Gastonia Housing Authority Application For Housing Assistance Page 2
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2If yes, please list the name of the head of household, the unit address or the name of the housing authority
_________________________________________________________________________________________________
Do you owe money to any housing authority? □ YES
□ NO
3. Has anyone in the household ever been subject to registration as a sex offender? □ YES
NO
If yes, please list person(s) _________________________________________________________________________
1. Please list the source and amount of all income expected for the next 12 months for each family member,
including yourself. Include all earning and benefits received from AFDC /TANF / WFFA, VA, Social Security, SSI,
SSID, Unemployment, Worker’s Compensation, Child Support, etc. EXAMPLE: Name, Wages, Hourly Rate,
Hours/week, $150/week - Name, SSI, $421/month
Family Member Name
Income
Hourly
Hours Per
Average Pay
Frequency - Per
Source
Rate $
Week
Amount $
□ Week □ Month □ Year
□ Week □ Month □ Year
□ Week □ Month □ Year
□ Week □ Month □ Year
□ Week □ Month □ Year
2. Does your household receive food stamps? □ YES
□ NO If yes, list amount your household receives
monthly _________________________________________________________________________________________
3. Does anyone outside your household pay for any bills, give you money, or provide goods and/or services in
lieu of cash support? □ YES
□ NO
If yes, give name and address _______________________________________________________________________
Amount and frequency _____________________________________________________________________________
3. Do you have a court order(s) for child support or alimony? □ YES
□ NO
If yes in which county and state? ____________________________________________________________________
I do hereby swear and attest that all of the information above about me and my family is true and correct.
Change in address must be reported to the Housing Authority IN WRITING within 14 days.
By checking box on left I / We hereby give the Gastonia Housing Authority permission to perform criminal and
credit background investigations for the purposes of determining eligibility.
**By signing this form, I/We recognize that the Lessor or his agent may investigate the information supplied by the
applicant, and disclosures of pertinent facts may be made to the lessor. (Pertains to Public Housing applicants only)
**Warning: 18 U.S.C 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document
or writing containing false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any
department or agency of the United States, shall be fined not more than $10,000 or imprisoned for not more than five (5)
years or both.
**I understand that all notifications are through the mail. If I do not respond or the mail cannot be delivered to the
address given, my application will be deleted from the waiting list.
______________________________________________________________________
Applicant’s Signature
Date
______________________________________________________________________
Co-Applicant’s Signature
Date
C:\Users\Caylyn\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\129M47J2\Pre-application open WL.doc
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