Supported Housing For Persons With Disabilities Pre-Application (Page 4 of 4) in pdf

Supported Housing For Persons With Disabilities Pre-Application Page 4

SUPPORTED HOUSING FOR PERSONS WITH DISABILITIES

PRE-APPLICATION

HOW MANY PEOPLE WILL LIVE IN THE UNIT?

Please include yourself: __________

______________________________________________

Name

Age

M / F

Name

Age

M / F

______________________________________________

Name

Age

M / F

Name

Age

M / F

______________________________________________

Name

Age

M / F

Name

Age

M / F

HAVE YOU OR ANYONE IN YOUR HOUSEHOLD BEEN ARRESTED FOR CRIMINAL AND/OR DRUG-

RELATED ACTIVITY WITHIN THE LAST 3 YEARS?

______Yes ______No

DO ANY PERSONS WHO WILL LIVE IN THE UNIT HAVE A DISABILITY?

______Yes ______No

FOR FEDERAL GOVERNMENT STATISTICAL PURPOSES ONLY.

Please identify your race and ethnicity by checking one box in each of the two categories below:

Category 1: Race

Category 2: Ethnicity



White

Hispanic



Black/African American

Non-Hispanic



American Indian/Alaska Native



Asian



Native Hawaiian/Other Pacific

Islander

10. SOURCE(S) OF FAMILY INCOME. CHECK ALL THAT APPLY AND IDENTIFY AMOUNT.



Wages

_________________

Social Security _________________

Public Aid

_________________



SSI/SSD

_________________



TANF/Welfare _________________



Child Support _________________



Pensions

_________________

Alimony

_________________

Other

_________________

11. I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE.

I understand that submission of false information or misrepresentation may result in loss of eligibility to participate in the

Housing Choice Voucher Program.

Signature of Head of Household: _________________________________________________ Date: ____ /_____ /______

If you are placed on the waiting list for supported Housing for Persons with Disabilities you will be

notified in writing. Once on the waiting list you MUST notify DHA in writing of any change of address,

phone number, e-mail address or other contact information. Please send changes to the attention of the

Waiting List Specialist.

If the DuPage Housing Authority is unable to contact you at the above address, your name may be

removed from the waiting list and you will have to reapply.

Completed pre-applications must be hand delivered to the DuPage Housing Authority at 711 E. Roosevelt

Road, Wheaton, IL 60187



Information is also available at

Supported Housing For Persons With Disabilities Pre-Application Page 4

Related Articles

Related forms

Related Categories