This application must be submitted electronically using this sytem to create a receipt
of application. Paper copies of this form cannot be accepted. The applicant family must qualify as a family as defined by HUD and be at least 62 years of age and/or qualify as a household with a disabled head of household or spouse.
Part 2: Household Information
(Where you currently live)
Mailing Address (If different from Legal)
(Where you currently receive mail)
List information for adults first, then children under age 18. Use "F"
or "M" to indicate sex. If a household member
qualifies for a reasonable accommodation due to a disability select "Y",
if not, select "N". List relationship of each
person to the Head of Household.
Part 3: Family Income and Assets
List total gross income (before taxes) and payment received by each family member
age 18 or older for wages, military pay, pensions, social security, SSI, welfare,
child support, unemployment business, profession, or any other source. Include
payments made to family members age 18 or older on behalf of other family members
under age 18.
List total cash value and total income received for assets owned by all family members.
Part 4:Eligibility and Preferences
Your response to the following statement will help determine your eligibility for
rental assistance and if you are entitiled to a preference when placed on the program's
waiting list. Select the approapriate responses for each question below.
Part 5: Supplemental and Optional Contact Information
You have the right to include as part of your application contact information for
a person or organization that may be able to help you resolve any issues that may
arise during your tenancy or to assist in providing any special care of services
you may require should you become a tenant. You are not required to provide
this contact information, but if you choose to do so, please click the "Add
Contact" button below to complete the form.mplete the form.
Part 6: U.S. Citizenship Notification and Certificationon
Housing may be contingent upon the submission and verification of evidence of citizenship
or eligible immigration status prior to the time housing is made available.
Based on the evidence submitted at that time, assistance may be prorated, denied
or terminated following appeals and informal hearing process.
I certify that the information on this form is ture and complete to the best of
my knowledge and belief. I understand that I can be fined up to $10,000 or
imprisoned up to five years if I furnish false or incomplete information.