Section 8 Housing Choice Voucher Waiting List Lottery Form
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2Department of Economic Development and Housing
WAITING LIST INFORMATION LINE (707) 543-3324 TDD (707) 543-3318
SECTION 8 HOUSING CHOICE VOUCHER WAITING LIST LOTTERY FORM
(PLEASE PRINT CLEARLY – Illegible and/or incomplete applications will NOT be processed)
___ ___ ___ - ___ ___ - ___ ___ ___ ___
(___ ___ ___) ___ ___ ___ - ___ ___ ___ ___
Social Security Number
Telephone Number
_______________________________________________
______
___________
First Name
MI
Gender (M/F)
(as it appears on your Social Security Card)
_______________________________________________
______/______/_________
Last Name
Date of Birth
(as it appears on your Social Security Card)
(MM/DD/Year)
________________________________________________________________________________
Mailing Address
City
State
Zip Code
________________________________________________________________________________
Residence Address
City
State
Zip Code
Household Members (people who will live with you). Attach additional pages if necessary.
Name
Date of Birth
SSN
Relationship to You
The following information is required by federal regulation
Race and Ethnicity of the Head of Household
White
Black/African American
American Indian/Alaskan Native
Native Hawaiian or Pacific Islander
Asian
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Total Number of Household Members: ________
The information below is collected for statistical purposes only. Check as many boxes as apply to you.
I am a Veteran
I am a senior (62 or older)
I am homeless
I am disabled
I have a child or children under the age of 18 in my household
I certify under penalty of perjury that the above information is true and correct.
Signature: _______________________________________________
Date: _______________
Note: Lottery forms will be selected at random for placement on the Section 8 Housing Choice Voucher Program Waiting
List. Completing a form does not guarantee you a spot on the Waiting List. You will not receive housing assistance
immediately. The Housing Authority is unable to estimate how long you will have to wait for assistance.
All duplicate lottery forms and lottery forms received before May 1, 2014 or after May 31, 2014
will be rejected.
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