Youngstown Metropolitan Housing Authority Housing Eligibility Application Form Page 3
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4Program Integrity Information
Do you expect anyone to move in or out of your household within the next 12 months?
Yes
No
Does anyone live with you now who is not listed above?
Yes
No
Do you anticipate any changes in your family composition?
Yes
No
If yes, what changes? ___________________________________________________________
Have you ever lived in assisted housing before?
Yes
No If yes: When? _________________________
Where? __________________________________ Under what name? _______________________________
Who was the head of household? _____________________________________
Have you ever used a name other than the one you are using now?
Yes
No
If yes, what name? ____________________________________
Have you ever used a social security number other than the one listed above?
Yes
No
If yes, what is it? ________________________________
Have you ever been evicted from Public or Assisted housing for violent criminal or drug related activity?
Yes
No
Have you ever violated a family obligation in a HUD-assisted housing program?
Yes
No
Do you owe money to a Public Housing Agency?
Yes
No
Current Expenditures
Rent
Phone
Medical
Disability
Electric
Auto Payment
Cable
Credit Card
Gas
Auto Insurance
Insurance
Loan
Water
Child Care
Rentals
Other
Do you have any other regular monthly payments besides those above?
Yes
No
If yes, please specify:
Work History
Where was the last place of employment for all adult household members?
Family Member
From (year)
To (year)
Employer
Pets
Do you have any pets?
Yes
No
If yes, what kind: ________________________________ Size: _________________ Weight: ____________
Vehicles: How many vehicles do the family own?
Owner
Make
Model
Year
Color
Tag #
State
Marketing: How did you hear about YMHA? (Check one or more below)
Newspaper
Radio
Television
Friend
Referral
Other:
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Parent category: Business