• Information for Program Eligibility

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • FAMILY COMPOSITION

    List ALL household members (including yourself) who will live in the unit. Children listed must live with you at least 50% of the time and MAY NOT receive housing assistance in another household.

  • Family Member #1

    YOURSELF/HEAD OF HOUESHOLD
  • Birth Date*
     / /
  • Race
  • Ethnicity

  • Family Member #2

  • Birth Date*
     / /

  • Family Member #3

  • Birth Date*
     / /

  • Family Member #4

  • Birth Date*
     / /

  • Family Member #5

  • Birth Date*
     / /

  • Family Member #6

  • Birth Date*
     / /

  • Family Member #7

  • Birth Date*
     / /

  • Family Member #8

  • Birth Date*
     / /

  • Family Member #9

  • Birth Date*
     / /

  • Family Member #10

  • Birth Date*
     / /

  • Family Member #11

  • Birth Date*
     / /
  • Do you expect any changes to your household composition?*
  • Is anyone over age 18 taking one or more classes at a college or technical school?*
  • Do you pay for childcare for children 12 years or younger while a household member is employed or attending school?*
  • Have you or any household member used, possessed, or trafficked illegal drugs in the past 2 years?*
  • Have you or any household member been involved in any violent criminal activity in the past 2 years?*
  • Are you or anyone in your household a registered sex offender?*

  • Income for all Household Members

    Please list ALL GROSS MONTHLY income coming into the household
  • Select ALL types of Income that are coming into your household

  • If an income applies to your household, it will ask for a number for which family member receives it. Use the number that you that household member under above. Example: Head of Household (youself) is #1.

  • Employment

  • Employment #1

  • Employment #2

  • County Financial Assistance

  • Select ALL types of County Financial Assistance the household receives

  • Child Support Income

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Social Security and/or RSDI (including income for minor children)

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Supplemental Security Income/SSI (including income for minor children)

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Veteran's Compensation

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Self-Employment Income OR Cashed Received for Odds Jobs

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Unemployment Benefits OR Severance Pay

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Alimony OR Spousal Maintenance

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Regular Payments from Pension (PERA, Railroad, etc.)

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Regular Payment from Annuities, Life Insurance, Inheritance, Insurance Settlements, Lottery, etc.

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Income from Rental Property

    IF MORE THAN ONE FAMILY MEMBER RECEIVES THIS INCOME SELECT ONLY ONE FAMILY MEMBER AND ADD ALL AMOUNTS TOGETHER AND ENTER THE TOTAL AMOUNT.

  • Regular Monetary Assistance form Others (rent, utilities, insurance, cellphone, gas, tobacco, etc.)

  • Other Income

  • Assets

  • Do you have cash on hand over $100?*
  • Do you have any Checking Accounts?*
  • Do you have any Savings Accounts?*
  • Do you have any Certificate of Deposits?*
  • Do you have any IRA Accounts?*
  • Do you have any Money Market Funds?*
  • Do you have any Annuities?*
  • Do you have any Stocks/Bonds/Mutual Funds?*
  • Do you have any US Savings Bonds?*
  • Do you have a Contract for Deed?*
  • Do you have any Real Estate/Property?*
  • Do you have any Business Assets?*
  • Have you disposed of any assets for less than Fair Market Value in the past 2 years?*
  • Date of Disposal*
     / /

  • Medical Expenses

    Only to be completed if head of household or spouse is elderly, disabled, or handicapped
  • Is the head of household or spouse elderly, disabled, or handicapped?*
  • Do you receive Medicare benefits?*
  • Do you receive Medical Assistance through the county?*
  • Do you pay for additional medical insurance? (Blue Cross, etc.)*
  • Are all your medical expenses covered by insurance or outside source?*

  • If all your medical expenses are not covered by insurance, indicate what expenses you are paying out of pocket on and the name of place below:

  • Select all out of pocket medical expenses that are applicable to you:
  • Do you have expenses for attendant care or special apparatus for a disabled or handicapped household member that is necessary for them to be employed? (do not count expenses paid by a family member or reimbursed by outside source)*

  • APPLICANT(S) STATEMENT:

    • I/We certify that the information given to Northwest Minnesota Multi-County Housing Authority on household composition, income, family assests, allowances, and decustions is accurate and complete to the best of my/our knowledge and belief.
    • I/We certify that false statements or information are punishable under Federal Law. I/We also understand that false statements or information are ground for termination of housing assistance and termination of tenancy.
    • I/We certify that any minor child(ren) listed reside in the unit at least 50% of the time. I/We also certify that any minor child(ren) listed are not receiving housing assistance through another household that I/we are aware of.
    • I/We authorize Northwest Minnesota Multi-County HRA to conduct a criminal background check for all adult household member (18 years of age and older) listed on this form.
  • Date*
     / /
  • Date*
     / /
  • Date*
     / /

  • If you believe you have been discriminated against, you may call the U.S. Dept. of HUD, Fair Housing and Equal Opportunity Chicago Rengial Office, Toll-Free Hot Line at 800-765-9372. TTY (312)353-7142.

    After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development on Form HUD-50058 (Tenant Data Summary). See the Federal Privacy Act Statement for more information about its use.

    If you are anyone in your household is a person with disabilities, and you require a specific accommodation to fully utilitze our programs and services, please contact the housing authority at 218-637-2431

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