Application for Admission or Continued Occupancy
Name
Address
Date of Application
Time of Application
Last Reexamination
Current Examination
Phone Number
Project Number
Site
Size Unit
Unit Number
Date Leased
Race Code
Choose one
Regular
Elderly
Disabled
Choose One
Married
Single
Divorced
Separated
Widowed
I
Family Members Registered
Name
Relation
DOB
Sex
Social Security Number
1
2
3
4
5
6
7
8
9
10
II.
Annual Income Data
Family Member
Source
Rate
Type
Next 12 Months
1
2
3
4
5
6
Plus income from assets (Next 12 Months)
Total Annual Income (Next 12 Months)
III.
Income for eligibility
Applicable income limit
IV.
Assets
Type
Amount
1
2
3
4
5
Total Assets (Amount)
V. Preference
Substandard Housing
Involuntary Displacement
More than 50% of Income for rent
Residency
Broad Range
All information furnished by me is true and accurate to the best of my knowledge. I understand that providing false information will be grounds for declaring this application ineligible.
Applicant:
Information taken by:
Please answer the following questions and read the notice to applicants:
1. What is your reason for wanting in Public Housing?
2Have you ever lived in Public Housing? (If so, which city and project?)
3. Do you have a Police Record for any offense? (If yes, specify nature of offense)
I have read and understand the above notice. All information furnished by me is true and accurate to the best of my knowledge:
Applicant/Tenant
Date
-
Month
-
Day
Year
Date
Application taken by:
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