Waiting List Application

469 East Ohio Street, Circleville, OH 43113-2034, , Phone: 740-477-1655 Fax: 740-477 9277 Note: PICCA gives priority to veterans and homeless persons.

How did you hear about PICCA Housing

NewspaperFriendReferralOther

Which location are you interested in?

Lincoln/Ohio HeightsPrairie View

If Lincoln/Ohio Heights, what number of bedrooms?

Efficiency2 Bedrooms3 Bedrooms4 Bedrooms

If Prairie View, what number of bedrooms?

1 Bedroom2 Bedroom

First Name

Last Name

Middle Initial

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone

Are you a veteran

Are you currently in a homeless shelter?

Date Entered?

Have a pet?

YesNo

How many adults in your household?

How many working individuals in household?

How many unemployed in household?

How many disabled in household?

How many children in household?

If there are children in your household, what are their ages?

TOTAL HOUSEHOLD INCOME (List Monthly Amounts)

YOU MUST MEET VERIFIABLE INCOME REQUIREMENTS TO BE PLACED ON THE WAITING LIST. ENTER MONTHLY AMOUNTS YOU RECEIVE - WE WILL CALL IF WE HAVE QUESTIONS

Wages

Number of Hours per Week

Child Support

Alimony

SSA

SSI

SSDI

Veterans Benefit

Pension

Other

Type

Are you now or will you be receiving Housing Assistance? (Section 8, Housing Choice Voucher, etc

YesNo

If yes, Source?

Amount

If PICCA is unable to offer you housing, do you grant permission for us to refer you to other Housing Programs, such as Rapid ReHousing, Permanent Supportive Housing, etc. if you are eligible?

YesNo

If permission is granted, sign here:

The application process requires us to obtain a credit report and verify information on your application by contacting former and current landlords, employers and others listed. Please keep your contact information current. By signing you agree this application only places you on a waiting list for the location and number of bedrooms you indicate. It is not an application to rent, or offer of a rental As units become ready to rent applicants will be contacted in the order they are placed on the list, and if still interested will then be required to complete background check at that time. When a unit becomes available, each person 18 years and older is required to fill out a BACKGROUND CHECK application and pay a $15.00 non-refundable fee. Unless updated this application will expire in 90 days

Signature

Today's Date

Date

NOTES

WAITING LIST APPLICATION