Application For Section 8 Rental Assistance Page 3
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2
3
4
5Please Circle One:
Member #3
:
Spouse Co-Head of Household
Adult-Other
Full-Time 18+
Foster Child
Live-In Aide
Youth-Under 18
Last Name: __________________________________ First Name: _______________________________
Middle Initial: ________ Sex: ___________ Date of Birth ______________ SS# ____________________
Birth City/State: ___________________ United States Citizen? (Circle One)
Yes or No
Disabled? *(Circle One) Yes or No
Race (Circle One)
White
Black
Asian
Mixed
American Indian
Hawaiian/Pacific Islander
(* Only a disability other than drug or alcohol addiction)
Ethnicity (Circle One) Hispanic or Latino Not Hispanic or Latino
Please Circle One:
Member #4
:
Spouse Co-Head of Household
Adult-Other
Full-Time 18+
Foster Child
Live-In Aide
Youth-Under 18
Last Name: __________________________________ First Name: _______________________________
Middle Initial: ________ Sex: ___________ Date of Birth ______________ SS# ____________________
Birth City/State: ___________________ United States Citizen? (Circle One)
Yes or No
Disabled? *(Circle One) Yes or No
Race (Circle One)
White
Black
Asian
Mixed
American Indian
Hawaiian/Pacific Islander
(* Only a disability other than drug or alcohol addiction)
Ethnicity (Circle One) Hispanic or Latino Not Hispanic or Latino
Please Circle One:
Member #5
:
Spouse Co-Head of Household
Adult-Other
Full-Time 18+
Foster Child
Live-In Aide
Youth-Under 18
Last Name: __________________________________ First Name: _______________________________
Middle Initial: ________ Sex: ___________ Date of Birth ______________ SS# ____________________
Birth City/State: ___________________ United States Citizen? (Circle One)
Yes or No
Disabled? *(Circle One) Yes or No
Race (Circle One)
White
Black
Asian
Mixed
American Indian
Hawaiian/Pacific Islander
(* Only a disability other than drug or alcohol addiction)
Ethnicity (Circle One) Hispanic or Latino Not Hispanic or Latino
Revised 03/15/2017
HUD Application
This institution is an equal opportunity provider.
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