Application For Public Housing Assistance Page 2
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2INCOME AVAILABLE TO HOUSEHOLD
List all income earned or received by everyone living in the household regardless of age. List gross
amounts of income (before deductions).
Family Member Name
Type of Income (Employment, SSI, Social
Amount Received Per
Security, Public Assistance, etc.)
Month
1.
2.
3.
4.
5.
6.
7.
8.
LOCAL PREFERENCES
You MUST provide documentation for any preference(s) you claim.
Check all that apply
1.
Residents who live and/or work in the jurisdiction (City of Chesapeake) (75 points)
Yes
No
2.
Involuntary displacement (disaster, government action, action of housing owner, inaccessibility, property
disposition) (50 Points)
Yes
No
3.
Victim of domestic violence (50 points)
Yes
No
4.
Victim of reprisals or hate crimes (50 points)
Yes
No
5.
Yes
No
Working families and those unable to work because of age or disability (20 points)
Definition: Applicant families whose head of household, or spouse is employed or has a bona fide offer for employment, (this
preference will not be based on the amount of earned income and the PHA may not prefer higher income families over families with
lower incomes to occupy a development or unit except to the extent that the PHA has identified the need to implement economic
deconcentration and income targeting). Families whose head of household or spouse is at least sixty-two (62) years of age or disabled
automatically receive the maximum level of local preference.
Yes
No
6.
Those currently enrolled in educational, training or upward mobility programs (15 points)
Definition: Graduate of, or participant in job training programs which have prepared the head of household, spouse or other adult
member(s) to enter the job market. Documentation of the completion of job training program will be required.
A statewide criminal and credit check will be run on all household members over age 17. All information provided
on this application and at the interview is subject to verification. All family members age 18 or over should review
the information on this form, the Federal Privacy Act and all required releases which MUST be signed in
order to be considered for housing.
By my signature below, I do hereby swear and attest that all information on this application is true and correct. I
understand that I must report any changes in income, assets, family composition, address, or phone number to the
Housing Authority within 10 days of such changes for my application to remain valid. By my signature, I grant
permission for the Housing Authority to verify information necessary to determine my eligibility and suitability for
housing. I further understand that false statements or information are grounds for denial of this application.
Signature of Head of Household
Date
Signature of Spouse of Head of Household or Other Adult
Date
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATED CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY
AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF AGENCY OF THE UNITED STATES.
If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll-free hot line at 1-800-669-9777.
CRHA Fair Housing and Equal Opportunity Statement
It is the policy of Chesapeake Redevelopment & Housing Authority (CRHA) to provide equal employment and fair housing opportunity to all
persons and to prohibit discrimination because of race, color, religion, national origin, age, sex, and familial status. CRHA does not
discriminate on the basis of disability status in admission or access to its assisted housing programs and activities.
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