Public Housing Application Form - Emery County, Utah Page 3
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4EMERY COUNTY HOUSING AUTHORITY
PO BOX 551, CASTLE DALE, UTAH 84513
APPLICATION FOR PUBLIC HOUSING
Please Print and Use Ink
I. APPLICANT INFORMATION
1._____________________________________________ 2.________________________________________________
NAME OF HEAD OF FAMILY
NAME OF SPOUSE
3._______________________________ 4._________________________________________ 5._______________________
MAILING ADDRESS (P.O. BOX)
EMAIL ADDRESS
TELEPHONE
6.____________________________________________________________________________________________________
STREET ADDRESS
CITY
STATE
ZIP CODE
7. I prefer an apartment in...(Check one) _____ Castle Dale
_____ Ferron
_____ No preference.
II. HOUSEHOLD MEMBERS AND INCOME
List all persons who will live with you, include yourself as the first person listed.
NAME
SOC. SEC.#
SEX
AGE
BIRTH DATE
RELATION
1.
2.
3.
4.
5.
6.
7.
8.
List names and addresses of all sources of income for all household members, and the GROSS amounts received.
Include all income from employment, child support, AFDC, social security, unemployment, pensions, tips, G.I. benefits, school
grants, and all other sources of income (FOOD STAMPS are NOT included).
HOUSEHOLD MEMBER
SOURCE OF INCOME AND ADDRESS
INCOME AMT.
1.
2.
3.
4.
1. RACE _______ 1. White
2. Black 3. American Indian 4. Asian/Pacific Islander
2. ETHNICITY _______ 1. Hispanic
2. Non-Hispanic
3. Is any member of your family handicapped or disabled? __________________________________________
4. Do you expect a change in family size? (If yes, explain) __________________________________________
5. Do you receive payment for child support? _______ Alimony? _______ Child Care? _______
6. Does your family have unusually high medical expenses not covered by insurance? ________
7. Do you have to pay to have children taken care of so you can work or attend school? _______
III. ASSETS
1. Do you have any Savings Accounts or Savings Bonds? _______ If yes, list the type and amount ________
2. Do you own a Home, Real Estate, or Mobile Home? _______ If yes, Explain ___________________________
3. Have you sold or disposed of Assets or Real Estate within the past two years? ______ If yes, explain on back.
IV. PRIORITIES
1. Are you a family who is being required to move, through no fault of your own? _______
2. Are you paying more than 50% of your income for rent and utilities? _______
3. Are you living in (or renting) a place of your own? _______
4. What is the monthly amount you are now paying for Rent? ________ For Utilities? (Not including phone) ______
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