Preliminary Application For Housing Choice Voucher Page 2
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24. ________________________________/____/__________________-______-___________________________________________
5. ________________________________/____/__________________-______-___________________________________________
6. ________________________________/____/__________________-______-___________________________________________
7. ________________________________/____/__________________-______-___________________________________________
8. ________________________________/____/__________________-______-___________________________________________
*RACE CODE: (1) White (2) Black (3) Native American
(4) Hispanic/Latino (5) Asian/Pacific Islander
Note: HUD requires CMHA to collect and report race/ethnicity information for statistical purposes.
NOTE: Will you require an interpreter at the time of your interview? Yes___ No___ What Language______________________
TOTAL HOUSEHOLD INCOME List all sources and amounts of household income.
Note: INCOME INCLUDES the following sources: Employment, Public Assistance, Pensions, Social Security, Worker's Comp,
Disability Payments, Child Support, Informal Support, Recurring Gifts, etc.
Please list the all income below:
Person Receiving Income
Gross Monthly Amount
Source
OTHER INFORMATION TO DETERMINE ELIGIBILITY: You must answer the following questions:
( ) Yes ( ) No Have you or anyone in your household been convicted of any drug related or violent criminal activity in the last 5
years? If yes, please explain: __________________________________________________________________.
( ) Yes ( ) No Have you ever been ever been evicted?
( ) Yes ( ) No Are you or any adult member a registered sexual offender?
I/We hereby swear and attest that all of the information given above about my household is complete, true and correct to the best of my knowledge. I/We agree that
my/our application may be withdrawn from the waitlist if I/we fail to inform CMHA of any change of address or if any of the above information that I/we provided is
.
determined to be untrue. I/we understand that I/we may be banned from federally assisted housing if I/we furnish false information to CMHA
_______________________________/_____________
________________________________/_____________
Head of Household
Date
Spouse/Co-tenant
Date
_______________________________/_____________
_______________________________/_____________
Other Adult
Date
Other Adult
Date
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to a department or agency of the United States.
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