waitingListPreApplication

Applicant Information

IP Address: 54.80.252.84

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: 54.80.252.84

Thank you for applying to the Waiting List. You will be contacted via United States First Class Mail once you reach the top of the waiting list. It is your responsibility to update your application with any and all mailing address changes. You may update your application using the www.senecamha.org or putting the change in writing to our office. **Attention** Once your name reaches the top of the waiting list you will be required to provide our office with proof of residency dated within 30 days of application if you desire to port outside of our jurisdiction.

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

Confirmation

Applicant Name:

Date / Time Applied: