Head of Household and Spouse:

 

 * Head of Household Name:              Spouse Name:

 * Address:                       Spouse Address:

 * City:      St:            Zip:              Spouse City:    Spouse St: 

                                                                                                                          Spouse Zip:

 * Phone:()                                                                    Spouse Phone:()

 * Have you or your spouse ever used different names other than indicated above, such as maiden names?         Pick One No Yes

 **If yes, indicate person and name used:

 

 * Have you or your spouse or ever received rental assistance from a HUD Program?   Pick One No Yes

**If yes, indicate program(s):

 

Household Composition: (Including those indicated above) PLEASE PRINT

 

    * Full Name                                                                 * Relation                    *Sex *Age  *Birth Date      *Occupation                           * SS#                  * Race  

1.         

2.  

3.  

4.  

5.  

6.  

 

Income from Employment

 

   *Member #    *Employer                                                      *Mailing Address                                                                *Telephone#           *Gross Wkly Income

1.   ()   $

2.   ()   $

3.   ()   $

 

Income from Other Sources: (SS, SSI, Pensions, Public Asst., Unemployment, Alimony, Child Support, etc.)

 

    *Member #    *Type of Income                                          *Address for Verification                                                      *Gross Wkly Amt

1.      $

2.      $

3.      $

 

Assets:

 

             Member #           Description                                                                             Est. Current Value                                                                    Gross Monthly Amt

1.                    $           $

2.                    $           $

3.                    $           $

 

Race and Ethnicity of Head of Household:

 

HUD requires us to report the race and ethnicity of the Head of Household for all applicants.  This response is optional and your entry will have no bearing on your eligibility for housing.

 

Race of Household Head:  Select One White Black Native American/Alaskan/Hawaiian Asian/Pacific Islander

Ethnicity of Household Head: Select One Non-Hispanic Hispanic  

                                                                                                                                                                                                               

 

 *HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD EVER BEEN ARRESTED OR CONVICTED OF ANY CRIMINAL ACTIVITY?   Select One No Yes  

 **IF YES, PLEASE EXPLAIN:

 

Allowances

 

Dependent Deductions:  Enter the names, separated by commas, of all household members other than head or spouse who are:

Under age 18 

18 or older and full time student

18 or older and disabled or handicapped

Each family member verified above = $480 deduction from Annual Income for computing rent.

 

Childcare Expenses:  List amounts your pay for the care of children or foster children in the household under the age of 13 to permit an adult family member(s) to work or go to school:
   $

List names of children for who care is provided:

List the name of any adult member of the family able to work or go to school because of the childcare paid indicated above:

Indicate the name of your childcare provider:

Indicate the address of your childcare provider:

 

Handicapped Care/Expenses:

List amounts you pay for care of a handicapped/disabled family member to permit an adult family member to work: $

Names of members who amounts are claimed for:

Names of care provider:  

Address of care provider:

 

Elderly Household Allowances: An elderly household is one in which the head, spouse, or sole member is 62 or older, disabled or handicapped. 

Such households qualify for a $400 deduction in computing rent.  Select to claim the deduction: Yes No

 

Special Needs Questionnaire

 

Do you, or does any member of your family need any of the following as a direct result of a disability?

A separate bedroom       A barrier-free unit             One Level unit         Unit for Vision-Impaired            Unit for Hearing –Impaired  

BR/Bath on 1^st Floor       Other:

 

If you checked any of the previous listed categories of units, please explain exactly what you need to accommodate your disability:
 

 What is the name of the family member who need the features or live-in- aide?

Who should be contacted to verify that the individual in your family who you have indicated as needing the feature(s) identified or live-in-aide has a disability and needs the reasonable accommodation requested as a direct result of his/her disability?  Indicate name, address & phone number:
  

 

EMERGENCY CONTACT INFORMATION

 *Nearest Relative:

 *Name:  

*Address:  

*Relationship:                 *Phone Number: ()

 

 *Person to notify in case of an Emergency:

*Name:  

*Address:  

*Relationship:                   *Phone Number ()

 

 *Other Relatives or Friends:

 

*Name:  

*Address:  

*Relationship:                 *Phone Number ()

 

*Name:  

*Address:  

*Relationship:                 *Phone Number ()

 

 

LANDLORD HISTORY FROM PRESENT TO PAST THREE YEARS 

 

 *Present Landlord:

 *Landlord Name                *Years         *Months       

 *Address      *Monthly Rent $       

 *Phone Number ()  

 

 *Previous Landlord:

 *Landlord Name                *Years         *Months       

 *Address      *Monthly Rent $       

 *Phone Number ()  

 

Previous Landlord:

Landlord Name          Years   Months

Address      Monthly Rent $

Phone Number ()

 

Previous Landlord:

Landlord Name          Years   Months

Address      Monthly Rent $

Phone Number ()