PUBLIC HOUSINGSECTION 8 NEW CONSTRUCTIONHOUSING CHOICE VOUCHER Head of Household: First Middle Last Residence Address: Street City State Zip Code Mailing Address: Street City State Zip Code Email Address: If you need us to provide an interpreter check here: Yes I. Household Composition: List below all persons who will be staying in your home, listing head of household first. Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Legal Name (First, Middle, Last) Age Date of Birth Relation to Head of Household Social Security Number Sex Race Hispanic Y/N YesNo Marital Status Maiden Name of female adult household member(s): Other Names/Social Security #'s used by any/all household members: Explain: II. Household Composition 1. Do you have custody of your minor children? YesNoNot applicable Explain the custody arrangements: If the parent of the minor is not living in the household, list information as follows: Absent Parent Name: Child's Name: Street Address: City, State, Zip: Telephone #: Absent Parent Name: Child's Name: Street Address: City, State, Zip: Telephone #: 2. Is anyone in your household attending any school or education program? YesNo Student: School: Full time, Part time: Full timePart time Student: School: Full time, Part time: Full timePart time Student: School: Full time, Part time: Full timePart time Student: School: Full time, Part time: Full timePart time Student: School: Full time, Part time: Full timePart time Student: School: Full time, Part time: Full timePart time Student: School: Full time, Part time: Full timePart time 3. Will anyone be leaving your household or family within the next 12 months? YesNo If yes, please explain: 4. Will you be adding anyone to your household in the next 12 months? YesNo If yes, please explain: III. Employment Enter earned income that any household member (18 years or older) will have within the next year. List most current first. Person Working: Employer: Income Amount: Position: Income Per Hour: Income Per Week: Income Per Month: Income Per Year: Hours Per Week: How long have you worked here/received this income? Start Date: End Date: Address: City, State, Zip: Telephone: Person Working: Employer: Income Amount: Position: Income Per Hour: Income Per Week: Income Per Month: Income Per Year: Hours Per Week: How long have you worked here/received this income? Start Date: End Date: Address: City, State, Zip: Telephone: Person Working: Employer: Income Amount: Position: Income Per Hour: Income Per Week: Income Per Month: Income Per Year: Hours Per Week: How long have you worked here/received this income? Start Date: End Date: Address: City, State, Zip: Telephone: Person Working: Employer: Income Amount: Position: Income Per Hour: Income Per Week: Income Per Month: Income Per Year: Hours Per Week: How long have you worked here/received this income? Start Date: End Date: Address: City, State, Zip: Telephone: Person Working: Employer: Income Amount: Position: Income Per Hour: Income Per Week: Income Per Month: Income Per Year: Hours Per Week: How long have you worked here/received this income? Start Date: End Date: Address: City, State, Zip: Telephone: IV. Income Do you or anyone in your household receive any of the following income? Child Support/Alimony Court Order Number Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Disability, Death Benefits or Life Insurance Dividends Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Educational grants or scholarships (for example Pell) Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Net Income from a Business, Rental property or Self Employment Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Other cash payments or contributions Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Pensions, Retirement Funds and Annuities Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Public Assistance (ADC, AABD, TANF) Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Social Security Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Supplemental Social Security (SSI) Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Unemployment Compensation Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Veterans Benefits Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: Workers Compensation Who Receives Income: Amount: How Often Paid or Received: YearlyMonthly2 times per monthWeeklyEvery two Weeks Source/Company: 1. Does any household member receive regular contributions (donations or gifts) from any organization or persons not living in your household? YesNo If yes, please explain: 2. Did any household member file a federal income tax return last year? YesNo If no, please explain: 3. Does any household member file a federal income tax return this year? YesNo If yes, please explain: 4. Has anyone in the household applied for any of the following within the last twelve months? Employment, AFDC, unemployment, compensation, social security, SSI, pension or disability benefits? YesNo If yes, please explain: V. Assets List all assets currently held by all household members and the cash value of each. Assets include Checking and Savings Accounts, CDs, Stocks, Bonds, Mutual Funds, Retirement Accounts, Real Estate and any other property held as an investment. Do you or anyone in your household have: Checking Account Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Savings Account Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Certificates of Deposit Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Any Stocks, Bonds, or Mutual Funds Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Retirement (401K, IRA) Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Life Insurance Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Policy Type: TermWhole Current balance/ value: Cash Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Savings Bonds Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: List any items not described above. Yes or No? YesNo Bank/ Source: Owner of Account: Account #: Current balance/ value: Own equity in Real Estate, rental property, land contracts, contracts for deeds or other real estate holding or other capital investments (this includes your personal residence, mobile homes, vacant land, farms, vacation homes, or commercial property)? YesNo Have you sold or given away any assets within the last two years for less than Fair Market Value? YesNo Type of Asset: Cash Value: Date Sold or Given Away: VI. Residence: Where have the household members resided? Please check the box indicating all states and/or territories where any household member has resided. In addition, list the household member's name on the line associated with the state or territory resided in. State/U.S. Territory and Resident Name: State/U.S. Territory and Resident Name: State/U.S. Territory and Resident Name: State/U.S. Territory and Resident Name: State/U.S. Territory and Resident Name: State/U.S. Territory and Resident Name: State/U.S. Territory and Resident Name: VII. Child Care 1. Do you pay child care expenses? YesNo Child care provider: Address: Amount: How Often: YearlyMonthly2 times per weekWeeklyEvery Two Weeks Children's Names: VIII. Medical Expenses (FOR 62 OR OLDER/DISABLED ONLY) 1. Do you pay health insurance premiums? YesNo Plan Number: Provider Name: Provider Address: 2. Premium Amount: How Often: YearlyMonthly 3. Do you pay prescription insurance premiums? YesNo Plan Number: Provider Name: Provider Address: 4. Do you anticipate any out-of-pocket medical expenses in the next 12 months? YesNo 5. Do you have any prescription expenses? YesNo Provider: Address: Amount: How Often: YearlyMonthly 6. Do you have any medical office visit expenses? YesNo Provider: Address: 7. Do you have other types of medical expenses or insurance expenses? YesNo 8. Do you have anything else taken out of Social Security check besides Humana Medicare Part D? YesNo Provider: Address: Amount: How Often: YearlyMonthly2 times per weekWeeklyEvery Two Weeks IX. Criminal and Drug-Related Activity: Answer for ALL Household Members 1. Are you or any other household member a current user or been arrested, ticketed, charged or convicted of possession, using, dealing or manufacturing a controlled substance? YesNo 2. Have you or any household member been convicted of methamphetamine production? YesNo 3. Are you currently on probation or parole? YesNo 4. Has any household member been arrested, charged, ticketed or convicted of any of the following? Please include both misdemeanors and felonies. Drug related activity including Sale: YesNo Drug related activity including Manufacture: YesNo Drug related activity including Possession: YesNo Use of illegal controlled substances: YesNo Alcohol related activity including Driving under the influence of alcohol: YesNo Other: YesNo If Yes, what?: Murder/Manslaughter: YesNo Battery: YesNo Assault: YesNo Sexual Assault: YesNo Sex Offender: Is anyone required to register on any state sex offender registry? YesNo Child abuse/Molestation: YesNo Burglary: YesNo Larceny: YesNo Robbery: YesNo Vandalism: YesNo Arson: YesNo Disturbing the peace/disorderly conduct: YesNo Other: YesNo If Yes, what?: If yes was answered to the questions above, complete the following. If you have more than two incidents provide the remaining information on a separate piece of paper. a. Who was charged or convicted? b. What crime was the charge or conviction for? c. When was the charge or conviction? The Month: The Year: d. Where did it occur? City: County: State: e. Were any of the crimes drug related? YesNo f. If drug related, has that person(s) successfully completed a supervised drug treatment program or is presently enrolled in such a program? YesNo g. If yes, please name the facility: h. Have you provided a certificate of completion? YesNo a. Who was charged or convicted? b. What crime was the charge or conviction for? c. When was the charge or conviction? The Month: The Year: d. Where did it occur? City: County: State: e. Were any of the crimes drug related? YesNo f. If drug related, has that person(s) successfully completed a supervised drug treatment program or is presently enrolled in such a program? YesNo g. If yes, please name the facility: h. Have you provided a certificate of completion? YesNo X. Additional Information Have you or has anyone in your household ever received rental assistance or paid rent based on income? YesNo What name was used by the person receiving assistance? City: State: Month: Day: Year: Name of Housing Agency: Has your rental assistance ever been terminated for fraud, non-payment of rent or failure to re-certify? If yes, please explain. YesNo Have you or has anyone in your household applied or rented with the York Housing Authority? YesNo Month: Day: Year: What name was used on the application? What name was used and/or who was the Head of Household? When: Address: Have you or has anyone in your household ever been evicted? YesNo When: Why: Address: Name of Landlord: Do you declare a disability for the purposes of eligibility? Some programs have preferences for persons with disabilities. You are under no obligation to declare this. YesNo If yes, provide name and address of doctor who can verify your disability: Would you or any members of your household benefit from a handicapped-accessible unit? YesNo Explain: Do you have a pet? YesNo How Many: Type/Breed and Weight: Do you or anyone in your household have a vehicle? YesNo Model/Year: License Plate Number: Do you have a second vehicle? YesNo Model/Year: License Plate Number: Do you or anyone applying for or receiving help have a guardian, conservator, or individual acting under power of attorney? YesNo Name of person with Guardian, Conservator or Power of Attorney: Name of Guardian, Conservator, or Power of Attorney: Address: Phone number: List any additional information or notes. Describe any additional information not previously covered such as special needs, required bedroom size, etc.: Has someone assisted you in completing this form? YesNo Name of person completing form: XI. Rental History List all places each household member has lived in the past five (5) years, beginning with your current address. Current Residence Who Lives Here? Street Address: City / State / Zip: Dates: From (Month/Day/Year): To (Month/Day/Year): Landlord: Landlord Address: City / State / Zip: Phone #: Why do you want to move? Rent Amount $: Do you: RentOwnOther If Other Explain: Previous Residence Who Lives Here? Street Address: City / State / Zip: Dates: From (Month/Day/Year): To (Month/Day/Year): Landlord: Landlord Address: City / State / Zip: Phone #: Why did you move? Rent Amount $: Did you: RentOwnOther If Other Explain: Previous Residence Who Lives Here? Street Address: City / State / Zip: Dates: From (Month/Day/Year): To (Month/Day/Year): Landlord: Landlord Address: City / State / Zip: Phone #: Why did you move? Rent Amount $: Did you: RentOwnOther If Other Explain: Previous Residence Who Lives Here? Street Address: City / State / Zip: Dates: From (Month/Day/Year): To (Month/Day/Year): Landlord: Landlord Address: City / State / Zip: Phone #: Why did you move? Rent Amount $: Did you: RentOwnOther If Other Explain: XII. Rights and Responsibilities I/We certify that all information given to the York Housing Authority is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements I/we give to the Housing Authority may be punishable under Federal Law. I/We also understand that false statements or information will be grounds for denial of your application, termination of housing assistance and/or termination of tenancy. I/We understand that this is an application for assistance and signing this application does not bind the Housing Authority to offer rental assistance nor does it bind me/us to accept any assistance offered. I/We have no objection to inquiries for the purpose of verifying the facts herein stated. I/We have received, read and understand the HUD fact sheet "Applying for HUD Housing Assistance." I/We authorize you to verify the above information through a consumer reporting agency. (This agency is Tenant Data Services Inc. (800) 228-1837. The function of this agency is to track and maintain records such as your resident conduct and personal credit history. Tenant Data Services Inc. also will obtain a credit report on all applicants for York Housing Authority owned/managed properties.) Authorization to Release Information Your signature on this form and the signature of each member of your household who is 1 8 years of age or older authorizes the Housing Authority of the City of York, NE, to use this authorization and the information obtained with it, to administer and enforce rules and policies. Any individual or organization, including any governmental agency may be asked to release information. Information may be requested from but is not limited to: banks and other financial institutions, courts, law enforcement agencies, credit bureaus, landlords, past and present employers, medical providers, educational institutions, Veterans Affairs, Social Service Agencies, utility companies, unemployment benefits, pensions/ annuities, child care providers, neighbors and the U.S. Post Office. By signing this form, I authorize the above persons, firms or corporations to make available any documents or record to the Housing Authority of the City of York for inspection and copying. Signature of Head of Household: Print Name Date Signature of Spouse/Co-Applicant: Print Name Date Signature of Other Adults/Co-Applicant: Print Name Date
