Section 8 Full Application Form - Charleston Kanawha Housing Page 2
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28)
Has any household member(s) ever been convicted of a crime?
If yes, please complete the following:
Family Member:
When:
Was person rehabilitated?
Probation Officer:
Any additional comments regarding above?
9)
Medical Information (Needed to determine medical allowances for disabled/elderly households)
Are you making regular payments on any outstanding medical bills?
If yes, please complete the following:
Physician/Medical Facility Owed:
Phone:
Mailing Address:
Balance Owed:
Monthly Payment:
10)
Does any household member take prescription drugs on a regular basis?
If yes, please complete the following:
Family Member(s):
Pharmacy:
Mailing Address:
Monthly Cost:
11)
Do you pay for health insurance?
If yes, please complete the following:
Insurance Company:
Agent:
Mailing Address:
Monthly Premium:
Failure to provide the necessary information to verify expenses will result these expenses NOT being deducted from your annual income.
For persons with disabilities, if you require a specific
accommodation to fully utilize our Section 8 program and services
please contact us at
348-6451 for more information.
TENANT CERTIFICATION
Give true and Complete Information
I certify that all the information provided on household composition, income, family assets and items for allowances and deductions, is accurate and
complete to the best of my knowledge. I have reviewed the application form and certify that the information shown is true and correct.
Reporting Changes in Income or Household Composition
I know I am required to report in writing, within ten (10) days, any changes in income and household composition, and when a person moves in or out
of the unit.
Reporting on Prior Housing Assistance
I certify that the have disclosed information regarding previous Federal housing assistance Ive received, and whether or not any money is owed to
such agency. I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information o r vacate the unit in
violation of the lease.
No Duplicate Residence or Assistance
I certify that the unit I lease will be my principal residence and that I will not obtain duplicate Federal housing assistance while receiving assistance
through this agency. I will not live anywhere else with out notifying Charleston Housing, in writing, immediately. I will not sublease my assisted
residence.
Cooperation
I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefit, or verif y my circumstances.
Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I understand failure or refusal to do so may
result in delays, ineligibility determination or termination of assistance.
Criminal and Administrative Action for False Information
I understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State criminal law. I understand that
knowingly supplying false incomplete or inaccurate information is grounds for termination of housing assistance or termination of tenancy.
SIGNATURE OF ALL HOUSEHOLD MEMBERS 18 YEARS OF AGE AND OLDER
1.
Date
2.
Date
3.
Date
4.
Date
After verification by Housing, the information will be submitted to the U.S. Department of Housing and Urban Development on Form
50058.
Date
Leased Housing Specialist
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EQUAL HOUSING OPPORTUNITY
We do Business in Accordance With the Fair Housing Act (The Civil Rights Act of 1968, as amended by the Fair Housing
Amendments Act of 1988)
IT IS ILLEGAL TO DISCRIMINATE AGAINST ANY PERSON BECAUSE OF RACE, COLOR, RELIGION, SEX, DISABILITY,
FAMILIAL STATUS (HAVING ONE OR MORE CHILDREN OR BEING PREGNANT), OR NATIONAL ORIGIN IN THE SALE OR
RENTAL OF HOUSING OR RESIDENTIAL LOTS
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