Application For The Public Housing And/or The Section 8 Housing Choice Voucher Program Sheet
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1V
-E
. Y
ET
MAN
OUTH
F
M
H
A
AIRFIELD
ETROPOLITAN
OUSING
UTHORITY
315 N. Columbus St.
Lancaster, OH 43130
P
: 740-653-6618 / F
: 740-653-7600
TTY & O
R
C
: 740-653-2653
HONE
AX
HIO
ELAY
ALLERS
YOU ARE APPLYING FOR THE PUBLIC HOUSING AND/OR
THE SECTION 8 HOUSING CHOICE VOUCHER PROGRAM
It is your family’s responsibility to inform our office of any change(s) such as address, family member or income changes.
Notifying the FMHA of changes will ensure correct status on the waiting list and an ability to reach your family by mail.
Name
______________________________________________
Address
__
Is this address a Homeless Shelter? Yes / No
City
County
State
Zip
Is Head of Household or Spouse presently employed? Yes_____ No_____
Average Hours per week:___________
Is anyone in the household presently employed or have been hired to work in Fairfield County?
Yes_____ No_____
PLEASE LIST HOW MUCH INCOME YOU RECEIVE PER YEAR:______________________________________________________
(example: $635 monthly x 12 = $7620 per year)
FROM WHAT SOURCE(s) DO YOU RECEIVE INCOME (Social Security/Wages/JFS, etc.):_________________________________
List each person who will be living in
Birth Date
Age
Relationship
Social Security
Sex
Is this member
disabled?
the household
# for all adults
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
PLEASE LIST ADDITIONAL MEMBERS ON THE BACK OF THIS FORM
Are you expecting any changes in your household? If yes, explain
___________
Is there anyone in the household in which English is not their primary language?
Yes _____ No_____
If English is not the primary language what is the primary language of that individual?_________________________________
Does the family member have difficulties speaking, understanding, reading or writing English?
Yes _____ No ____
YES
NO
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Is there any household member who served in the active military of the US and was discharged
under conditions other than dishonorable, or is serving in the active military of the United States?
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Is there any household member who is a dependent spouse, surviving spouse, dependent parent,
minor child or ward of: a person who served in the active military of the US and was
discharged under conditions other than dishonorable, a person who was deceased while
serving in the active military at the time of death or a person who is serving in the active
military?
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□
Does anyone in the household owe a debt to any Housing Authority? If yes, where?______________
The Department of HUD uses this information to determine the degree to which its programs are utilized by minority families;
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Head of the household is:
White
Black
Spanish Origin
American Indian
Asian or Pacific Islander
Other__________
I CERTIFY THAT ALL INFORMATION ON THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE
HEAD OF HOUSEHOLD SIGNATURE
DATE:______________________
The FMHA is required to inform the INS of anyone not lawfully present in the United States and submit quarterly reports of their residence.
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