Application For Luther House Apartment Template Page 3
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14Lutheran Senior Services of Southern Chester County (PA),
Inc.
Luther House II, Inc.
Luther House III, Inc.
Luther House IV, Inc.
APPLICATION FOR LUTHER HOUSE APARTMENT…Page 1 of 4
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OFFICE USE ONLY: DATE RECEIVED_________ APPLICATION #__________
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Name (Head of Household)__________________________________________ M or F
First
M.I.
Last
Present Address__________________________________________________________
Street Address
Apt. #, if applicable
__________________________________________________________
City
State
Zip Code
Number of years living at present address ________ Telephone#_________________
Email Address __________________________________________________________
Date of Birth______________ Social Security # ______________________________
Marital Status: (Circle One) Single Married Divorced Separated Widow Widower
The Information Requested Below is for Federal Reporting Only and is Voluntary:
Race: (Please circle all that apply)
American Indian/Alaskan Native
Asian
Black/African American
Native
Hawaiian or Other Pacific Islander
White
Other Elect Not to Answer
Ethnicity: (Please circle all that apply)
Hispanic or Latino
Not Hispanic or Latino
Elect Not to Answer
Place of Birth_____________________________ Citizenship: USA Canada Mexico
Building Preference? LH I __ LH II ___ LH III ___ LH IV ___ No Preference_____
*You will only be placed on the waitlist for the building(s) you have checked
Do you need an accessible unit? Yes _____ No _____
If yes, considers self: (circle all that apply)
Mobility Impaired
Vision Impaired
Hearing Impaired
Impaired
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