Application For Public Housing Assistance

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Date/Time:
Chesapeake Redevelopment & Housing Authority (CRHA)
Client #:
1468 S. Military Highway
Phone: (757) 233-6410
Bedroom Size:
Chesapeake, VA 23320
Fax: (757) 523-1601
Received by:
(757) 523-0401
TDD: (757) 523-1316
Application for Public Housing Assistance
If you need assistance filling out this form, please contact our office at (757) 233-6410 or 233-6416
Print information in ink ONLY
Last Name of Applicant
First Name of Applicant
Social Security # of Applicant
Home Address (street/city/state/zip):
Mailing Address (If different)
Home Telephone: (
)
Work/Cell Telephone:(
)
Family Information: First list applicant, spouse and all children (who will live with you) in order of age, starting
with the oldest, then list all others who will live with you.
Last
First
MI
Social
Relationship
Sex
Race &
Birth
Disabled
Student
Place of
Security #
Ethnicity
Date
Yes/No
Yes/No
Birth
Head of
1.
Household
2.
3.
4.
5.
6.
1. Have you or any other adult family member listed on this application ever lived in CRHA Public Housing?
Yes
No If yes, please list name of property:
2. Have you or any other adult family member listed on this applicarion ever received Housing Choice Voucher
(Section 8) Housing Assistance?
Yes
No
IF YOU ARE A FORMER RESIDENT OF CRHA PUBLIC HOUSING OR HOUSING CHOICE VOUCHER (SECTION 8)
PROGRAM AND OWE A RENTAL BALANCE, YOU CANNOT BE ASSISTED UNTIL THE BALANCE IS PAID IN FULL.
If you are requesting a reasonable accommodation, complete the question below:
Do you or any member of your household need an accessible unit because of disability, mobility
impairment or special feature(s) due to a disability? (Ex: wheelchair or difficulty walking)
Yes
No
TENANCY INFORMATION
Do you owe money to CRHA or any other federally subsidized housing program?
Yes
No
Details:
Has any household member been evicted from federally subsidized housing?
Yes
No
Details:
Has any household member been evicted for drug-related criminal activity, disturbing neighbors or property
destruction? If yes, please explain:
Yes
No
Has any household member abused the use of alcohol within the last three years resulting in an alcohol related
arrest or traffic violation?
Yes
No
Details:
Has any household member ever been arrested or charged with any felony or misdemeanor?
Yes
No
Details:
Is any household member required to register on any state sex offender list?
Yes
No
Please list the highest grade completed in school:
Are you currently attending College?
Yes
No If yes, list school:
Have you graduated?
Yes
No If yes, what year:
Do you have a GED Certificate?
Yes
No If yes, list year certificate received:

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