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HND Wait List for TBRA

Preliminary Application

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.

Waiting List:  TBRA  

Part 1:  Head of Household

First Name:  
Last Name:  

Social Security Number:

Date of Birth:  (mmddyyyy) 

Telephone Number:

Other Phone/E-mail:
Other Phone Type:

Ethnicity (Check one box)

Race (Check all that apply)

Racial and ethnic data for statistical purposes only.
Do you qualify for a reasonable accommodation due to a disability?

Part 2:  Household Information

Legal Address
(Where you currently live)

Address Line 1:  
Address Line 2:
ZIP Code:  

Mailing Address (If different from Legal)
(Where you currently receive mail)

Address Line 1:
Address Line 2:
Zip Code:

Household Members

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.

First Name
Last Name
Social security #
Date of Birth

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.

Frist Name

How Often
If Income is from Wages
List Name and Address of Employer

List total cash value and total income received for assets owned by all family members.

Type of Asset
Cash Value of Asset
Income Received from Asset
Checking Accounts   $ $
Savings Accounts $ $
Stocks, Bonds, CDs, Ivestment  $ $
Real Estate $ $
Other  $ $

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.

Have you or any members listed on this application ever been terminated from housing assistance program

Have you or any members listed on this application ever been convicted of drug related or violent criminal activity?

Are you or any member listed on this application a registered lifetime sex offender?

Have you used another name then the one listed above

 First NameĀ                          Last Name


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.

 Check this box if you choose not to provide the contact information.


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.
                                                                                                                                                                        Equal Housing Opportunity

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Polk County Board of County Commissioners | 330 West Church Street | P.O. Box 9005 | Bartow, FL 33830 | 863.534.6000