Preliminary Application Form - Housing And Redevelopment Authority Of Winona, Mn
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1
2Housing and Redevelopment Authority of Winona, MN
1756 Kraemer Drive, Suite 100
Winona, MN 55987
(507)454-3665
Preliminary Application
Social Security
Head of Household (Legal Name)
Sex
Date of Birth
Number
M
F _____-____-_____ ____/____/____
First
Last
M.I.
Race
Ethnicity
Monthly Income - Income Source
White
American Indian/Alaska Native
Hispanic
$
Black
Asian or Pacific Islander
Non-Hispanic
Which Housing Programs are you applying for?
Public Housing
Present Address
Emergency Contact
Name ______________________________
Street
City
State
ZIP
Address ____________________________
Mailing Address
Phone
( _______ )
Street
City
State
ZIP
Telephone
Home (__________) _______________________
Work (_____________) ________________________
Other adults who will be living
Relationship
Social
Date
Occupation &
Sex
in the unit: (Legal Name)
to Head
Security Number
of Birth
Monthly Income
M / F
First
MI
Last
Other minors who will be living
Relationship
Social
Date
Name of
Sex
in the unit: (Legal Name)
to Head
Security Number
of Birth
School Attending
M / F
First
MI
Last
Are you a veteran or the spouse of a veteran?
Yes
No
If yes, provide DD-214 papers.
Do you require any modifications or accommodations in order to fully utilize the unit
or the program and its services?
Yes
No
Have you or anyone in your household been evicted from public or assisted housing
for drug related activity within the past three years?
Yes
No
Would you accept an effienceny apartment if one was available?
Yes
No
Applicant(s) statement: I/we certify that the information given to the Housing Authority on household composition, income,
net family assets, and allowances and deductions is accurate and complete to the best of my/our knowledge and
belief. I/we understand that false statements or information are grounds for termination of housing assistance and
termination of tenancy.
Signature--Head of Household
Date
Signature--Spouse OR Other Adult
Date
Notice: You are required to notify the Housing Authority in writing of any change of address. If we cannot contact
you at the above address, your name may be removed from the waiting list, and you will have to re-apply.
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