SPC Graduate HCV Application 2018

Stanislaus Regional Housing Authority is an equal opportunity housing provider. Stanislaus Regional Housing Authority does not discriminate on the basis of disability status in its admission or access to housing programs. If you need assistance completing this form, or if you require assistance in another language, please call (209) 557-2000.

Si necesita ayuda para completar el proceso de solicitud, llame al 209-557-2000.
Housing Choice Voucher Application

Stanislaus Regional Housing Authority
Shelter Plus Care (SPC) Graduates
and
Permanents Supportive Housing Graduates
Applications are limited to Stanislaus County residents who qualify for the following preference:

Applicant families who meet the definition of family/elderly/or disabled who are:

-Participating in the Shelter Plus Care Program (SPC), and who are graduating from the Shelter plus Care Program and certified as “graduating” from the support service agencies known as Behavioral Health and Recovery Services or Community Impact Central Valley

-Participating in a Permanent Supportive Housing Program who are graduating from the program and certified as “graduating” from the support service agency providing the permanent supportive housing. A Permanent Supportive Housing Graduate Form must be submitted with the application.

Note: Failure to provide true and complete information regarding residence may result in denial of waitlist placement.
By clicking next, you are confirming that you meet the preference criteria to complete this application.

Will the Head of Household or Co-head of Household be graduating from the Shelter Plus Care (SPC) program or PSH? *

Yes No
Based on your response, you are not eligible to apply at this time

In order to apply, applicants must be graduating from the Shelter Plus Care (SPC) program or Permanent Supporting Housing.
Please select the name of the referring Shelter Plus Care (SPC) agency/PSH agency: *

BHRS-Behavioral Health and Recovery Services CICV-Community Impact Central Valley
What is the name of the SPC/PSH case manager or housing specialist? *
Do you currently reside in a unit where the owner/landlord will accept Housing Choice Voucher? (Section 8) *

Yes No
Will the owner/landlord rent to you under the Housing Choice Voucher Program? (Section 8) *

Yes No

Household Information

Complete the following information about the applicant's household.
First Name *
Middle Initial
Last Name *
Does Head of Household have a Social Security Number, or a Tax ID Number (TIN)? *

Yes No
Social Security Number or TIN *
Date of Birth *
Date of Birth *

Month Day Year
Is there a Co-Head of Household? *

Yes No
First Name (Co-Head) *
Middle Initial
Last Name *
Does Co-Head of Household have a Social Security Number, or a Tax ID Number (TIN)? *

Yes No
Social Security Number or TIN *
Date of Birth *
Date of Birth *

Month Day Year
Physical Address (must be in Stanislaus County) *
Number and street of physical address
City *
State
Zip Code *
Mailing Address (if different from physical address)

Mailing address or P.O. Box

Street Address Line 2

City State

Zip Code
Phone Number *

Area Code Phone Number
Cell Phone or Message Number *

Area Code Phone Number
Email
Enter email address to receive a confirmation of application
Head or Co-head is a US Veteran, current service person, or surviving spouse?: *

Yes No
Head or Co-head is 62 years of age or older; or is disabled?: *

Yes No
Family Size *
Including yourself, the number of persons who will live with you under the HCV program
Number of children (under 18) living in household *
(must have at least 51% custody to claim children in household)
Total Gross Monthly Income (before taxes or deductions) *
Include income for all members from all sources
Source(s) of Income/Benefits: (check all that apply) *

Social Security (SSA) Supplemental Social Security (SSI) AFDC/TANF (CalWorks) Unemployment (UIB/EDD) Employment/Wages Self-Employed Pension or Retirement VA Pension/Benefits Workman's Compensation/State Disability (SDI) Child Support/Alimony
Monthly Rent *
Housing Circumstances: select your current housing circumstance *

Renting from a Landlord or Property Management, paying full rent Shared Housing/Renting a room Mobile Home (own home, paying space rent) Group Home Congregate Housing Single Room Occupancy (SRO)
Is there a disabled person in the household who requires a Reasonable Accommodation in order to have access to the Housing Authority's programs? *

Yes No
If yes, please briefly describe the accommodation.
Did a service provider, or other individual, complete this application on behalf of the applicant? *

Yes No
What is the name and contact information of the person who completed the application *
Applicants are considered for housing without regard to age, race, color, familial status, religion, sex, disability, or national origin. To help the Housing Authority comply with Federal/State record keeping and other legal requirements, please check the appropriate box.
Race (check all that apply) *

White Black/African American Asian Native American or Alaskan Native Native Hawaiian or other Pacific Islander Decline to answer
Ethnicity (choose one) *

Hispanic Non-Hispanic Decline to answer
VAWA (Violence Against Women Act)

Protections for Applicants
If you otherwise qualify for assistance under the Housing Choice Voucher Program, you cannot be denied admission or denied assistance because you are or have been a victim of domestic violence, dating violence, sexual assault, or stalking.
For more information on VAWA, contactStanislaus Regional Housing Authority at (209) 557-2000.
Stanislaus Regional Housing Authority is an equal opportunity housing provider. Stanislaus Regional Housing Authority does not discriminate on the basis of disability status in its admission or access to housing programs. If you need assistance completing this form, or if you require assistance in another language, please call (209) 557-2000 for assistance.
DISCLAIMER: Submission of this application does not guarantee placement on a Waiting List, eligibility, or an offer of housing.
Date

Month Day Year
Date
Should be Empty:

Housing Choice Voucher Application

By clicking next, you are confirming that you meet the preference criteria to complete this application.

Household Information