Application Form - Louisville Metro Housing Authority (Page 2 of 2) in pdf

In the past two years have you disposed of (sold or given away) assets for less than the current value? _____ If yes, what was

it?_____________________ What was the value $__________ Who did you give it to or sell it to? ______________________

______________________________

Relationship ___________________________________

Was there a financial penalty in selling or giving this asset away? Explain__________________________________________

III.

PAST PARTICIPATION: Have you ever applied for or participated in Section 8 Rental Assistance Program or Public

Housing? _____. If yes, when and where ____________________________________________________________.

Do you have an outstanding debt owed to the Housing Authority? ________ If yes, amount if known. $____________

Have you or a family member been convicted of methamphetamine production on the premises of Federal assisted

housing? _______ Date of conviction _______________.

Have you or a family member been evicted from Federal assisted housing in the last five years, because of drug related

criminal activities? _______. If yes, date of eviction _________________.

***VERY IMPORTANT PLEASE COMPLETE ALL BLANKS. FAILURE TO ANSWER ALL QUESTIONS MAY

DELAY YOUR ELIGIBILITY FOR A LOCAL PREFERENCE. REMEMBER TO SIGN AT THE BOTTOM OF THIS

PAGE.***

IV.

LOCAL PREFERENCES (COMPLETE IN FULL QUESTIONS 1 THROUGH 11)

1. How much do you pay for rent each month? $___________

2. Do you pay the bill for:

LG&E Yes _____ No _____, Average cost per month $__________

If not LG&E, do you pay for:

Gas, Yes ____ No ____, Average cost per month $______Electricity, Yes ____ No ____, Average cost per

month$________

Do you pay the bill for:

Heating Oil, Yes___ No___, Average cost per month $______Water/Sewer, Yes___ No ____, Average cost per

month$_______

Bottled Gas, Yes____ No____, Average cost per month $_______Garbage, Yes____ No_____ Average cost per month

$________

3. Do you live in Public Housing or do you reside in a unit which receives rental subsidy/assistance? Yes _____

No ___ If yes, please explain ___________________________________________________________

4. Does someone outside your household or a Government or Private Agency or Charity or Religious Organization regularly

help you pay your bills or utilities? __________ If yes, tell us from whom and how much. ______________ $ ___________

5. Has a Government Agency sent you a written notice to move from your home within the last six months? ____Yes ____ No

If yes, were you told you would have to move because your home was condemned or found to be unsafe? _________

(KEEP A COPY OF THE NOTICE SINCE YOU WILL HAVE TO BRING IT IN WITH YOU IF YOU ARE

SCHEDULED FOR AN APPOINTMENT.)

6. a. Has someone in your household physically abused you or other family members, or threatened to do so? ______________

b. Has someone in your household been a victim of a hate crime in your neighborhood within the last six months? ________

Has this been reported to the police or a Human Rights Agency? _________________________________________

7. Does the home you now live in have: (Check Yes or No)

Hot and Cold running water? Yes _____ No _____

A usable flush toilet inside your home for the exclusive use of your family? Yes _____ No _____

A usable bathtub or shower inside your home? Yes _____ No _____

A Kitchen? Yes _____ No _____Electricity? Yes _____ No _____Adequate Heat? Yes _____ No _____

Any unsafe electrical service? Yes _____ No _____

Does your home have any other unsafe conditions? Yes _____ No _____ Explain __________________________________

8. Do you live in a shelter for homeless families or individuals or in transitional housing? _____ Name the shelter/transitional

housing:_____________________________________________________________

9. Check here if you do not have one place where you can stay every night. _____

10. Does any member of your family have a mobility or other impairment that prevents them from using critical elements of the

unit?_________

11. Are you a former Section 8 Homeownership Participant?___________

DO YOU REQUIRE REASONABLE ACCOMMODATION in order to take full advantage of the Louisville Metro Housing

Authority housing programs and related services? Yes_____ No_____.

Type of accommodation needed_____________________________________________________________________________

WARNING: Section 1001 of Title 18 of the U. S. code makes it a criminal offense to make willful false statements or

misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. If information is

reported in error or omitted from this form, the family will be determined to be ineligible at the time of application.

ALL APPLICATION INFORMATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

SIGNATURE _____________________________________________________ DATE _______________________

MAIL TO LMHA, PO BOX 189, LOUISVILLE, KY 40201-0189

DO NOT WRITE BELOW THIS LINE FOR LMHA STAFF ONLY

_______________________________________________________________________________________________________

ELIGIBLE FOR LOCAL PREFERENCE, YES _________ NO __________

RENT_____ INVOLUNTARILY DISPLACED – PHYSICAL VIOLENCE _____ SUBSTANDARD _____

HOMELESS_____

INVOLUNTARILY DISPLACED – GOVERNMENT ACTION ______ FORMER SECTION 8 HOMEOWNER PARTICIPANT _____

03/10

Application Form - Louisville Metro Housing Authority Page 2

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