Application For Section 8 Rental Assistance (Page 5 of 5) in pdf

Is there any current income you have not reported for any household members? ________________

If yes, Please explain: ________________________________________________________________

Do you NOW own real estate? _____________ If yes, what is the value: _______________________

Do you own vehicles? ____________ If yes, list make, model and year: ________________________

Names and Phone numbers of two friends or relatives we may contact if we are unable to reach you at the phone

numbers listed on this application.

Name: __________________________________________

Phone: __________________________________

Name: __________________________________________

Phone: __________________________________

Program Information:

How did you learn about the program? ____________________________________________________________

Have you ever applied for or received rental assistance? ______________________________________________

If yes, explain: ________________________________________________________________________________

Are you in Federally Assisted Housing at this time? __________________________________________________

Where? _____________________________________________________________________________________

Do you owe any money to Public Housing Authority or other Housing Agency? ____________________________

If yes, list Housing Authority and approximately how much owed: _______________________________________

_____________________________________________________________________________________________

Release and Certification

I/We certify the information given to the Pulaski County Public Housing Agency in this application is accurate and complete to the

best of my/our knowledge and belief. I/We understand that false statements or information are grounds for termination of housing

assistance payments and may result in a report to the Inspector General, investigation and prosecution for fraud, and future denial

of assistance from federally funded housing assistance programs.

I/We further understand the Pulaski County Public Housing Agency will release the following information to properly identified

potential landlords: Present Address, name and address of the current landlord, name and address of previous landlords; known

information about tenancy, history of drug trafficking by household members, information obtained and confirmed from law

enforcement agencies and other criminal record checks.

_______________________________________

________________________________

Head of Household

Date

_______________________________________

_________________________________

Spouse/Co-Head

Date

Revised 03/15/2017

HUD Application

This institution is an equal opportunity provider.

Application For Section 8 Rental Assistance Page 5