Rochester Housing Charities--Housing Application

Housing Application

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Applicant Information
Name

First NameMiddle NameLast Name
Present Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #
Format: (000) 000-0000.
Other Phone #
Format: (000) 000-0000.
Email Address
example@example.com
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Race (Optional)
Ethnicity (Optional)
Served in US Military?
Currently homeless?
Household Information
Are there any member of this household is subject to a lifetime state sex offender registration program in any state.
Head of Household
Name

First NameMiddle NameLast Name
Social Security Number
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Disabled?
Pregnant?
Additional Household member 1
Name

First NameMiddle NameLast Name
Social Security Number
Relation To applicant
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Disabled?
Pregnant?
Additional Household member 2
Name

First NameMiddle NameLast Name
Social Security Number
Relation To applicant
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Disabled?
Pregnant?
Additional Household member 3
Name

First NameMiddle NameLast Name
Social Security Number
Relation To applicant
Gender
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Disabled?
Pregnant?
Unit Accommodations Needed:
TOTAL Annual income for all family members
$USD
SOURCE(s) Of income for the family check ALL that apply:
Applying to Location(s):
Typing your name in the section below carries the same level of authority as a pen-based signature. This gives Rochester Housing and its agents permission to fully process this application, including independently verifying the information provided.
Signature (Head of Household)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Rochester Housing Charities | 5 Antionette Dr. | Rochester, NY 14623
Please verify that you are human
Should be Empty:

Housing Application

Applicant Information

Household Information

Head of Household

Additional Household member 1

Additional Household member 2

Additional Household member 3