Pre-Application Form Page 3
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2
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4Please deliver or mail to:
Portola Vista (Main Office)
TO BE COMPLETED BY MANAGER
20 Del Monte, Monterey, CA 93940
Application #:
_________________
(831) 372-5057 TDD (831) 754-2951
Fax (831) 372-2057
Pre-application for
OAKGROVE-MONTEREY
Please print clearly and legibly.
Name of household: ___________________________________________________________________________________________
First Name
Middle Name
Last Name
_____________________________________________________________________________________________________________
Mailing Address
City
State
Zip Code
Permanent Address if different from above __________________________________________________________________________
How long at present address? ___________ Monthly Rent $____________ Estimated Utilities $____________
Phone: HOME_________________________
WORK_________________________
MESSAGE_____________________
BEGINNING WITH YOURSELF, list all persons who will live in your household. All information must be given for each person.
List all money earned or received by ALL members living in your household including yourself. This includes money from wages,
pensions, Social Security, SSI, Child Support, TANF/Cal-Works, contributions, employment, unemployment, etc.)
Last Name
First Name
Sex
Date of
Relationship To
Social Security
Monthly
Source of
M/F
Birth
Head of Household
Number
Income
Income
1.
Head
2.
3.
4.
Are you a veteran?
Yes
No
Family of a veteran or serviceman?
Yes
No
Relationship to Veteran: ____________________________ (Provide a copy of DD Form 214)
For Accommodation Purposes-Do you claim the following:
Mobility Impairment
Hearing Impairment
Sight Impairment
Do you or a member of the household claim status as a person with a disability?
Yes
No
If yes, who? ______________________________________________________________________
Do you or any member of your household need special features in a rental unit (for example wheelchair access)?
Yes
No
If yes, what features do you need? ______________________________________________________________________________
Race/Ethnicity: This information is confidential and is only used for government reporting purposes to monitor compliance with equal
opportunity laws. Your voluntary cooperation in providing the information is appreciated, and will not affect your place on the waiting
list.
White
Black/African American
Black/African American and White
Asian
Asian and White
American Indian or Alaska Native
American Indian/Alaska Native and Black/African American
American Indian or Alaska Native and White
Native Hawaiian or Other Pacific Islander
Other: _________________
Hispanic/Latino Ethnicity
Yes
No
Yes, Mexican/Chicano
Yes, Cuban
Yes, Puerto Rican
Yes, Other Hispanic/Latino: ____________________
_______________________________________________________________________________________________________________
1. Have you ever violated a previous family obligation with a HUD Program?
Yes
No
2. Have you ever lived in Public Housing or Section 8 Housing in any City?
Yes
No Where? ______________
3. Have you ever engaged in use/possession of drugs or violent criminal activity?
Yes
No
4. Do you owe any money to a Public Housing Authority?
Yes
No Where? ______________
5. Is any household member subject to a lifetime registration requirement under a State sex
offender program?
Yes
No Where? ______________
Who? _______________
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