Bernie Housing Authority Application

Application 2026

Complete the application using the fields and groupings from the referenced PDF. Preserve the original wording and organization as closely as possible.
Household Members
Head of Household Full Name

First NameMiddle NameLast Name
Head of Household Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Head of Household SSN
Head of Household Sex
Head of Household Race
Head of Household Ethnicity
Head of Household Language
Head of Household Student Status
Head of Household Disability Status
Head of Household Citizenship Status
Head of Household Relation to Head of Household
Head of Household Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Head of Household Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Head of Household Email
example@example.com
Head of Household Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Co-Head Full Name

First NameMiddle NameLast Name
Co-Head Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Co-Head SSN
Co-Head Sex
Co-Head Race
Co-Head Ethnicity
Co-Head Language
Co-Head Student Status
Co-Head Disability Status
Co-Head Citizenship Status
Co-Head Relation to Head of Household
Co-Head Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Co-Head Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Co-Head Email
example@example.com
Co-Head Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Additional Household Member #1 Full Name

First NameMiddle NameLast Name
Additional Household Member #1 Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Household Member #1 SSN
Additional Household Member #1 Sex
Additional Household Member #1 Race
Additional Household Member #1 Ethnicity
Additional Household Member #1 Language
Additional Household Member #1 Student Status
Additional Household Member #1 Disability Status
Additional Household Member #1 Citizenship Status
Household Composition and Background
How many people live in your household?
Will the number of people in your household change in the next 12 months?
If yes, explain the expected change.
Have you received any of the following types of assistance in the past 12 months?

Other
If you selected Other, please describe.
Have you ever been evicted from a residence?
If yes, please explain.
Has any adult household member ever been convicted of a crime?
If yes, please explain.
Does anyone in the household need a reasonable accommodation?
If yes, describe the accommodation requested.
Do you currently have any pets?
If yes, what kinds of pets do you have?

Other
If Other, please specify pet type.
How many pets do you have?
Do you anticipate any change in pet ownership in the next 12 months?
If yes, explain the expected change in pet ownership.
Has your household received assistance from this program before?
If yes, please describe when and what type of assistance was received.
Please provide any additional information about your household composition or background.
Income and Employment
Household member(s) with employment income

Other
Employment status
Employer name
Employer phone
Employer address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Job title
Pay frequency
Gross pay amount
Gross pay amount unit
Average hours worked per week
Employment start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employment is
Income types received from this job

Other
Other job income type
Expected gross income this month
Expected gross income next month
Do you have more than one job?
Second employer name
Second job title
Second job pay frequency
Second job gross pay amount
Second job gross pay amount unit
Other income sources

Other
Other income source - specify
Other income amount
Other income frequency
Do you receive child support?
Child support amount
Child support frequency
Child support source name
Do you pay child support?
Child support paid amount
Child support paid frequency
Do you pay for childcare so you can work or attend job training?
Childcare provider name
Childcare provider phone
Childcare provider address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Childcare cost amount
Childcare cost frequency
Do you expect any employment change in the next 3 months?
Expected change type

Other
Expected change effective date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Describe expected change
Are you self-employed?
Business or trade name
Self-employment description
Estimated monthly business income
Benefits, Medical, and Assets
Benefits Received

Other
Benefit Source / Agency
Monthly Benefit Amount
Benefit Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you or any household member have a disability or medical condition that affects daily activities?
Describe the disability or medical condition
Monthly Medical Expense Amount
Describe medical expenses
Do you or any household member pay for ongoing medical care or therapy?
Medical Provider Name
Type of Care or Therapy
Real Estate Owned

Other
Property Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Owner Name on Property
Estimated Property Value
Mortgage/Lien Holder
Outstanding Mortgage/Lien Amount
Bank Accounts Held

Other
Financial Institution Name
Account Holder Name
Current Account Balance
Other Assets Owned

Other
Asset Description
Estimated Asset Value
Has any asset been sold, transferred, given away, or disposed of in the last 5 years?
Date of Disposal

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Who received the asset?
Amount Received
Reason for Disposal
Do you have any burial funds or prepaid funeral arrangements?
Burial Fund / Provider Name
Burial Fund Value
Do you have any life insurance policies with cash value?
Insurance Company Name
Cash Value Amount
Assistance, Contacts, Certifications, and Signatures
Who can we contact about this application?

Other
Primary contact person's full name

First NameMiddle NameLast Name
Primary contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Primary contact email address
example@example.com
Primary contact relationship to applicant
Secondary contact person's full name

First NameMiddle NameLast Name
Secondary contact phone number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary contact email address
example@example.com
Secondary contact relationship to applicant
Can we leave voicemail messages?
Can we send text messages?
Can we send email messages?
Can we share information with the primary contact person?
Can we share information with the secondary contact person?
Adult member certification and consent
Adult member 1: I certify that the information provided in this application is true and complete to the best of my knowledge.
Adult member 1: I understand that providing false information may affect eligibility and benefits.
Adult member 1: I authorize verification of the information provided for eligibility determination.
Adult member 1: I understand I may be required to provide additional proof if requested.
Adult member 1 signature
Adult member 1 signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult member 2: I certify that the information provided in this application is true and complete to the best of my knowledge.
Adult member 2: I understand that providing false information may affect eligibility and benefits.
Adult member 2: I authorize verification of the information provided for eligibility determination.
Adult member 2: I understand I may be required to provide additional proof if requested.
Adult member 2 signature
Adult member 2 signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult member 3: I certify that the information provided in this application is true and complete to the best of my knowledge.
Adult member 3: I understand that providing false information may affect eligibility and benefits.
Adult member 3: I authorize verification of the information provided for eligibility determination.
Adult member 3: I understand I may be required to provide additional proof if requested.
Adult member 3 signature
Adult member 3 signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult member 4: I certify that the information provided in this application is true and complete to the best of my knowledge.
Adult member 4: I understand that providing false information may affect eligibility and benefits.
Adult member 4: I authorize verification of the information provided for eligibility determination.
Adult member 4: I understand I may be required to provide additional proof if requested.
Adult member 4 signature
Adult member 4 signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult member 5: I certify that the information provided in this application is true and complete to the best of my knowledge.
Adult member 5: I understand that providing false information may affect eligibility and benefits.
Adult member 5: I authorize verification of the information provided for eligibility determination.
Adult member 5: I understand I may be required to provide additional proof if requested.
Adult member 5 signature
Adult member 5 signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult member 6: I certify that the information provided in this application is true and complete to the best of my knowledge.
Adult member 6: I understand that providing false information may affect eligibility and benefits.
Adult member 6: I authorize verification of the information provided for eligibility determination.
Adult member 6: I understand I may be required to provide additional proof if requested.
Adult member 6 signature
Adult member 6 signature date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional information
Should be Empty:

Application 2026

Household Members

Household Composition and Background

Income and Employment

Benefits, Medical, and Assets

Assistance, Contacts, Certifications, and Signatures