Sample Housing Authority Waiting List Change Form printable pdf download

Sample Housing Authority Waiting List Change Form

HOUSING AUTHORITY WAITING LIST CHANGE FORM

Please check the waiting list(s) you are on:

(

) Housing Choice Voucher (Section 8) Program

(

) Section 8 Moderate Rehabilitation Program (Carriage House Apts., 117 S. Market Street)

NAME: ___________________________________

ADDRESS: ________________________________

PHONE NUMBER: _________________________

________________________________

CHANGE REQUESTED:

New Address: __________________________________________________________________________

APPLICATION FAMILY CHANGE: I would like to ADD / REMOVE (circle one) the following people:

Name

Relationship

Date of

Sex

Social Security

Income

Source of

Birth

M/F

Number

Income

PREFERENCE CERTIFICATIONS

(Select only those for which you feel you are qualified):

____1. Head of Household or co-head is elderly (62 or older), handicapped or disabled

____2. I live or work within the Frederick City limits or within the Frederick County limits

____3. Head of Household or co-head is employed, working an average of 30 hours per week for at least 6

months.

Name of Employer: _________________________________________________________________

Employer’s address:_________________________________________________________________

I work ______________ hours per week

____4. Head of Household or co-head is actively participating in programs such as attending Community

College full-time, or similar instruction program of professional or career development.

I am enrolled at: ____________________________

____5. Head of Household or co-head is a veteran

BY SIGNING THIS FORM, I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT.

__________________________________________________________ _____________________________________

Signature

Date

11/2016

Sample Housing Authority Waiting List Change Form