Request for Portability

Housing Authority of Champaign County

2008 N Market St. Champaign, IL 61822
WARNING:A portion of the application requires your landlord's information and signature. We recommend completing this section with your landlord present. If this is not feasible, please contact our Eligibility Specialist, Carlos Ujueta, at extension 5030.
REQUEST FOR PORTABILITY
Participant Name print (First and Last Name)
Last 4 of SSN
Email
example@example.com
Home Telephone
Work Telephone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Porting Housing Authority Information

(For Housing Authority Use Only, Leave Blank if You are The Client)
Name of Housing Authority
Address
Name of Contact Person
Email
example@example.com
Telephone #
Fax
Date

MonthDayYear
Date
Receiving Housing Authority to complete and return to portability@hacc.net

The household has requested to port their voucher to your jurisdiction. Please indicate below whether you will be billing or absorbing this client
Please indicate below whether you will be absorbing this client (Please Do Not Select if Unsure)

Absorb
Please indicate below whether you will be billing this client (Please Do Not Select if Unsure)

Bill
By signing below, I am certifying that I wish for the Housing Authority of Champaign County (HACC) to port my paperwork to the Housing Authority listed above. I understand that I must remain in good standing with my current landlord and compliant with HACC at all times for the request to be approved. I understand and acknowledge it is my responsibility to contact the porting Housing Authority and HACC, in writing, if I choose to cancel my port request. I understand that HACC may not extend my voucher.
Signature

Clear
Any individual with a disability may request a reasonable accommodation at any time during the application process or during participation in the Housing Choice Voucher Program by contacting the Housing Authority of Champaign County Office at 217-378-7100.
Participant Name (Print: First, Last)
Date

MonthDayYear
Date
Last 4 of SSN
Email
example@example.com
Home Telephone
Work Telephone
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OWNER INFORMATION
Name (PRINT

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Work Telephone
Please enter a valid phone number.
Home Telephone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Effective Date of Termination

MonthDayYear
Date
Participant Signature

Clear
Date

MonthDayYear
Date
Owner Signature (Please have them sign this - complete form with Owner)

Clear
Date

MonthDayYear
Date
To be completed by the landlord
Is the Tenant in compliance with all terms and conditions of the lease agreement?

YesNo
if no, please explain:
Should be Empty:

Housing Authority of Champaign County

OWNER INFORMATION