Housing Authority Waiting List Change Form printable pdf download

HOUSING AUTHORITY WAITING LIST

CHANGE FORM

Please check the waiting list you are now on:

( ) Public Housing

NAME: ____________________________________ ADDRESS:______________________________________

CHANGE REQUESTED:

Address Change:

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

Name:

Relationship:

Date of

Social Security

Income:

Source of Income:

Birth:

Number:

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

_____1. Head of household and/or any co-head is:



working at least 30 hours per week for 6 months prior to being housed.



working an average of 20 hours per week for 6 months prior to being housed and actively participating in attending

college or instructional program of professional or career development on at least a half-time basis for 2 consecutive

semesters.

Name of Employer: ____________________________________________________________

Address of Employer: ___________________________________________________________

Start Date: ___________ Number of hours worked per week:________ Pay per hour:________



receiving unemployment payments after having been employed on a continuous basis for at least 1 year.

_____2. Head of household and/or any co-head is age 62 or older or is receiving any payments based on the individual’s inability to

work.

_____3. I am homeless (have a primary nighttime residence that is supervised publicly or privately operated shelter or transitional

housing or currently reside in a hotel/motel in Frederick City or County for a minimum of thirty (30) days.)

_____4. I am displaced by fire or natural disaster or by government action.

_____5. I live or work within Frederick City or County.

_____6. Head of Household or spouse is a disabled veteran.

_____7. Other veterans or servicemen and their families.

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

_________________________________________________________________________________________________

Signature

Date

Housing Authority Waiting List Change Form