Pbv Application Packet - Housing Authority Of Snohomish County

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HOUSING AUTHORITY OF SNOHOMISH COUNTY
Avenue West • Everett, Washington 98204
th
12711 - 4
PHONE (425) 290-8499 • FAX (425) 290-5618
PBV APPLICATION PACKET
If you need assistance completing this packet, please contact a PBV Specialist by email or phone. If you require an
interpreter, let us know and one will be provided at no cost.
Please complete, sign and return the following forms:
 PBV Referral Form.
 Cooperative Agreement.
 Personal Declaration. Completed accurately, clearly and signed by Head of Household. Include all supporting
documentation for income, assets and deductions as applicable. See Verification Requirements for more information on
acceptable verification.
 Homeless Status Form.
 No Income Statement. If any adult member of your household has zero income, sign and return the no income statement.
 HUD and HASCO Release Form. Signed by all adult members.
 Supplemental Contact Form.
 Verification of Citizenship Consent Form.
 Declaration 214. If non-eligible citizen, please include copy of alien registration card.
 HUD Form 52675. Notification of EIV system, separate signed forms for each adult member.
 LEP Language Survey.
 Verification of Social Security Number. Copies of SS cards or documents (e.g. SS award letter, Medicare/Medicaid ID
card, receipt from SS showing you’ve applied for a new card, for ALL household members).
 Verification of Student Status and financial aid. If the head, co-head, or spouse is a full time student receiving financial
aid, the housing authority must take addition steps to determine program eligibility. If your household is eligible for the
program, student financial aid may be included in the income calculation.
The Housing Authority is committed to providing those with disabilities full access to HASCO programs and services.
For further information about HASCO’s commitment to removing barriers to access or for ADA assistance or to request
a reasonable accommodation for a disability please contact your housing representative.
Equal Housing Opportunity
U:\TBA Department\Forms Database\16 Special Housing Programs\PBV

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