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3419475-396240The Lee County Housing Authority PUBLIC HOUSING DEPARTMENT14170 Warner CircleNorth Fort Myers, Florida 33903Phone 239-997-6688Fax # 239-997-7970TTY: (800)955-877100The Lee County Housing Authority PUBLIC HOUSING DEPARTMENT14170 Warner CircleNorth Fort Myers, Florida 33903Phone 239-997-6688Fax # 239-997-7970TTY: (800)955-8771PUBLIC HOUSING WAIT LIST PREFERENCE AND/OR SECTION 8 REASONABLE ACCOMMODATION APPLICATIONRACIAL GROUP:( ) White( ) Black/African American( ) Asian( ) Native American( ) Pacific Islander( ) OtherETHNICITY:( ) Hispanic/Latino( ) Non Hispanic/Latino( ) PUBLIC HOUSING ( ) SECTION 8 WAIT LIST PREFERENCES:Please indicate if you meet one of the following preferences( ) Federally Displaced Person (FEMA documentation)( ) Veteran (with DD-214 documentation)( ) Displaced Person by Government Action (Letter from agency) ____________________________________________________________________( ) Reasonable Accommodation Requested1. APPLICANT HEAD OF HOUSEHOLD:Applicant Name: _____________________________________________________________ Last Name, First Name M.I. Current Address: _____________________________________________________________ Street Address and Apt #, City, State ZipMailing Address: _____________________________________________________________ Mailing Address (PO Box) City, State ZipHome Phone # _________________________ Cell # _________________________________2. HOUSEHOLD COMPOSITION: List all persons that will live in the unitFull Name (s)Relation toHead ofHouseholdBirth DateAgeSexSocial Security NumberLegalStatusYes or No1HEAD2345678Do you or does anyone in your household, require any modifications or accommodations in order to fully utilize the unit or the program and its services? FORMCHECKBOX Yes FORMCHECKBOX No If yes, explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________3. HOUSEHOLD INCOME: List all household income including employment, unemployment, Social Security, SSI, pensions, child support, babysitting, help from family members, TANF, assets, etc.Household MemberSource of IncomeAmount of Income andFrequency ((weekly, bi-weekly, 4. MEDICAL EXPENSES: Only applicable if Head, Spouse or Co-Head are elderly or disabled1. Are you receiving Medicare benefits? Yes ? No ? If yes, monthly cost of premium amount $______2. Do you pay for any medical insurance such as Blue Cross or AARP? Yes ? No ? If yes, monthly amount of premium $_____________3. Are you making monthly payments on outstanding medical bills? Yes ? No ? If yes, monthly amount paid $ __________4. Do you take prescription drugs on a regular basis? Yes ? No ? If yes, your cost paid per month $__________5. PROGRAM INFORMATION:Have you or any family member in the household been arrested in the last five years? Yes ? No ? Have you or any family member in the household ever been subject to a lifetime registration under the state sex offender registration program? Yes ? No ? Have you ever lived in Public Housing? Yes ? No ? If yes, where? __________________Have you ever participated with the Section 8 Program before? Yes ? No ? If yes, where? __________________________Have you ever lived or currently live in a unit where the amount of rent you pay is based on your income? Yes ? No. HUD__ LIHTC__ HOME__ Other__ ? If yes, where? _______________Do you owe any money to any Public Housing Agency and/or Section 8 Housing Program? Yes ? No ? If yes, name of Housing Agency____________________________ Amount owed $________________.Have you lived anywhere other than Lee County, Florida? Yes__ No ___ If yes where________________________________________________________WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make false statements or misrepresentation to any department or agency of the U.S. as to any matter within its jurisdiction. CONSENT: By submitting my application, I do hereby certify that all of the above information is true and correct to the best of my knowledge. I understand that false statements or information is punishable under Federal Law and may cause my application to be denied. I hereby authorize the Housing Authority of the City of Fort Myers to obtain any information necessary to process my Public Housing Application. _______________________________________ ____________________________________ Applicant Signature/Date Co - Applicant Signature/ Date TO BE COMPLETED BY HOUSING AUTHORITY REPRESENTATIVEDate Application Received:_________________ Time Received: ________________Application Received by: __________________________________________________Date Inputted in SACS: SACS Application #: ................
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