Permanent Supportive Housing Program (Page 3 of 4) in pdf

Permanent Supportive Housing Program Page 3

City:

State:

ZIP Code:

Position:

Supervisor’s Name

Monthly Income:

Other Sources of Income

Amount:

How often received:

Social Security:

SSI:

AFDC:

Unemployment Benefits:

Child Support:

Pension:

Food Stamps:

Employment:

Other:

Assets

Cash on Hand:

Banking Institution:

Checking Account No:

Balance:

Banking Institution:

Savings Account No:

Balance:

Banking Institution:

IRA Account No:

Balance:

Real Estate (Description):

Value:

Monthly Income:

Other:

Have You Disposed of Any Assets For Less Than Fair Market Value Within the Last Two Years?

If Yes, Explain:

Other Occupants in Household

Persons who are not listed below are not authorized to live in the apartment.

Name:

Date of Birth:

Sex:

Relationship:

SSN:

Name:

Relationship:

Date of Birth:

Sex:

SSN:

Name:

Date of Birth:

Sex:

Relationship:

SSN:

Name:

Date of Birth:

Sex:

Relationship:

SSN:

Criminal History

Have you or any member of your household been convicted of a violent crime within the last 10 years?

Have you or any member of your household been convicted of a non-violent crime within the past 5 years?

Have you or any member of your household been involved in the sale, manufacture or distribution of a controlled

substance?

Have you or any member of your household been arrested or convicted for illegal use, sale, distribution or manufacture

of a controlled

substance?

Are you or any member of your household a registered sex offender? If yes, in which state:

Have you or any member of your household been evicted from a Federally Assisted property within the last 3 years?

If yes, when?

What property?

Please describe your current legal status:

Please list all states that you have lived in:

Permanent Supportive Housing Program Page 3

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