Accommodation

		Needs Accommodation
	Explain:

Annual Income

	Pension:
	SSI:
	Wages:
	Social Security:
	TANF:
	Unemployment:
	Child Support:
	Other non-Wage:

Additional Info

Current Residence Information

Move In Date:

(mm / dd / yyyy)

Rent / Own:

Rent Own

Rental Amount:

Address Line 1:

Address Line 2:

Apartment/Unit Number:

Zip Code:

City:

State:

Reason you are looking to move:

Current Landlord Information

Landlord Name:

Landlord Phone #:

( ) -

Landlord Address Line 1:

Landlord Address Line 2:

Apartment/Unit Number:

Zip Code:

City:

State:

References

Reference 1 Name:

Relation:

Phone #:

( ) -

Reference 2 Name:

Relation:

Phone #:

( ) -

Reference 3 Name:

Relation:

Phone #:

( ) -

Applicant Questions

Contact Information

Email:

Primary Phone:

( ) -

Secondary Phone:

( ) -

Primary Mailing Address

Address Line 1: *

Address Line 2:

Apartment/Unit Number:

Zip Code: *

City: *

State: *

Secondary Mailing Address

Address Line 1:

Address Line 2:

Apartment/Unit Number:

Zip Code:

City:

State:

Waiting List Preferences

Waiting Lists To Apply To

Agreement

IP Address: 3.235.25.27

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. Any person who knowingly or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at **208 (a) (6), (7) and (8).** Violation of these provisions are cited as violations of 42 U.S.C. Section **408 (a) (6), (7) and (8).**

The above information is correct and complete to the best of my knowledge.

Confirmation

Applicant Name:

Date / Time Applied: