Affordable Housing Application Nc
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1
2
3
4PLEASE PRINT LEGIBLY IN INK AND RETURN BY MAIL
APPL # __________
Applform.wpd
Revised 3.11.15
HOUSING AUTHORITY OF THE CITY OF RALEIGH, NORTH CAROLINA
900 HAYNES STREET, RALEIGH, NORTH CAROLINA 27604 ~
***FOR ASSISTANCE, CALL 919.508.1105*** PARA ASISTENCIA EN ESPANOL, LLAMADA 919.508.1110***
Form must be COMPLETE to be accepted. If your application is incomplete (ex. missing SSN, signature, etc),
you will be notified in writing and you will need to complete a NEW application.
NAME
________________________________________________________________________________________________
FIRST
MIDDLE
LAST
ADDRESS
________________________________________________________________________________________________
________________________________________________________________________________________________
CITY
STATE
ZIP CODE
EMAIL
______________________________________________
TELEPHONE
(
)_______________________________________
A
I WISH TO APPLY FOR:
PUBLIC HOUSING
CURRENT P
H
R
?
RE YOU A
UBLIC
OUSING
ESIDENT
SECTION 8 (VOUCHER)
C
O
: YES NO
IRCLE
NE
BOTH
_______
(See Definitions on the back)
ARE YOU CURRENTLY HOMELESS? ____YES ____ NO
Y
MUST
CLEAR, LEGIBLE COPIES ONLY
A
:
OU
ATTACH
OF THE FOLLOWING VERIFICATIONS WHEN RETURNING YOUR
PPLICATION
1. R
(
)
EQUEST FOR A PREFERENCE
IF APPLICABLE
2. D
’
L
S
–I
ID
H
H
ALL
RIVER
S
ICENSE OR
TATE
SSUED
FOR
EAD OF
OUSEHOLD AND
18
(
)
OTHER MEMBERS
YEARS OF AGE AND OLDER
COPIES ONLY
LIST ALL HOUSEHOLD MEMBERS ---USE A SEPARATE SHEET FOR ANY ADDITIONAL MEMBERS
NAME
DATE OF BIRTH
LAST, FIRST, M.I.
RELATIONSHIP
SEX
MM-DD-YY
PLACE OF BIRTH
SOCIAL SECURITY #
HEAD OF HOUSEHOLD
LIST ALL INCOME IN THE HOME (LIST ADDITIONAL INCOME ON A SEPARATE SHEET IF NECESSARY)
NAME
EMPLOYER/SOURCE OF
START
MONTHLY
WEEKLY
HOURLY
# of HOURS
INCOME
DATE
WORKED
(GROSS)
(GROSS)
(GROSS)
D
OR
CIRCLE ONE:
O YOU
ANY MEMBER OF YOUR HOUSEHOLD NEED A
RACE: 1=WHITE 2=BLACK 3=AMERICAN INDIAN/
?
YES
NO
HANDICAPPED ACCESSIBLE UNIT
NATIVE ALASKAN 4=ASIAN/PACIFIC ISLANDER
What type of unit do you need? Please indicate below:
ETHNICITY:
. W
YES NO
1= HISPANIC
2 = NON-HISPANIC
A
HEELCHAIR ACCESS
. V
/
YES NO
B
ISUAL AND
OR HEARING EQUIPPED
A
. O
(
) ______________________________
USA?
YES NO
C
THER
COMMENTS
RE YOU A LEGAL RESIDENT OF THE
A
A
,
?
YES NO
W
C
TANF (P
RE YOU ELDERLY
DISABLED OR HANDICAPPED
RE YOU A CURRENT
AKE
OUNTY
UBLIC
[
: E
: 62
; D
,
A
)
?
YES NO
DEFINITIONS
LDERLY
YEARS OR OLDER
ISABLED
OR
SSISTANCE
RECIPIENT
(
S
S
A
)]
HANDICAPPED
AS DEFINED BY THE
OCIAL
ECURITY
CT
H
A
-
-
RE YOU INTERESTED IN ELDERLY OR NEAR
ELDERLY
AVE YOU RECEIVED GOVERNMENT ASSISTED HOUSING
HIGH
RISE
? YES NO
? YES NO (I
Y
, P
&
)
FACILITIES
BEFORE
F
ES
LEASE LIST WHEN
WHERE
W
: _________________________________________
HEN
D
F
I
T
R
ID YOU FILE A
EDERAL
NCOME
AX
ETURN FOR THE
?
YES NO
W
: _________________________________________
PREVIOUS YEAR
HERE
P
(2)
:
AST LANDLORD HISTORY FOR THE LAST TWO
YEARS
N
:
______________________________________________
N
:
___________________________________________
AME
AME
A
: ______________________________________________
A
: ___________________________________________
DDRESS
DDRESS
P
# ______________________________________________
P
# ___________________________________________
HONE
HONE
SIGNATURE: ________________________________________
DATE: _____________________________________________
NOTE:
/
.
A CRIMINAL HISTORY REPORT
BACKGROUND CHECK IS REQUIRED TO DETERMINE ELIGIBILITY OF ALL APPLICANTS
A CREDIT CHECK IS REQUIRED FOR ALL
.
. *F
W
: T
18, S
1001
U
PUBLIC HOUSING APPLICANTS
A TENANT HISTORY WILL BE CHECKED ON ALL PAST HOUSING TENANTS
RAUD
ARNING
ITLE
ECTION
OF THE
NITED
S
,
U
S
TATES CODE
STATES THAT A PERSON WHO KNOWINGLY AND WILLINGLY MAKES FALSE STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE
NITED
TATES
.
IS GUILTY OF A FELONY
2015 INCOME LIMITS FOR SECTION 8 AND PUBLIC HOUSING (MAX amount of household income to qualify for housing assistance)
1 PERSON - $27,600
2 PERSON - $31,550
3 PERSON - $35,550
4 PERSON - $39,400
5 PERSON - $42,600
6 PERSON - $45,750
7 PERSON - $48,900
8 PERSON - $52,050
Revised 3.11.15 mlb
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