Forms - Public Housing - Housing Authority

Public Housing Application - Resident

Applicant Identification

Full Name:		Email Address:
Present Address:		Unit or Apt. #:
City:		State:
Zip:		County:
Phone:		Alt Phone:
Marital Status:

Family Composition:
List all household members that will be living with you (Oldest to Youngest):

Name Social Security #: - -

Date of Birth / / Race:

Sex: Relation to HOH:

Name Social Security #: - -

Date of Birth / / Race:

Sex: Relation to HOH:

Name Social Security #: - -

Date of Birth / / Race:

Sex: Relation to HOH:

Name Social Security #: - -

Date of Birth / / Race:

Sex: Relation to HOH:

Name Social Security #: - -

Date of Birth / / Race:

Sex: Relation to HOH:

Name Social Security #: - -

Date of Birth / / Race:

Sex: Relation to HOH:

Income:
List Source, Rate, Type of Income for Each Family Member: ie. SS, SSI, Wages, Tips, Child Support, etc..:

Source, Rate & Type: Current: Anticipated:

Source, Rate & Type: Current: Anticipated:

Source, Rate & Type: Current: Anticipated:

Do you pay for Childcare? If yes, enter amount:

Landlord Information:

Full Name: Phone:

Address: Unit or Apt. #:

City: State:

Zip:

Have you ever lived in Public Housing? Have you ever lived in Section 8 Housing?

If Yes, where? Do you owe money?

Have you or any family member ever appeared in court, magistrates office, been on probation, or served time in any type of correctional facility?

If so, why and when?

Location:
Choose which area you prefer. You may select more than one:

AMP 1 - Oakcrest: 13th St., 11th St., Pierce St., Cooper St., Washington St., Thompson St., Bridge St., Trade St.

AMP 2 - Eastern Village, Eastern Village Annex: Simmons St., Pennsylvania Ave., Hudnell St., E. 7th St., E. 8th St.

AMP3 - Old Fort, Westbrook: 9th St., Mayo Drive, W. 7th St., Gladden St., Sparrow Dr., Manuel Dr., Pontiac Dr.

East Haven (Elderly/Disabled Only)

WARNING: Section 1001 of Title 18 of the US Code makes it a criminal offense to make willful false statement of misrepresentation to any Department or Agency of the US as to any matter within its jurisdiction.

I have read the above statement and the above information is correct to the best of my knowledge. I have no objection to inquiries for the purpose of verifying the facts herein stated.

Name		Social Security #:	- -
Date of Birth	/ /	Race:
Sex:		Relation to HOH:

Name		Social Security #:	- -
Date of Birth	/ /	Race:
Sex:		Relation to HOH:

Name		Social Security #:	- -
Date of Birth	/ /	Race:
Sex:		Relation to HOH:

Name		Social Security #:	- -
Date of Birth	/ /	Race:
Sex:		Relation to HOH:

Name		Social Security #:	- -
Date of Birth	/ /	Race:
Sex:		Relation to HOH:

Name		Social Security #:	- -
Date of Birth	/ /	Race:
Sex:		Relation to HOH:

Source, Rate & Type:	Current:	Anticipated:
Source, Rate & Type:	Current:	Anticipated:
Source, Rate & Type:	Current:	Anticipated:

Have you ever lived in Public Housing?		Have you ever lived in Section 8 Housing?
If Yes, where?		Do you owe money?

Have you or any family member ever appeared in court, magistrates office, been on probation, or served time in any type of correctional facility?
If so, why and when?

	AMP 1 - Oakcrest: 13th St., 11th St., Pierce St., Cooper St., Washington St., Thompson St., Bridge St., Trade St.
	AMP 2 - Eastern Village, Eastern Village Annex: Simmons St., Pennsylvania Ave., Hudnell St., E. 7th St., E. 8th St.
	AMP3 - Old Fort, Westbrook: 9th St., Mayo Drive, W. 7th St., Gladden St., Sparrow Dr., Manuel Dr., Pontiac Dr.
	East Haven (Elderly/Disabled Only)