Application Form

1
Preferred Housing Selection* This field is required.The Housing Authority, City of Spencer, operates in the City of Spencer, Roane County, West Virginia, and has three apartment complexes with its own waiting list. Please check the box of the area in which you wish to be put on the waiting list. You may check multiple boxes but you are required to check at least one.
Marcap Manor
Sunset Apartments
Ann Street Apartments
2
Applicant Name (Head of Household)* This field is required.
First Name
Last Name
3
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Home Phone Number
Area Code
Phone Number
6
Cell Phone Number
Area Code
Phone Number
7
Email Address
example@example.com
8
Household residents* This field is required.List below the names of ALL persons who will reside in the household including the head of household. If you require additional space, please provide information on a separate sheet and include with your final application package. Use the tab key to move from left to right on each row.
Last Name
First Name
Middle Name
Date of Birth (mm/dd/yy)
Sex
Race
Student
Social Security Number
Relationship to Head of Household
Resident #1 (Head of Household)
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Male
Female
Row 0, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 0, Column 5
Yes
No
Row 0, Column 6
Row 0, Column 7
Row 0, Column 8
Resident #2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Male
Female
Row 1, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 1, Column 5
Yes
No
Row 1, Column 6
Row 1, Column 7
Row 1, Column 8
Resident #3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Male
Female
Row 2, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 2, Column 5
Yes
No
Row 2, Column 6
Row 2, Column 7
Row 2, Column 8
Resident #4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Male
Female
Row 3, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 3, Column 5
Yes
No
Row 3, Column 6
Row 3, Column 7
Row 3, Column 8
Resident #5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Male
Female
Row 4, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 4, Column 5
Yes
No
Row 4, Column 6
Row 4, Column 7
Row 4, Column 8
Resident #6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Male
Female
Row 5, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 5, Column 5
Yes
No
Row 5, Column 6
Row 5, Column 7
Row 5, Column 8
Resident #7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Male
Female
Row 6, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 6, Column 5
Yes
No
Row 6, Column 6
Row 6, Column 7
Row 6, Column 8
Resident #8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Male
Female
Row 7, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 7, Column 5
Yes
No
Row 7, Column 6
Row 7, Column 7
Row 7, Column 8
Resident #9
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Male
Female
Row 8, Column 4
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 8, Column 5
Yes
No
Row 8, Column 6
Row 8, Column 7
Row 8, Column 8
Resident #1 (Head of Household)
Resident #2
Resident #3
Resident #4
Resident #5
Resident #6
Resident #7
Resident #8
Resident #9
Last Name
Row 0, Column 0
First Name
Row 0, Column 1
Middle Name
Row 0, Column 2
Date of Birth (mm/dd/yy)
Row 0, Column 3
Sex
Male
Female
Row 0, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 0, Column 5
Student
Yes
No
Row 0, Column 6
Social Security Number
Row 0, Column 7
Relationship to Head of Household
Row 0, Column 8
Last Name
Row 1, Column 0
First Name
Row 1, Column 1
Middle Name
Row 1, Column 2
Date of Birth (mm/dd/yy)
Row 1, Column 3
Sex
Male
Female
Row 1, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 1, Column 5
Student
Yes
No
Row 1, Column 6
Social Security Number
Row 1, Column 7
Relationship to Head of Household
Row 1, Column 8
Last Name
Row 2, Column 0
First Name
Row 2, Column 1
Middle Name
Row 2, Column 2
Date of Birth (mm/dd/yy)
Row 2, Column 3
Sex
Male
Female
Row 2, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 2, Column 5
Student
Yes
No
Row 2, Column 6
Social Security Number
Row 2, Column 7
Relationship to Head of Household
Row 2, Column 8
Last Name
Row 3, Column 0
First Name
Row 3, Column 1
Middle Name
Row 3, Column 2
Date of Birth (mm/dd/yy)
Row 3, Column 3
Sex
Male
Female
Row 3, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 3, Column 5
Student
Yes
No
Row 3, Column 6
Social Security Number
Row 3, Column 7
Relationship to Head of Household
Row 3, Column 8
Last Name
Row 4, Column 0
First Name
Row 4, Column 1
Middle Name
Row 4, Column 2
Date of Birth (mm/dd/yy)
Row 4, Column 3
Sex
Male
Female
Row 4, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 4, Column 5
Student
Yes
No
Row 4, Column 6
Social Security Number
Row 4, Column 7
Relationship to Head of Household
Row 4, Column 8
Last Name
Row 5, Column 0
First Name
Row 5, Column 1
Middle Name
Row 5, Column 2
Date of Birth (mm/dd/yy)
Row 5, Column 3
Sex
Male
Female
Row 5, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 5, Column 5
Student
Yes
No
Row 5, Column 6
Social Security Number
Row 5, Column 7
Relationship to Head of Household
Row 5, Column 8
Last Name
Row 6, Column 0
First Name
Row 6, Column 1
Middle Name
Row 6, Column 2
Date of Birth (mm/dd/yy)
Row 6, Column 3
Sex
Male
Female
Row 6, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 6, Column 5
Student
Yes
No
Row 6, Column 6
Social Security Number
Row 6, Column 7
Relationship to Head of Household
Row 6, Column 8
Last Name
Row 7, Column 0
First Name
Row 7, Column 1
Middle Name
Row 7, Column 2
Date of Birth (mm/dd/yy)
Row 7, Column 3
Sex
Male
Female
Row 7, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 7, Column 5
Student
Yes
No
Row 7, Column 6
Social Security Number
Row 7, Column 7
Relationship to Head of Household
Row 7, Column 8
Last Name
Row 8, Column 0
First Name
Row 8, Column 1
Middle Name
Row 8, Column 2
Date of Birth (mm/dd/yy)
Row 8, Column 3
Sex
Male
Female
Row 8, Column 4
Race
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
White
Row 8, Column 5
Student
Yes
No
Row 8, Column 6
Social Security Number
Row 8, Column 7
Relationship to Head of Household
Row 8, Column 8
1 of 9
9
Income Disclosure* This field is required.Please list all income received on a monthly basis for ALL household members.
Resident Name
Source of Income
Monthly Amount
Resident Name 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Resident Name 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Resident Name 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Resident Name 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Resident Name 1
Resident Name 2
Resident Name 3
Resident Name 4
Resident Name
Row 0, Column 0
Source of Income
Row 0, Column 1
Monthly Amount
Row 0, Column 2
Resident Name
Row 1, Column 0
Source of Income
Row 1, Column 1
Monthly Amount
Row 1, Column 2
Resident Name
Row 2, Column 0
Source of Income
Row 2, Column 1
Monthly Amount
Row 2, Column 2
Resident Name
Row 3, Column 0
Source of Income
Row 3, Column 1
Monthly Amount
Row 3, Column 2
1 of 4
10
Do you have a checking or savings account, or own any Certificates of Deposit, stocks, bonds, etc.?* This field is required.
YESNO
11
If yes, describe the type of asset(s).
Huge
Large
Normal
Small
Ok
Ok
12
What is the market value of all assets?
13
Do you own any real estate?
YESNO
14
What is the address?
15
Have you sold any real estate in the past two years?
YESNO
16
If yes, what was the address?
17
Will the information you are providing be for your current landlord or a previous landlord?
Current
Previous
18
Landlord NamePlease enter the name of your landlord.
First Name
Last Name
19
Landlord Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
Landlord Phone Number
Area Code
Phone Number
21
Criminal Record* This field is required.Have you or any of the intended occupants been convicted of a crime, including but not limited to: drug-related or violent criminal activity, use, distribution, or manufacturing of a controlled substance?
YESNO
22
Please explain the nature of the crime. Include the date convicted, file number, and county/state where the crime was committed.
23
Is any member of the household subject to a lifetime sex offender registration program in any state?Failure to respond to this question may jeopardize the approval of your application.
YESNO
24
Please list any names any member of the household has used, including maiden names or any alias.
Huge
Large
Normal
Small
Ok
Ok
25
Handicap-accessibility: Do any member(s) of the household request a handicapped-accessible apartment?
YESNO
26
Have you or anyone in your household ever been a tenant of any housing authority or any other federal housing programs?
YESNO
27
Are you currently receiving housing assistance?
YESNO
28
Have you or anyone in your household ever moved from a rental unit while still owing rent or been evicted from a rental unit?
YESNO
29
You have applied for public housing occupancy and in order for your application to be considered complete and approved, we must have additional information. I will provide proof of income for all household residents
Please Select
Please Select
Yes
Proof of income
Please Select
Please Select
Yes
Divorce papers if currently married and partner is not on the application
Please Select
Please Select
Yes
I consent to a criminal background check *
Please Select
Please Select
Yes
Social security card copies for all residents
Please Select
Please Select
Yes
Legal verification that I am not receiving child support payments
Please Select
Please Select
Yes
Birth certificate copies for all residents
Please Select
Please Select
Yes
Recommendation of the previous landlord
30
Everyone 18 years of age or older in your household must complete the form below. By providing your electronic signature: * This field is required.
Name
Date of birth
Social security number
Electronic signature
Adult resident 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Adult resident 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Adult resident 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Adult resident 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Adult resident 1
Adult resident 2
Adult resident 3
Adult resident 4
Name
Row 0, Column 0
Date of birth
Row 0, Column 1
Social security number
Row 0, Column 2
Electronic signature
Row 0, Column 3
Name
Row 1, Column 0
Date of birth
Row 1, Column 1
Social security number
Row 1, Column 2
Electronic signature
Row 1, Column 3
Name
Row 2, Column 0
Date of birth
Row 2, Column 1
Social security number
Row 2, Column 2
Electronic signature
Row 2, Column 3
Name
Row 3, Column 0
Date of birth
Row 3, Column 1
Social security number
Row 3, Column 2
Electronic signature
Row 3, Column 3
1 of 4
31
Verifications and Signatures* This field is required.All adult members of the household must sign below. By entering your name, you are verifying the following: I/We understand that the Housing Authority, City of Spencer, is relying on this information to determine my/our eligibility, and will investigate employment records, rental history, credit history, criminal/public records as well as any source of income or assets held by household members. The information obtained by SHA and/or its agents will be used for management purposes only and will be held confidential. I/We certify that all the information given above is true and complete. I/We understand that pursuant to Section 1001 of Title XVIII of the U.S. Code, any misrepresentation or willfully false statements made to Department or Agency of the U.S. Government is grounds for denial or termination of assistance and punishable by fine and/or imprisonment.
Name
Signature
Date
Adult resident 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Adult resident 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Adult resident 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Adult resident 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Adult resident 1
Adult resident 2
Adult resident 3
Adult resident 4
Name
Row 0, Column 0
Signature
Row 0, Column 1
Date
Row 0, Column 2
Name
Row 1, Column 0
Signature
Row 1, Column 1
Date
Row 1, Column 2
Name
Row 2, Column 0
Signature
Row 2, Column 1
Date
Row 2, Column 2
Name
Row 3, Column 0
Signature
Row 3, Column 1
Date
Row 3, Column 2
1 of 4
Should be Empty: