Homeless Voucher Nomination Form Page 2
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4Has any family member previously received housing assistance from another housing agency in the past
three years?
Yes
No
If yes, what is the name of the agency and the state in which they received assistance and what form of
assistance did they receive?
Why are you nominating this family for a Homeless Voucher?
How long has your agency been serving this family?
Year’s _______
Months _______
Gross monthly income $ __________ Source(s) of income ____________________________________
Does the family need an interpreter?
Yes
No
Language: ______________________
Is your agency represented at the monthly Emergency Housing Network Meeting?
Yes
No
Please provide the name of the individual in your agency that will assist this family in the process and
whom we may contact for further information:
Name:
Date:
Agency:
Phone #:
Address
Fax:
Email:
Mail form to Heather Jones, TBHS Dept., Housing Authority of the City of Salem, 360 Church Street SE, Salem,
Oregon 97301 or fax form to (503) 588-6465 (attention to Heather Jones) or e-mail to
hijones@cityofsalem.net
The Fair Housing Act prohibits discrimination in the sale, rental, or financing of housing on the basis of race, color, religion,
sex, handicap, familial status, or national origin. Federal law also prohibits discrimination on the basis of age. Complaints
may be forwarded to the Administrator, USDA, Washington DC 20250
The Housing Authority of the City of Salem does not discriminate against any person due to disability, race, color, religion, sex,
source of income, familial status, national origin, actual or perceived sexual orientation, gender identity, marital status,
and/or domestic partnership in accessing, applying for or receiving assistance, or in treatment or employment in any of its
programs and activities.
Complaints regarding accessibility of the Authority’s programs to individuals should be submitted to Dominique Donaho,
Salem Housing Authority, 360 Church Street SE Salem, Oregon 97301 or at
ddonaho@cityofsalem.net
Questions or comments
may also be made by phone at 503-588-6368 or 411 for hard of hearing clients; appropriate auxiliary aids (interpreters,
readers, assistance filling out forms, etc. will be provided upon request.
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