Belmar Housing Authority



Belmar Housing Authority

710 8th Avenue

Belmar, NJ 07719

App. No.__________

Date of Application_________________

Name________________________________

Address_____________________________

Phone No.___________________________

Social Security No._________________

Place of Birth______________________

Minority (Enter One)

1. White 2. Black 3. American or

Alaskan Native 4. Asian or Islander

Ethnicity (Enter One)

1. Hispanic 2. Non-Hispanic

APPLICATION FOR ADMISSION

I. FAMILY COMPOSITION:

A. Person(s) Who Will Move Into The Project:

Family Name of Family Members Relation to Date of Age Sex

Member Family Head Birth No.________________________________________________________

1____________________________________HEAD__________________

2._________________________________________________________

3._________________________________________________________

4._________________________________________________________

II. INCOME:

A. Total Income:

Family Source Rate & Type of Estimated Income:

Member No.___Income_________________Past 12 Mos__Next 12 Mo

____________________________________$____________$_________

____________________________________$____________$_________

____________________________________$____________$_________

____________________________________$____________$_________

III. HOUSING CONDITIONS:

A. Present Housing Conditions & Need:

1. Without Housing: Yes_______ No_________

a. Reason________________________________________

b. Present Living Arrangements___________________

2. About to be Without Housing:

a. Reason________________________________________

b. Type Notice & Effective Date__________________

3. Living under Substandard Housing Conditions

Yes______ No______

(If yes check conditions present:)

a. Dwelling structurally unsafe

b. No potable running water

c. No usable flush toilet dwelling nit

d. No installed usable tub or shower in dwelling unit

e. No operating sink or proper stove connections in the kitchen

f. Inadequate or no electric wiring system in dwelling unit

g. Inadequate or unsafe heating facilities for dwelling unit

h. Overcrowded: No. BR______ No. of People______

i. Single family unit by 2 or more families

4. Other Conditions and Factors of Housing Need

(Specify)___________________________________________

____________________________________________________

B. Monthly Amount Now Paid for Rent and Utilities

___________________________________________________

IMPORTANT NOTICE TO APPLICANTS

Under Federal Law, which was implemented beginning July 13, 1988, the Housing Authority to select certain applicants for housing, ahead of others.

Applicants who have been involuntarily displaced from their homes, or who are living without housing, or who are paying more than 50% of their income for rent, are entitled to be considered for apartments in our building when they are available.

You may be able to move up on the list of applicant if you qualify for a preference of the above reasons.

If you are applying for the first time, or if you are already on a waiting list and if you are eligible for a preference in selection, then you must complete and sign the Preference Certification.

If you cannot claim a preference, then other applicants who do have a preference, may be placed ahead of you on the waiting list.

PREFERENCE CETIFICATION

I,_______________________, hereby certify that I am entitled to a Federal position in Federal Housing for the following reasons: (Check and complete)

_____1. I was (or am about to be) involuntarily displaced from my home as a result of ______________________ and do not have a permanent home that is in standard condition.

_____2. I live in housing that is substandard because it is ________________________________________________________

_____3. I pay more than 50% of my income for rent

You can verify this information by contacting______________

___________________________________________________________

Name:__________________________________________

Date:__________________________________________

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