Public Housing Application Form - Emery County, Utah Page 4
ADVERTISEMENT
1
2
3
4V. APPLICANT HISTORY AND REFERENCES
1- Have you ever lived in Public Housing before?
Where?
2- Have you ever vacated an apartment owing rent?
Where & When?
3- Have you ever been convicted or arrested for use, possession, or distribution of illegal drugs? _________
If so, when and where?
4- Have you ever been charged or convicted of a violent crime?
When?
LIST BELOW YOUR THREE MOST RECENT ADDRESSES AND ALL OTHER
APPLICABLE INFORMATION REQUESTED FOR EACH. (MOST RECENT FIRST)
Address:
Landlord Name
and address:
Dates: From:
To:
Landlord Phone #:
Rent Amount you are/were paying:
$
This Landlord’s family relationship to you:
Reason for leaving/wanting to leave this unit:
Do/Did you owe rent, or are/were you in violation of the Lease
Agreement? If yes, please explain.
Address:
Landlord Name
and address:
Dates: From:
To:
Landlord Phone #:
Rent Amount you were paying: $
Reason
This Landlord’s family relationship to you:
for leaving this unit:
Did you owe rent, or were you in violation of the Lease
Agreement? If yes, please explain.
______________________________________________________________
__________
Address:
Landlord Name
and address:
Dates: From:
To:
Rent
Landlord Phone #:
Amount you were paying:
$
This Landlord’s family relationship to you:
Reason for leaving this unit:
Did you owe rent, or were you in violation of the Lease
Agreement? If yes, please explain.
VII. I hereby certify that the above information is correct and complete to the best of my knowledge and may be used for the
purpose of verification. I understand that this application is not a contract and does not bind either party. I understand that
false information will constitute grounds for cancellation of this application, or my Lease if I should be housed, and I hereby
authorize the release to the Emery County Housing Authority any information requested to determine eligibility for housing
programs.
Date:
Signed: _________________________________________________
Witness: ________________________________________________
WARNING: Section 1001 of Title 10 of the U.S. Code makes it a criminal offense to make willful false statements or
misrepresentation to any Department or Agency of the United States as to any matters within its jurisdiction.
Explanations and/or comments:
OFFICE USE ONLY -- DO NOT WRITE BELOW THIS LINE --
OFFICE USE ONLY: WIT._________________________________________
RECEIVED:_____________________________
MAIL:________________________
HOUR: _____________________________
PRIORITY:___________________
BEDROOM SIZE: _______________ DEPENDENTS: ______________
05/10/2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business