Application for Housing Fayette County Housing Authority Application for Housing Date of Application Time Application # Head of Household’s Name Maiden Name Previous Spouses Bedroom Size Required Current Rent $ Phone # (1) Phone # (2) Family Composition Name (First, Last) Social Security # Date of Birth & Place of Birth Age Sex Relation to Head Race 1.Head 2.Spouse 3.Member 4.Member 5.Member 6.Member 7.Member 8.Member 9.Member 10.Member Is English your primary language? Yes No If no, specify Anticipated changes in family composition: Current place of residence & mailing address: Current landlord’s name & address: Reason you want to move from this address: Second most recent address: Prior landlord’s name & address: Reason for leaving this address: Annual Income Checklist Annual Income Checklist 1. Do any household members, 18 or older, receive employment income? If yes, list first names of the family members: Yes No 2. Do any household members, 18 or older, receive income from a family operated business (self-employment)? If yes, list first names: Yes No 3. Does the family receive an Earned Income Tax Credit? Yes No 4. Does anyone in the household receive Social Security Benefits? If yes, list first names: Yes No 5. Does anyone in the household receive periodic payment from annuities, insurance policies, retirement funds, pensions, disability or death benefits, maternity or military leave, Military Reserves, or National Guard pay or other similar amounts? Yes No 6. Does anyone in the household receive unemployment or disability compensation, workers compensation or severance pay? Yes No 7. Does anyone in the household receive welfare benefits? Yes No 8. Does anyone in the household receive alimony or child support payments? Yes No 9. Does anyone in the household receive income from assets? Yes No 10. Are there any full time students, 18 or older, residing in the household, who will be receiving education grants, scholarships or VA Education benefits? Yes No 11. Does any member of your household receive regular cash contributions from individuals not living in the unit or from agencies? Yes No 12. Have you ever participated in the Earned Income Disallowance (EID) Program in this county or any other county? Yes No Asset Checklist 1. Do you have a savings account? Yes No a checking account? Yes No a safety deposit box? Yes No 2. Do you have any trust funds available to your household? Yes No 3. Do you have any equity in rental property or other capital investment? Yes No 4. Do you have any stocks, bonds, treasury bills, certificates of deposit, or market funds? Yes No 5. Do you have any retirement or pension funds? Yes No 6. Will you receive any lump sum payments? Yes No 7. Do you have a life insurance policy with a cash value? Yes No 8. Have you sold any assets (home, property, etc.) within the past two years? Yes No If yes, what was sold and when: Employment Employment Are you a resident of Fayette County? Yes No Have you ever participated in any Section 8 Program? Yes No Have you ever lived in ANY low income/subsidized housing? Yes No If yes, where: When: Have you or any member of your household (including those minors under the age of 18) ever been convicted of a crime in this state or any other state? Yes No If yes, date of conviction Details of conviction(s): Are there any criminal charges currently pending against you? Yes No If yes, please explain: Do you have any special needs? Yes No If yes, list: Income Family Member Income Sources Amount Total Family Income: Allowances: Allowances: Child Care Allowance Do you pay for Child Care for children under age 13 which enables you or another family member to work or go to school? Yes No Does this amount change in the summer? Yes No Handicapped Allowance Do you pay for a care attendant or for other equipment used by handicapped members of the family which are necessary to permit that person or someone else in the family to work? Yes No Elderly / Disabled Allowance Is the head, spouse or sole member of the household 62 or older, handicapped or disabled? Yes No Do you have outstanding medical bills you are paying? Yes No Do you expect to have any medical expenses during the next 12 months? Yes No Preferences Elderly / Disabled Allowance 1. Violence Against Women Act (VAWA) – Any woman, man, or child who is a victim of domestic violence, dating violence, sexual assault, and stalkingwithin the last six (6) months. Yes No 2. Applicants for whom a law enforcement agency is seeking housing as an accommodation for its Witness Protection Program – Applicants who need to be relocated while they await a criminal trial where they will testify against the person on trial Yes No 3. Families of Federal Declared Disasters – Any Family who has been displaced by a Federally Declared Disaster, such as a hurricane, tornado, flood, etc. Yes No Local Preferences 1. Veterans/Spouse of Veterans – Veteran must have served with the Armed Forces and received either an Honorable or General Discharge and provide evidence of such Discharge. Yes No 2. Applicants Displaced by Public Action – Any applicant who has been displaced by a Public Entity for building or construction on their property, such as a highway. Yes No 3. Applicants Displaced by Civil Action, Order of Court – Any applicant who has been displaced because their home was lost through divorce decrees or house foreclosures (this action must have taken place within the last six (6) months).Requires court documentation. Yes No Applicant’s Certification I do hereby certify that all statements contained in this application are true and complete, to the best of my knowledge. I understand that deliberate misrepresentation of any facts will result in being rejected for admission into Public Housing/Section 8, and are punishable under Federal Law. In addition, after I have been placed in housing, if any deliberate misrepresentation is determined, I will be subject to eviction. (Refer to HUD form 52675 Debts owed to Public Housing Agencies and Terminations). Applicant’s Signature: Date: PHA Representative’s Signature:
