Public Housing Pre Application Waiting List
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3HOUSING AUTHORITY OF THE COUNTY OF CONTRA COSTA
MAIL TO:
Public Housing Pre-Application Waiting List
P.O. Box 156
Rodeo, CA 94572
SECTION I.
Please fill in the information below (Please print legibly)
___________________________________
_______-_____-______
LAST NAME of Head of Household
Social Security Number
___________________________________
________
FIRST NAME of Head of Household
Middle initial
Date of Birth
[ ] Male [ ] Female
___________________________________
____________________
Current mailing address
Apartment Number
___________________________________
_____-______________
City
State
Zip
Telephone Number
_______________________________________________
E-mail Address
SECTION II. Please answer the following questions for all household members 18 years and older:
1. Are you a U.S. Citizen, or do you have eligible immigration status?
Yes[ ] No[ ]
2. Please check the race of the Head of Household
[ ] White
[ ] African American
[ ] Asian
[ ] American Indian
[ ] Other
3. Please check ethnicity of Head of Household
[ ] Hispanic
[ ] Non-Hispanic
4. Please check if any of the following applies to Head of Household or Spouse:
[ ] Over age 62
[ ] Disabled
[ ] Need accommodation? Please check: [ ] wheelchair access [ ] flat unit [ ] other
SECTION III.
Preference Points:
1. Residency Preference: do you live, work or attend school in Contra Costa County?
Yes[ ] No[ ]
2. Veteran preference: are you or anyone living in your household currently in the
Military or a Veteran?
Yes[ ] No[ ]
3. Disabled: is the head of household or spouse disabled?
Yes[ ] No[ ]
SECTION IV.
1. Have you or anyone in your household ever-engaged in drug-related or criminal activity?
Yes[ ] No[ ]
2. Are you or any member of your household currently a registered lifetime sex offender?
Yes[ ] No[ ]
3. Are you or any member of your household on parole or probation?
Yes[ ] No[ ]
4. Have you or anyone in your household ever been convicted of a felony?
Yes[ ] No[ ]
5. Have you or any member of your household ever lived in Public Housing or Section 8 housing?
Yes[ ] No[ ]
6. Have you or any family member ever been evicted from Public Housing?
Yes[ ] No[ ]
7. Have you or any family member ever been terminated from participation in the Section 8 Program?
Yes[ ] No[ ]
MAIL TO:
Public Housing Pre-Application Waiting List P.O. Box 156 Rodeo, CA 94572
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