Housing Choice Voucher Program - Pre-Application For Housing Assistance printable pdf download

Section 8

Housing Choice Voucher Program

Complete and return to

one of the regional

agencies listed on the

reverse of this form

For agency use only:

Pre-Application for housing assistance

Date/Time Stamp/

Control Number

Please print neatly in ink. All fields are required. Submit this form only. Incomplete, photocopied, e-mailed or faxed applications will not be accepted.

If you are already on our Section 8 waiting list your record will be updated using the information that you provide below. Due to the volume of

applications received, we will not verify the receipt of mailed applications. We cannot be responsible for material that is illegible or missing as a result of

transmitting by fax or e-mail or lost/delayed through the mail.

IMPORTANT!

One-third 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 in writing to one of the regional agencies listed on the reverse of this form.

Head of Household Information

Social Security Number

Phone (include area code)

First Name

Middle Name

Last Name

Address

City/Town

State

Zip code

Shelter Name

Shelter Address

City/Town

State

Zip code

Household and Demographic Information

How many people will live in the unit? Include yourself. _____

Gross annual household income $_____________

Write in the approximate amount of your family’s

gross (before taxes) annual income. Include all

sources for all family members.

Check if the head of household or spouse is:

62 years old or older

Disabled

Displaced by government action

We collect data on race & ethnicity in accordance with federal regulations. People of various races may also be of Hispanic

ethnicity. Please indicate if you are Hispanic. Your answers will not affect your application.

Is the head of household (Select as many as appropriate)

White

Black/African American

American Indian/Alaskan Native

Asian

Native Hawaiian/Other Pacific Islander

Is the head of household (Check only one)

Hispanic

Non-Hispanic

What is your current housing situation? (Check one box that best applies)

I am homeless

I am doubled up with friends or relatives

I live in substandard housing

I live in public housing

I have been involuntarily displaced

I live in a transitional housing program

I pay more than 50% of my monthly income for

I live in subsidized housing

rent and utilities

I live in a shelter

Other (describe)

Certification of Applicant -

Please read this statement very carefully. By signing, you are agreeing to its terms.

I hereby certify that the information I have provided in this pre-application is true and accurate. I understand that:

- any misrepresentation or false information will result in my application being cancelled or denied, or in

termination of housing assistance;

-this is a pre-application for tenant-based rental assistance through DHCD and its regional administering

agencies and is not an offer of housing;

-at the time I rise to the top of the waiting lists, I will be required to provide verification of the information

I have provided here, in accordance with federal housing regulations and DHCD policy;

-it is my responsibility to notify any one of DHCD’s regional administering agencies of any change of

address in writing and I understand that my application may be cancelled if I fail to do so;

-my participation in the Section 8 housing program is subject to my being eligible and in compliance with

HUD and DHCD regulations; and that I will be subject to a criminal history check.

I agree that DHCD can share my information with other state agencies for the purposes of determining program

eligibility.

Signature of head of household

Date

DHCD manages a limited number of project-based Section 8 apartments in or near most major cities and

towns throughout the state. To find out more contact one of the agencies on the reverse of this form or

visit the Housing Consumer Education Center website at

DHCD pre-application form for HCVP| 11/3/05

Housing Choice Voucher Program - Pre-Application For Housing Assistance

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