Pbv Application Packet - Housing Authority Of Snohomish County Page 10
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38The Housing Authority of Snohomish County
th
12711 4
Ave. W, Everett, WA 98204
Phone:425-290-8499; Fax: 425-290-5618
Initial Personal Declaration
Head of Household Name:
Phone Number:
Email:
Mailing Address:
A. FAMILY COMPOSITION
Please list yourself and anyone living in your home. If a question does not apply put N/A. For Race, please enter:
1) White, 2) Black/African American, 3) American Indian/Alaskan Native, 4) Asian, 5) Native Hawaiian/Other
Pacific Islander. Multiple race codes can be indicated for each family member.
Adults
Relationship
Gender
Hispanic or
Date of
Place of
Social Security
(18 and older;
to Head of
Race
Latino?
(Male or
Birth
Birth
Number
name as it appears on
Household
(Yes or No)
Female)
SS card)
Self
Children
Gender
Relationship
Hispanic or
Date of
Social Security
(Male or
Place of Birth
to Head of
Race
Latino?
(Under 18; name as it
Birth
Number
Female)
Household
(Yes or No)
appears on SS card)
If more space is needed, please add an additional page
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