Homeless Voucher Nomination Form
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4HOUSING AUTHORITY OF THE CITY OF SALEM
HOMELESS VOUCHER NOMINATION FORM
Nomination Date:________________
To be eligible for a Homeless Voucher the family must have lived in the Salem area for the past 6-
months;
As the referring agency partner you certify that this family has lived in the Salem area for the past 6-
months?
Yes
No (If no, the family is not eligible for a Homeless Voucher Nomination)
Where has the family resided in the past 6-months?
Head of Household
Last
First
Middle
Date of Birth
Social Security #
Other Adult
Last
First
Middle
Date of Birth
Social Security #
If there is other adults age 18 or over in the household, you must provide name and Social Security # on
a separate page and attach to this form.
Other Household Members
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Name
Age
Where is family currently residing?
Has the Family voluntarily declined or refused any other forms of housing assistance in the past 12-
months?
Yes
No
If the answer is yes, please explain
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