Fillable Preliminary Application For Public Housing (Page 2 of 2) in pdf

Brookline Housing Authority Preliminary Application Continued

Gross Income: List the income amount before deductions and source for each household member.

Name of Household Member

Source of Income

Gross Monthly Income

Salaries/wages including overtime/tips

VA Disability

Net income from business or self-employment

Asset income: trusts, interest, dividends, etc.

Pensions and annuities

Unemployment, disability/workers compensation

Regular Social Security benefits, SSI and/or SSDI

AFDC, EAEDC, RRP or TAFDC

10.

Alimony and/or Child Support

Total Gross Monthly Income:

$ 0.00

Priority/Preference:

Before answering this question, please refer to the page with the required documentation of each priority/preference category that accompanies this application. You

will not be required to provide verification of the priority/preference until your name approaches the top of the wait list. However, if you do not qualify for a priority/preference at that time, you will

not be given that status but may remain on the waiting list as a standard applicant.

Displaced: Please check off if you have been displaced due to:

Code Enforcement

Natural Disaster

No Fault Eviction

Severe Medical Emergency

Public Action

Fleeing Domestic Violence

Veteran:

You may apply for Veteran’s Preference if you are a Veteran, the spouse, surviving spouse, dependent parent or child, or divorced spouse with a dependent child of the Veteran. A copy

of the Veteran’s discharge or separation papers (form DD214) will be required at the time of final verification.

If you are a veteran or a family member of a deceased veteran whose death was service related please check here

Local:

You may apply for Local Preference if you live or work in Brookline.

If you live or work in Brookline please check here

10. Mobility: If you or any members of your household use a wheelchair or have limited mobility please check here

Briefly explain your needs:

(i.e. first floor or elevator, wheelchair accessible unit, etc.)

11. Household Racial/Ethnic Designation:

(optional, for statistical purposes only):

Asian/Pacific Islander

Hispanic

White/Caucasian

Black/African American

Decline to Answer

Native American/Alaskan Native

Non-Hispanic

Multi-Racial

I understand that this application is not an offer of housing. I understand that the Brookline Housing Authority will make no more than one offer of a unit per program. If I am

offered a unit and refuse this offer of an BHA owned unit, my application will be removed from the waiting list for that program.

I also understand that if I refuse an offer of an apartment that I will not be granted Preferences consideration in the future.

I understand that it is my responsibility to inform the Brookline Housing Authority, in writing of any change of address, income or household composition. I authorize the

Brookline Housing Authority to make inquiries to verify the information I have provided in this application. I certify that the information I have given is true and correct. I

understand that any false statement or misrepresentation may result in the disqualification of my application.



By checking this box I, the Head-of-Household, certify that the above information is true and accurate to the best of my knowledge.

 SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY 

WARNING: Title 18, Section 1001 of the US Code, states that a person is guilty of a felony for knowingly or willingly making false or fraudulent statements to any department or agency of the United States.

EQUAL HOUSING OPPORTUNITY

No applicant shall be rejected or in any other way unlawfully discriminated against because of race, color, religious creed, national or ethnic origin or ancestry, sex, age, mental or physical disability, military status, sexual

orientation, marital status, presence of children in household (born within or out wedlock), or source of income. Furthermore, no otherwise qualified individual with handicaps shall, solely by reason of his/her handicap, be

excluded from participation in be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

Preliminary Application For Public Housing Page 2

Related Articles

Related forms

Related Categories