Application Form - Louisville Metro Housing Authority printable pdf download

THIS APPLICATION MUST BE MAILED TO THE

LOUISVILLE METRO HOUSING AUTHORITY, P O BOX 189, LOUISVILLE, KY 40201-0189

FILL OUT COMPLETELY OR THE APPLICATION WILL NOT BE PROCESSED***PLEASE PRINT CLEARLY***

LOUISVILLE METRO HOUSING AUTHORITY SECTION 8 & MOD REHAB PROGRAMS FOR 801 VINE STREET OFFICE.

*** APPLICATONS ARE ACCEPTED BY MAIL ONLY AT THE ADDRESS LISTED ABOVE ***

YOUR FAILURE TO COMPLETE ALL SECTIONS MAY DELAY YOUR APPLICATON FROM BEING PROCESSED

PERSONAL INFORMATION

NAME _________________________________________________________________________________________________

(Last Name)

(First Name)

(Middle Initial)

ADDRESS ____________________________________________

__________ ____________________________________

(Street)

(Apt #)

(City)

_______________

____________________

(State)

(Zip Code)

(Home Phone #)

(Work Phone #)

MAILING ADDRESS (If different from above) _____________________________________________________Zip ________

***FOR STATISTICAL PURPOSES ONLY*** (CHECK ONLY ONE)

RACE: _____White _____Black _____

American Indian / Native Alaskan

_____ Asian / Pacific Islander

ETHNICITY (CHECK ONE)

_____ Hispanic

_____ Non-Hispanic

LIST ALL PERSONS INCLUDING YOURSELF WHO WILL LIVE WITH YOU IN ASSISTED HOUSING

***At least one member of the household listed below must have legal residency status for the family to be eligible for

housing assistance***

(Full Legal Name)

(Relationship)

(Date of Birth)

(Age)

(Sex)

(Social Security #)

______________________________ _____ Head______

_____/______/_____

_____ _____ ____________________

______________________________ ________________

_____/______/_____

_____ _____ ____________________

______________________________ ________________

_____/______/_____

_____ _____ ____________________

______________________________ ________________

_____/______/_____

_____ _____ ____________________

______________________________ ________________

_____/______/_____

_____ _____ ____________________

______________________________ ________________

_____/______/_____

_____ _____ ____________________

______________________________ ________________

_____/______/_____

_____ _____ ____________________

(List Additional Members on a separate paper. Make sure you list Name, Relationship, DOB, Age, Sex and Social Security #)

If the Head of Household listed above is under 18 years of age, are you legally emancipated? __________

If you are a one-person family, check here if you are eligible because you are pregnant. __________

Is any member listed above handicapped or disabled? __________

How long is the handicap or disability expected to continue? ___________

Does any member of your family require the use of a wheel chair? __________

Please list the name of the disabled or handicapped family member (s). _____________________________________________

Is this person(s) able to use all areas of your current home and are they able to easily get out of the unit? __________

Are you enrolled in an institution of higher learning?_______________

Are you a veteran?___________________________

II.

SOURCES OF INCOME: List all checks and money you and everyone who will be in your assisted household NOW

receive. See INFORMATION SHEET listing EXAMPLES of income that needs to be included.

HOUSEHOLD MEMBER(S)

SOURCE OF INCOME

AMOUNT PER MONTH

DO NOT WRITE IN THIS BOX

_________________________

___________________

$_____________________

Annual $___________

Annual $_____________________

_________________________

___________________

$ ____________________

Annual $ ___________

Annual $_____________________

_________________________

___________________

$ ____________________

Annual $ ____________

Annual $ ____________________

_________________________

___________________

$ ____________________

Annual $ ____________________

Total $ ___________________

ASSETS: (ANSWER YES OR NO. IF YES, LIST NAME OF BANK, ACCOUNT # AND ACCOUNT BALANCE)

Checking _______ Name of Bank _____________________Account # _________________ Account Balance $____________

Savings ________ Name of Bank _____________________Account # __________________Account Balance $___________

Certificates of Deposits _____Name of Bank __________________Account # _____________Account Balance $ __________

Credit Union Shares _______ Name of Bank ______________Account # _________________Account Balance $ __________

Stocks and Bonds _________ Value $ _______________ Retirement/Pensions/IRA Program _________ Value $ _________

Life Insurance (Cash Value) $ ____________ List all Real Estate you own (Do not include burial plots):

Current Value of Real Estate $ __________ Amount you still owe $__________ Is this your home? __________

List all other assets/items (or lump sum payments made to you in the last 3 months) which are of value. (DO NOT include

personal property such as jewelry or cars unless they are an investment.) __________________________________________

03/10

(CONTINUED ON OTHER SIDE)

Application Form - Louisville Metro Housing Authority

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