Change Of Mailing Address Form

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OFFICE USE ONLY
UPDATED ___________
DONE BY ____________
HOUSING ASSISTANCE APPLICATION UPDATE (PLEASE PRINT)
NAME OF HEAD OF HOUSEHOLD _______________________________________ SSN # __________________
CHANGE OF MAILING ADDRESS
If you are only reporting a CHANGE of Address, you do NOT need to complete the remainder of the form.
File Address____________________________________________City_______________________Zip______________
NEW Address___________________________________________City_______________________Zip______________
Current Landlord________________________________________ Lease Start Date_____________________________
ADDING OR REMOVING PEOPLE FROM YOUR APPLICATION
ADDING OR REMOVING PEOPLE FROM YOUR APPLICATION
You MUST list the full name, relationship, sex, date of birth and SS# of people your are referencing
You MUST list the full name, relationship, sex, date of birth and SS# of people your are referencing
FULL NAME
RELATIONSHIP
SEX
DATE OF
ETHNICITY
RACE
SOCIAL
DESIRED ACTION
DOES THIS
TO YOU
BIRTH
SECURITY #
PERSON HAVE
INCOME?
ADD OR REMOVE
YES OR NO
ADD OR REMOVE
YES OR NO
ACCESSIBILITY/ACCOMMODATIONS
Do you or any household member have a disability or handicap that we need to be aware of because you require an
apartment with specific features such as hearing/visual, mobility or wheelchair accommodations? ____ YES _____ NO
If yes please indicate which of the following feature is required and who needs this feature
I require a dwelling with special features for the ______ VISUALLY or ______ HEARING impaired or _____ BOTH
I require a dwelling with special features for the ______ MOBILITY impaired, EXPLAIN
ADDING OR REMOVING INCOME FROM YOUR APPLICATION
FULL NAME
DESIRED ACTION
WEEKLY
TANF/CASH
FOOD
CHILD
SOCIAL SECURITY
UNEMPLOYMENT
OTHER
WAGES
ASSISTANCE
STAMPS
SUPPORT
OR SSI BENEFITS
COMPENSATION
EXPLAIN
ADD OR REMOVE
ADD OR REMOVE
If NEW employment, please answer the following questions:
Employer Name & Address ____________________________________________Phone________________________________
Start Date _______________ Pay Rate $________ per hour Are you paid ______ weekly ______ bi-weekly ______monthly
st
nd
rd
Do you work _____ full time _____ part time
Do you work ____ 1
shift _____ 2
shift _____ 3
shift
If you are receiving Unemployment Compensation please provide your pin # used to report a claim to the PAT System ____________
_______________________________________________________________________________________________________
I do hereby swear and attest that all of the information above about me is true and correct. I also understand that ALL CHANGES
in the income of any member of this household as well as any changes in the household members must be reported to the
Housing Authority IN WRITING IMMEDIATELY.
I hereby authorize the Housing Authority to obtain a criminal report for all adult household members for an criminal activity or
proceeding for pending charges or prior convictions of a crime in any court or jurisdiction.
Signature________________________________________________________ Date_____________________________
CHANGING YOUR WAIT LIST
The York Housing Authority allows Public Housing Applicants to be on a wait list for ONE specific geographical area in addition to the
General Occupancy waiting list. If you want to change your geographical wait list please select ONE below.
GEOGRAPHICAL WAIT LIST – ELDERLY
GEOGRAPHICAL WAIT LIST – FAMILY
_____ Springfield Apartment, West Manchester Twp
_____ Hanover (2 & 3 Bedroom Dwellings)
_____ Stony Brook Manor, Springettsbury Twp
_____ Northern York County, New Cumberland (2 & 3 Bedroom Dwellings)
_____ The Fairmont, New Cumberland
_____ Yoe/Red Lion/Windsor/Glen Rock (2 & 3 Bedroom Dwellings)
1 Bedroom Dwellings Only
_____ Wrightsville (2 & 3 Bedroom Dwellings)
_____ General Occupancy
_____ General Occupancy, York City (2-5 Bedroom Dwellings)
Efficiency and 1 Bedroom Dwellings Only
TAX CREDIT/AFFORDABLE HOUSING WAIT LIST
The York Housing Authority manages three (3) Tax Credit Properties that income eligible applicants can apply for. To be eligible for one of the wait
lists below, you must meet the minimum income eligibility requirements annually, unless you currently have a Section 8 Voucher. There are no one
(1) bedroom units available at these sites. If you want to be on one or all of these entire wait lists, please indicate below.
_____ Village Court Apartments, Dover PA (2 and 3 bedroom units)
_____ Waverly Court Apartments, Springettsbury Township (2 and 3 bedroom units)
_____ Homes at Thackston Park, York City (2, 3 and 4 bedroom units)
OFFICE USE ONLY ______ Tax Credit _____ Section 8 _____ Public Housing

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