HOUSING APPLICATION
HOUSING APPLICATION
Date ____________________ Time ____________
Please check all programs you are signing up for:
_____ Low income Housing - Parkside Apartments - one bedroom
_____ Low income Housing - Elizabeth Manor - one bedroom
_____ Public Housing - Family 2 and 3 Bedroom Units
_____ Voucher Program - Rental Assistance
Applicant Name ________________________________________________________
Current Address ________________________________________________________
________________________________________________________
Home Phone _____________________ Cell Phone________________________
List names, addresses and phone numbers of two relatives or friends who generally know how to contact you.
Name ___________________________ Name___________________________
Address _________________________ Address ________________________
_________________________ ________________________
Phone ___________________________ Phone __________________________
List the head of household and all other members of the household who will be living in the unit.
Full Name Relationship Date of Birth Sex S.S.#
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Are any family members 18 or older full-time students? ______ If yes, verification is needed.
The City of Shawano Housing Authority has a policy of NO SMOKING at anytime in any of the buildings that have apartments connected by common halls. This will include tenants of Parkside Apartments, Elizabeth Manor and Oak Street. This applies to every apartment in these buildings and every person in the buildings whether a tenant or a guest. Do you smoke? Yes_____ No_____
Verification of social security #’s is mandatory. Documents provided _______________
Applicants are required to submit evidence of citizenship or eligible immigration status. For citizens: signed declaration. For eligible immigration status: signed declaration and proof of age.
The following information is required for statistical purposes so HUD may determine the degree to which its programs are utilized by minority families.
White ____ Black ____ American Indian ____ Asian/Pacific Islander ____
Hispanic ____ Non-Hispanic ____
Place of Birth:
Name ____________________ City __________________________ State _______
Name ____________________ City __________________________ State _______
Name ____________________ City __________________________ State _______
Name ____________________ City __________________________ State _______
Current Housing Status
Landlord: Name ________________________________________________________
Address _______________________________________________________
City___________________________Phone # _________________________
How long have you lived there? _____________________ Amount of rent ___________
Previous Housing Status
1. Address______________________________________________________________
City_________________________________________________________________
How long in unit? From ________________ to ________________
Landlord: Name ______________________________________________________
Address _____________________________________________________
City___________________________ Phone # _________________________
2. Address______________________________________________________________
City_________________________________________________________________
How long in unit? From ________________ to ________________
Landlord: Name ____________________________________________________
Address _______________________________________________________
City___________________________ Phone # _________________________
*We request at least a five-year history - if you need additional space, please list on the back of this page.
Has any family member who will be living in the unit ever lived in Public Housing or participated in a Rental Assistance Program? _____ If yes, when and where ____________________________________________________________________
Does any family member who will be living in the unit owe money for damages, unpaid rent or unpaid utility bills to any current or previous landlord, including a Public Housing Authority or to a utility or gas company (excluding your current monthly bill)? ______If yes, explain amount and circumstances ______________________________________
______________________________________________________________________
Has any family member who will be living in the unit ever been evicted from a housing unit? _____ If yes, explain _______________________________________________
______________________________________________________________________
Has any family member who will be living in the unit ever been convicted of any drug related criminal activity to include the sale, manufacture, distribution or possession of a controlled substance including drug paraphernalia? ____ If yes, explain _____________
_______________________________________________________________________
Has any family member who will be living in the unit ever been convicted of a felony? _______ If yes, explain ___________________________________________________
Are any members of the household who will be living in the unit subject to a lifetime sex offender registration program in any state? _____________________ Failure to respond to this question may jeopardize the approval of the application.
Income Information
List all money earned or received by everyone who will be living in your household. This includes money from wages, self-employment, social security, disability payments (SSI), retirement benefits, veteran benefits, W-2, alimony, child support, per-capita, workman’s compensation, unemployment, interest from bank, stock dividends, contributions and all other sources.
Household members Source & address Amount
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Asset Information
List financial institutions, amounts and type of assets or investments (including stocks, bonds or trusts).
Amount &
Family member Bank name & address Acct. type Interest rate
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Real estate income such as rent or land contract payments _____________________.
Market value of real estate ____________ Equity ____________
Have you disposed of an asset worth more than $2,000 for less than its value in the past two years? _______ If yes, what is the current market value of this asset? _______
____________________________________________________________________
Expenses
List approximate medical expenses annually not covered by insurance or Medicare.
Insurance premiums ___________________________________________________
Prescription drugs _____________________________________________________
Doctor bills/other expenses ______________________________________________
Family expenses
Do you pay for childcare, which enables you or any other family member to work or go to school? ________ If you are not reimbursed by any agency for this childcare, list the name and address of the childcare provider and weekly cost ____________________
_____________________________________________________________________
_____________________________________________________________________
**Please review your application for complete information such as addresses and phone numbers on landlord information. We must have complete information to perform a background check. If we are unable to do so, your application will be rejected until we receive the information required.**
Applicant Certification
I/We certify that the information given to the City of Shawano Housing Authority on household composition, income, net family assets and allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal law. I/We also understand that false statements or information are grounds for denial of admission or termination of tenancy after admitted.
I/We further certify that this application is true and complete to the best of my/our knowledge and that the City of Shawano Housing Authority and its staff is authorized to contact any agencies, offices, organizations, present and/or past employers, present and/or past landlords to obtain any information or any materials which is deemed necessary to complete my application or annual or interim reexamination.
___________________________ __________________________
Head Spouse/Other adult
PHA Representative ___________________________
Date ___________________
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
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