Application for Occupancy (Page 1 of 6)

THIS IS NOT A LEASE OR RENTAL AGREEMENT

Please have the following information available:

• Social Security Numbers & Birth Dates for All Family Members
• 3 Years of Housing History with Landlord Contact Information
• Monthly Gross Income
• Monthly or Annual Income from Assets (if any)

COMPLETE THIS APPLICATION IN FULL. ANSWER ALL THE QUESTIONS. COMPLETE ANSWERS TO THE QUESTIONS WILL DETERMINE YOUR PRIORITY FOR HOUSING. IF THE APPLICATION IS NOT COMPLETE, IT WILL NOT BE ACCEPTED.

SECTION A - APPLICANT

*Applicant's Name: *Present Address: Apt. No.: *City: *State: *Zip Code: *Phone - Day: Phone - Night: E-Mail: Any applicant who purposefully falsifies, misrepresents, or withholds any information related to program eligibility or submits inaccurate and/or incomplete information on this application, or during the interview, will not be considered for housing nor placed on the waiting list.

SECTION B - HOUSEHOLD COMPOSITION

List the Head of Household and all other persons who will be living in the unit. Give the relationship of each family member to the Head. Each household member age 18 years or older must sign this application.

*MEMBER'S FULL NAME *RELATIONSHIP *BIRTHDATE     *SEX     *SOCIAL SECURITY NUMBER *STUDENT *CITIZEN/ US NAT'L *RACE *ETHNICITY Head of Household Male Female Yes No Yes No  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or other Pacific Islander  White  Other Hispanic or Latino Not Hispanic or Latino Person 2 Male Female Yes No Yes No American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other Hispanic or Latino Not Hispanic or Latino Person 3 Male Female Yes No Yes No American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other Hispanic or Latino Not Hispanic or Latino Person 4 Male Female Yes No Yes No American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other Hispanic or Latino Not Hispanic or Latino Person 5 Male Female Yes No Yes No American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other Hispanic or Latino Not Hispanic or Latino Person 6 Male Female Yes No Yes No American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other Hispanic or Latino Not Hispanic or Latino

Citizenship and/or Eligible Alien Status must be verified by, and you must possess an acceptable document recognized by, the Federal government.