Application

PUBLIC HOUSINGSECTION 8 NEW CONSTRUCTIONHOUSING CHOICE VOUCHER

Head of Household:






Residence Address:








Mailing Address:










Yes

I. Household Composition: List below all persons who will be staying in your home, listing head of household first.



























































































































II. Household Composition



If the parent of the minor is not living in the household, list information as follows:





































III. Employment

Enter earned income that any household member (18 years or older) will have within the next year.
List most current first.







































































IV. Income

Do you or anyone in your household receive any of the following income?

Child Support/Alimony Court Order Number





Disability, Death Benefits or Life Insurance Dividends





Educational grants or scholarships (for example Pell)





Net Income from a Business, Rental property or Self Employment





Other cash payments or contributions





Pensions, Retirement Funds and Annuities





Public Assistance (ADC, AABD, TANF)





Social Security





Supplemental Social Security (SSI)





Unemployment Compensation





Veterans Benefits





Workers Compensation













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






Savings Account






Certificates of Deposit






Any Stocks, Bonds, or Mutual Funds






Retirement (401K, IRA)






Life Insurance






Cash






Savings Bonds






List any items not described above.











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.








VII. Child Care







VIII. Medical Expenses (FOR 62 OR OLDER/DISABLED ONLY)


























IX. Criminal and Drug-Related Activity: Answer for ALL Household Members






























The Month:
The Year:


City:
County:
State:








The Month:
The Year:


City:
County:
State:





X. Additional Information














































XI. Rental History

List all places each household member has lived in the past five (5) years, beginning with your current address.

Current Residence














Previous Residence














Previous Residence














Previous Residence














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.



Date