Pre-Application For Public Housing (Page 2 of 4) in pdf

MISSISSIPPI REGIONAL HOUSING AUTHORITY IV

P.O. BOX 1051 COLUMBUS, MS 39703-1051 / PHONE (662) 327-4121 / FAX (662) 327-4344

HEARING AND SPEECH IMPAIRED (662) 327-8114

PRE-APPLICATION FOR PUBLIC HOUSING

Please circle the county(ies) you wish to apply for

and indicate your first choice:

For Official Use:

____Lowndes

Lowndes

Date __________

(Columbus)

____

(Crawford)

____Oktibbeha

Time __________

(Starkville)

(Maben)

____Choctaw

____Winston

Application # _____

____Webster

____Grenada

Bedroom Size ____

If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to full

utilize our programs and services, please contact the Director of Special Programs at 662-327-4121 ext. 8031 at the

housing authority.

In accordance with the Violence Against Women Act (VAWA) of 2013, the Mississippi Regional Housing Authority IV shall

not deny admission to the project to any applicant on the basis that the applicant is or has been a victim of domestic violence,

dating violence, sexual assault or stalking if the applicant otherwise qualifies for assistance or admission. The information

provided by the applicant about the violence will be kept confidential unless needed in an eviction proceeding, applicant gives

written permission or required by applicable law.

This form must be filled out completely using blue or black ink:

Family Composition: List members names and information who will be living in your household

Name

Relation

Birth date

Age

Sex

Soc. Sec. #

HEAD

List additional family member on a separate sheet of paper

*Your Street Address: _________________________ Mailing Address: ____________________________

City _____________________________________ State _______________ Zip __________________

Phone Number: _______________________

Cell Phone Number ______________________________

(circle):

*Race

White, Black, American Indian, Asian, Hawaiian/Pacific Islander, Mixed

*Marital Status: Single, Married, Widowed, Separated, Divorced

*Family Status: Family, Elderly/Disabled

*Are you a U.S. citizen by birth, naturalized or a national? □Yes □No

Income:

*Do you or any family member in your household work? □Yes □No

If yes, list name of family member(s), name and address of employer, hire date, gross monthly income.

______________________________________________________________________________

*Do you or any family member receive TANF, Child Support or Food Stamps? □Yes □No

If yes, list name of family member(s), source and monthly amount ______________________________________

______________________________________________________________________________

*Do you or any family member receive Social Security/SSI, VA, Unemployment? □Yes □No

If yes, list name of family member(s), source and monthly amount ______________________________________

______________________________________________________________________________

*Do you or any family member receive other income not listed above? □Yes □No

__________________________

If yes, list name of family member(s), source of income and monthly amount.

______________________________________________________________________________

*Do you or any family member own or have disposed of any assets? □Yes □No

Value $____________ Describe _______________________________________________________________

Pre-Application For Public Housing Page 2

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