Pre-Application For Dhcd'S Section 8 Housing Choice Voucher Program
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2Pre-Application for DHCD's Section 8 Housing Choice Voucher Program
Complete all information. Incomplete or duplicate applications will not be accepted. Do not reapply if your
name is currently on the waiting list through any of the agencies listed on the back of this form.
IMPORTANT!
1/3 of all applications are dropped from the waiting list due to unreported address changes. Do not let this
happen to you. Report any change of address to one of the regional agencies on the reverse of this form.
General Information:
Social Security Number
First Name
Middle Name
Last Name
Address
City
State
Zip Code
Shelter Name
Phone (include area code)
Household and Demographic Information:
?
Total number of household members (include self)
Check If the head of household or spouse is:
62 years old or older ?
Disabled ?
Displaced ?
Gross annual household income
$_______
Racial & ethnic data is collected for statistical purposes only. Your answers or failure to answer will not
affect your application.
Is the head of household (please check one)
?
?
?
White
Black
American Indian/Alaskan Native
Asian/Pacific Islander
?
Is the head of household (please check one)
?
?
Hispanic
Non-Hispanic
DHCD Preference (you must check one)
?
?
?
Homeless/Substandard Housing
Involuntarily Displaced
Rent Burdened
?
Homeless in shelter
(If you check this box, enter shelter name above)
Is any adult member of the applicant household a current or former (in the past 24 months)
recipient of any of the following public assistance benefits: TAFDC Temporary Assistance to
Families with Dependent Children), TANF (Temporary Assistance to Needy Families) or EA
?
(Emergency Assistance)
Check if Yes
Control Number (for agency use only)
Agreement and Signature:
By signing below, applicant agrees to the following:
I understand that this is a pre-application for rental assistance through DHCD and its regional
administering agencies and is not an offer of housing. When I am selected from the waiting list, I
will have to verify and document all the information that I am self-certifying today. If I do notmeet
a DHCD preference at the time of selection, my name will be dropped from the list. I understand
that: 1) it is my responsibility to notify any one of DHCD's regional administering agencies of any
change of address; 2) my participation in the Section 8 housing program is subject to my being
eligible and in compliance with HUD and DHCD regulations; and 3) my participation is subject to
a criminal history check using CORI, and I must be in compliance with DHCD's drug and violent
crime policy. I agree that DHCD can share this information with other state agencies for the
purposes of determining program eligibility and to assist other agencies in conducting
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