Housing Choice Voucher Program Pre-Application
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1
2Housing Choice Voucher Program
OFFICE USE ONLY
Pre-Application 2015 Waiting List
APPL #:__________
DATE: ___________
Return Application to:
TIME: ___________
Orange County Housing Authority
PREF: ___________
P.O. Box 8181
rd
300 West Tryon Street, 3
Floor
Hillsborough, NC 27278
ALL MAILED APPLICATIONS MUST BE POST-MARKED BY NOVEMBER 2, 2015
If you need assistance completing the Application or have questions about the Application process, please contact the Orange County Housing
Authority at (919) 245-2490. (Deaf and hearing impaired TDD/TTY (919) 644-3045)
Please print neatly in ink. ALL INFORMATION WILL BE VERIFIED BEFORE YOU RECEIVE A VOUCHER. Only one (1) application per household.
HEAD OF HOUSEHOLD
Head of Household
Date of Birth
Age
Sex
Social Security Number (SSN):
-
-
_____________________ ____________________
____/_____/19____
First Name
Last Name
Month/ Day / Year
Race:
Ethnicity:
Are you or your spouse a veteran?
0 White 0 Black
0 American Indian/ Alaskan
0 Hispanic
0 Asian
0 Native Hawaiian/ Pacific Islander 0 Other___________________
0 Non-Hispanic
Yes ____ No ____
Annual Income
List all sources of income (wages, unemployment, SSDI)
Do you work or have been hired to work in Orange
County? Yes ____ No ____
$ ____________
Current Address (include Apt. #):
City:
County:
State:
Zip:
Home Phone:
Alternate Phone:
Email:
(
)
(
)
)
Relationship
Address or email
Phone
Alternative Contact Person
(
)
HOUSEHOLD COMPOSITION
List all other persons who will be living in your household. (ALL FIELDS REQUIRED)
First Name
Last Name
Social Security Number
Date of Birth
Sex
Annual Income/Source
Relationship
Age
Month/Day/Year
SPOUSE
Do you or any person listed above have a disability? Yes ____ No ____
If yes, please indicate how the disability is validated. Check all that apply:
___ Doctor/Professional Statement
___ Social Security Administration (SSDI)
___ Other: ________________________________
Revised 10/20/2015 jed
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