Application For Section 8 Rental Assistance Page 4
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5Does any member of the household have a disabling condition that requires reasonable accommodation?
_________ If yes, list their name(s): _____________________________________________________
Are there any children in the household with an elevated lead blood level? __________
If yes, you must provide documentation.
Has any adult household member been charged or convicted of a crime? ___________ Year? ___________
If so, please explain: ______________________________________________________________________
Is any member of the household subject to a lifetime registration requirement under a state Sex Offender
Registration Program? _______________________
If yes, give the person’s name and location of Sex Offender: _______________________________________
List All Sources of Income
Source, Rate and Type of Income
Estimated Annual Income
____________________________________
____________________________________________
____________________________________
____________________________________________
____________________________________
____________________________________________
____________________________________
____________________________________________
____________________________________
____________________________________________
Complete the following if household members are employed:
Employer # 1
Employer #2
Name of Employer:
_______________________
_________________________
Address of Employer:
_______________________
_________________________
City, State, Zip Code:
_______________________
_________________________
Phone Number:
_______________________
_________________________
Family Member Employed:
_______________________
_________________________
Assets: Check and List All of the following your family has:
Asset Description
Yes
No
Value
Income
Checking Account
___
___
$________
$_________________
Savings Account
___
___
$________
$_________________
C.D.’s/Investments
___
___
$________
$_________________
Real Estate
___
___
$________
$_________________
Stocks/Bonds
___
___
$________
$_________________
Other
___
___
$________
$_________________
Total Net Family Assets
$________
$_________________
Revised 03/15/2017
HUD Application
This institution is an equal opportunity provider.
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