Pre-Application For Housing Assistance


Section 8
Housing Choice Voucher Program
Complete and return to
one of the regional
agencies listed on the
reverse of this form
For agency use only:
Pre-Application for housing assistance
Date/Time Stamp/
Control Number
Please print neatly in ink. All fields are required. Submit this form only. Incomplete, photocopied, e-mailed or faxed applications will not be accepted.
If you are already on our Section 8 waiting list your record will be updated using the information that you provide below. Due to the volume of
applications received, we will not verify the receipt of mailed applications. We cannot be responsible for material that is illegible or missing as a result of
transmitting by fax or e-mail or lost/delayed through the mail.
One-third of all applications are dropped from the waiting list due to unreported address changes. Do not let this happen
to you. Report any change of address in writing to one of the regional agencies listed on the reverse of this form.
Head of Household Information
Social Security Number
Phone (include area code)
First Name
Middle Name
Last Name
Zip code
Shelter Name
Shelter Address
Zip code
Household and Demographic Information
How many people will live in the unit? Include yourself. _____
Gross annual household income $_____________
Write in the approximate amount of your family’s
gross (before taxes) annual income. Include all
sources for all family members.
Check if the head of household or spouse is:
62 years old or older
Displaced by government action
We collect data on race & ethnicity in accordance with federal regulations. People of various races may also be of Hispanic
ethnicity. Please indicate if you are Hispanic. Your answers will not affect your application.
Is the head of household (Select as many as appropriate)
Black/African American
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
Is the head of household (Check only one)
What is your current housing situation? (Check one box that best applies)
I am homeless
I am doubled up with friends or relatives
I live in substandard housing
I live in public housing
I have been involuntarily displaced
I live in a transitional housing program
I pay more than 50% of my monthly income for
I live in subsidized housing
rent and utilities
I live in a shelter
Other (describe)
Certification of Applicant -
Please read this statement very carefully. By signing, you are agreeing to its terms.
I hereby certify that the information I have provided in this pre-application is true and accurate. I understand that:
any misrepresentation or false information will result in my application being cancelled or denied, or in
termination of housing assistance;
 this is a pre-application for tenant-based rental assistance through DHCD and its regional administering
agencies and is not an offer of housing;
 at the time I rise to the top of the waiting lists, I will be required to provide verification of the information
I have provided here, in accordance with federal housing regulations and DHCD policy;
 it is my responsibility to notify any one of DHCD’s regional administering agencies of any change of
address in writing and I understand that my application may be cancelled if I fail to do so;
 my participation in the Section 8 housing program is subject to my being eligible and in compliance with
HUD and DHCD regulations; and that I will be subject to a criminal history check.
I agree that DHCD can share my information with other state agencies for the purposes of determining program
Signature of head of household
DHCD manages a limited number of project-based Section 8 apartments in or near most major cities and
towns throughout the state. To find out more contact one of the agencies on the reverse of this form or
visit the Housing Consumer Education Center website at
DHCD pre-application form for HCVP| 8/1/14


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