Housing Services Mid Michigan

Housing Services Mid Michigan
Mainstream Voucher Pre-Application

In order to qualify for a Mainstream Voucher from Housing Services Mid Michigan either the head of the household, co-head, or spouse must be permanently disabled as verified by a certified physician or by proof of receipt of SSI or SSDI Social Security Administration award letter.
Last*
First*
Middle
Mailing Address*
City*
State*
Zip Code*
County*
Telephone Number*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Family Composition Section

For the following three sections please fill each section out, including yourself, for any members of your household over the age of 18.
Name*

First NameLast Name
Relationship to Head of Household*
Date of Birth*

MonthDayYear
Date
Disabled*

YesNo
Social Security Number*
Sex (as stated on ID)*

MaleFemale

Click for additional 18+ household member
Name

First NameLast Name
Relationship to Head of Household
Birth Date

MonthDayYear
Date
Disabled

YesNo
Social Security Number
Sex (as stated on ID)

MaleFemale

Click for additional 18+ household member
Name

First NameLast Name
Relationship to Head of Household
Birth Date

MonthDayYear
Date
Disabled

YesNo
Social Security Number
Sex (as stated on ID)

MaleFemale

Click for additional 18+ household member
Name

First NameLast Name
Relationship to Head of Household
Birth Date

MonthDayYear
Date
Social Security Number
Disabled

YesNo
Sex (as stated on ID)

MaleFemale

How many minor children in the household*
3 HUD Statistical Purpose Only (optional)

Black/African AmericanWhiteAsianAmerican Indian/Alaskan NativeNative Hawaiian/Other Pacific Islander
Check One

Hispanic or LatinoNot-Hispanic or Latino
Other Contacts - List two relatives or friends who know how to contact you:
Contact Name*

First NameLast Name
Phone #*
Address*
Contact Name*

First NameLast Name
Phone #*
Address*
Have you or anyone in your family ever been convicted of any crime other than traffic violations?*

noyes If "yes", please explain:
Please explain conviction:
By signing the application below, you are allowing HSMM to run a background check on all adults over the age of 18 in the household, prior to being offered a Mainstream Voucher. All personal information requested will only be used to run a background check on all adults in the household and to place the household on the Mainstream Voucher Waitlist.

Federal Law prohibits HSMM from providing subsidies to individuals who are currently engaged in illegal drug activity; are fugitive felons or parole violators; have been convicted of producing Methamphetamines on federally assisted housing property; any sex offender required to register with a State program; those engaged in illegal drug or alcohol abuse that threatens the health, safety and peaceful enjoyment of the premises; and anyone evicted from federally assisted housing for drug-related activity within the last 3 years.

In order to qualify for a Mainstream Voucher from Housing Services Mid Michigan either the head of the household, co-head, or spouse must be permanently disabled as verified by a certified physician or by proof of receipt of SSI or SSDI.

By signing this application, I/we declare that all of my/our responses are true and complete and I/we authorize Housing Services Mid Michigan (HSMM) to verify this information. Any false statement on this application can lead to the rejection of this application or immediate termination of your lease. I/we understand that in order for my/our application to remain current I/we must notify HSMM of any change in address.
Head of Household Signature*

Clear
Date*

MonthDayYear
Spouse or Co-head Signature

Clear
Date

MonthDayYear
"HSMM is an equal opportunity provider"
Time Stamp*

MonthDayYear
Date
Hour MinutesAM/PM Option
You can upload your proof of disabilities below.

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Housing Services Mid Michigan

Family Composition Section