Housing Choice Voucher Program Centralized Waiting List Pre-Application printable pdf download

SECTION 8 HOUSING CHOICE VOUCHER PROGRAM

For Agency Use Only:

Date/Time

CENTRALIZED WAITING LIST PRE-APPLICATION

1. HEAD OF HOUSEHOLD

Social Security or Alien Registration #: __________________________ Date of Birth: ______________

First Name: ________________________ Middle: _____________ Last Name: __________________________________________

Home Address*: ____________________________________________________________________________________________

City/Town: ________________________________________________ State: ________ Zip Code: __________________________

Telephone: ___________________ E-mail: ___________________________Work Address* (City/Town ONLY): _____________

*Some housing authorities give preference to applicants and/or spouses living or working in the housing authority’s town.

Mailing Address (if different from Home Address): ________________________________________________________________

City/Town: ________________________________________________ State: ________ Zip Code: __________________________

2. SPOUSE/PARTNER

Social Security or Alien Registration Number: _____________________________ Date of Birth: ___________________________

First Name: ________________________ Middle: _____________ Last Name: __________________________________________

Work Address* (City/Town ONLY): ____________________________________________________________________________

3. HOW MANY PEOPLE WILL LIVE IN THE UNIT? Please include yourself. ______________________________________

4. TOTAL GROSS ANNUAL HOUSEHOLD INCOME: __________________________________________________________

5. RACE & ETHNICITY (Not mandatory. For HUD statistical purposes only)

Check all that apply:

Check one:

White

Hispanic or Latino

Black/African American

Non-Hispanic or Non-Latino

American Indian/Alaska Native

Asian

Native Hawaiian/Other Pacific Islander

6. PREFERENCES (Check ALL that apply.)

Please read attached “Definitions of Preferences” to determine which apply to you. NOTE: Participating housing authorities may

or may not use some or all of the preferences listed below. (A housing authority will request documentation of preferences at the time

you reach the top of the waiting list and are selected for final determination.)

1. Board of Health Condemnation

14. Rent Burdened 40% of Income

2. Disabled

15. Resident of Greater Chelmsford Area (see town list)

3. Displaced by Hate Crimes, Reprisals

17. One-person Family

4. Displaced by Landlord Non-Renewal

18. Substandard Housing (includes homeless)

5. Displaced by Natural Disaster

19. Client for Project Based Section 8 Unit

6. Displaced by Public Action

20. Tenant of Project Based Section 8 Unit

7. Displaced by Domestic Violence

21. Veteran

8. Elderly

22. Working

9. Near Elderly (55+)

25. Participant in Metco Program in Wayland school

10. Extremely Low Income

26. Resident of South Berkshire County (see town list)

11. Health Condition (disability affecting housing need)

27. Resident of Quincy or Adjacent Town (see town list)

12. Homeless

28. Activated Military Personnel to Persian Gulf

13. Rent Burdened 50% of Income

7. I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE.

I understand that submission of false information or misrepresentation may result in loss of eligibility to participate in the

Section 8 Housing Choice Voucher Program. I certify that I have attained the age of eighteen and therefore have full legal

capacity to act on my own behalf in the matter of contracts.

Signature of Head of Household __________________________________________ Date ______________________

Complete ALL information. Return completed application to one of the participating housing authorities listed on the back of

this form. Incomplete, photocopied, e-mailed, or faxed applications will not be accepted.

preapp 6/10

Housing Choice Voucher Program Centralized Waiting List Pre-Application

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