Pre-Application For Public Housing (Page 3 of 4) in pdf

MISSISSIPPI REGIONAL HOUSING AUTHORITY IV

PRE-APPLICATION FOR PUBLIC HOUSING Pg. 2

Past Rental History for the last 7 years:

1. Landlord Name: ___________________

2. Landlord Name: _______________________

Address: ___________________________

Address: ______________________________

City, State Zip:_______________________

City, State Zip:__________________________

Phone: _____________________________

Phone: ________________________________

Address of Unit:______________________

Address of Unit:_________________________

From ______________ To _____________

From ______________ To ________________

List additional rental history on a separate sheet of paper

Person To Contact In Case of Emergency:

Name: _______________________________________ Relation: ______________

Address: ______________________________________ Phone: ________________

Records:

*Have you or anyone in your household ever been arrested or convicted of a Felony, Crime of Physical

Violence, or a Drug-Related Crime? □Yes □No

*Are you or anyone in your household subject to a sex offender registration requirement under a

State/National Sex offender registration program? □Yes □No

*Have you or anyone in your household ever committed any fraud in a federally assisted housing program

or been requested to repay money? □Yes □No

*Have you or anyone in your household ever been evicted or had your assistance terminated from any

federally assisted housing program or been evicted from a private landlord? □Yes □No

)? □Yes □No

*Do you currently owe a private landlord or a utility company

(Electric, Gas, or Water

I have no objections to inquires being made for the purpose of verifying the statements made above.

I/We certify the information given to the Mississippi Regional Housing Authority IV on household

composition, income, assets, and rental/criminal history is accurate and complete to the best of

my/our knowledge. I/We understand that false statements or information are reasons for denial.

______________________________

_____________________________

_____________

Signature(Head)

Signature(Other Adult)

Date

LOCAL PREFERENCES

1. Involuntarily Displaced:

(a) I have (within the last 6 months) been displaced as a result of a disaster such as a fire, flood, hurricane,

tornado, etc. located within the Housing Authority's area of operation and my housing unit is

□Yes □No

uninhabitable and I am not living in standard permanent replacement housing.

(b) I have (within the last 6 months) been displaced as a result of a disaster located within a federally

declared disaster area and my housing unit in uninhabitable and I am not living in standard permanent

□Yes □No

replacement housing.

2. Working Preference:

(a) I am currently employed (head, spouse or co-head) and my hire date was at least 6 months previous

and I am working at least 20 hours per week or make the equivalent of 20 hours at the current minimum

□Yes □No

wage.

(b) I am the head, spouse or sole member and am a person whose age is 62 or older, or am a person with

□Yes □No

disabilities.

Certification:

We do hereby certify that, as indicated above, we are □, are not □ applying for a local preference. We

understand that prior to receiving the preference we will be required to furnish documented proof, as

requested by the Housing Authority.

______________________________

_____________________________

_____________

Signature(Head)

Signature(Other Adult)

Date

____________________________________________________________________________________

(PHA Use Only) Previous claims with any PHA?□Yes □No; Checked mdoc/nsopw.gov.?□Yes □No

The applicant is (__) is not (___) pre-eligible; does (___) does not (___) have a preference.

Reviewed By: _________________________________ Date __________________

(11/2014)

Pre-Application For Public Housing Page 3

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