Public/PHA-Owned Housing Application Form

Date of Application

Time of Application

Name of head of household:

Name of adult co-head of household:

Current address, Street, Apt. #

Current City, State and Zip

Current Area Code, Home & Work Phone

Current Email

For Statistical Purposes Only:

Race of Head

Ethnicity of Head

Family Information:

List all persons who will live in the unit, including foster children, live-in aides (if needed for the care of a family member). No one except those listed on this form may live in the unit.

Family Information: #member1

First Name & Last Name

Date of Birth

Sex

SSN

Relation

Disabled Person?

Birthplace (Country)

Full-time Student?

Family Information: #member2

First Name & Last Name

Date of Birth

Sex

SSN

Relation

Disabled Person?

Birthplace (Country)

Full-time Student?

Family Information: #member3

First Name & Last Name

Date of Birth

Sex

SSN

Relation

Disabled Person?

Birthplace (Country)

Full-time Student?

Family Income Information

Please list the source and amount of all income expected for the coming 12 months for all family members, including but not limited to all earnings and benefits received from working, TANF, VA, Social Security, SSI, SSID, Unemployment, Worker’s Compensation, pension, Child Support, etc.

Example: Wages, $150/week, SSI, $421/month

Family Income Information: #member1

Family Member Name

Income Source

Amount $

Frequency - Per

Week Month Year

Family Income Information: #member2

Family Member Name

Income Source

Amount $

Frequency - Per

Week Month Year

Do you have a checking or savings account or own any Certificates of Deposit, stocks, bonds, etc.?

Yes
No

If yes, describe the type of asset(s) please:

What is the market value of all assets?

Do you own any real estate?

Yes
No

If yes, what is the Address?

Have you sold any real estate in the past two years?

Yes
No

If yes, what was the Address?

Current Landlord’s Name and Phone

Current Landlord’s Address

Date Family Moved to this location

Most Recent Former Address, Street, Apt.

Most Recent Former City, State and Zip

Most Recent Former Area Code and Phone

Screening

Have you ever been evicted from housing?

Yes
No

If yes, why?

Have you ever lived in public housing before?

Yes
No

If yes, where?

Date from:

Date to:

Name of Lessee

Do you owe any money to the housing authority?

Yes
No

Do you have any past due utility bills?

Yes
No

If yes, please describe and give amount owned:

Have you, or any member of the applicant household ever been arrested or convicted of a crime other than a traffic violation?

Yes
No

If yes, please explain the problem and who was involved:

Is anyone in your household currently on parole or probation?

Yes
No

If yes, please explain

Qualifying for Deductions in Calculating Rent

Is the head of household or spouse age 62 or older or a person with a disability?

Yes
No

If yes, please answer the following questions. (If no, please skip down to question upto, "Do you have child care expenses for children under age 13 so an adult in the family can work, go to school or attend job training?")

Does your household have any medical expenses (include insurance, Medicare deduction, doctor bills, dentist bills, hospital bills, clinic costs, medicine, therapy, supplies, medical transportation, etc.)?

Yes
No

If yes, please describe the type of expense (not your medical condition) and the unreimbursed amount you spend per month on each medical expense: Type of expense:

Monthly medical expense, Amount($):

Name, address & phone of person who can verify expense:

Do you have any expenses on behalf of a household member with disabilities so an adult in the family can work?

Yes
No

If yes, describe the nature of the expense and the monthly amount:

Name, address & phone of someone who can verify the expense:

Do you have childcare expenses for children under age 13 so an adult in the family can work, go to school or attend job training?

Yes
No

If yes, Name, address and phone of childcare provider:

Monthly unreimbursed child care cost, Amount($):

Is any member of the household age 18 or older (other than family head and spouse) a full-time student or person with a disability?

Yes
No

If yes, Name of the family member and name and address of someone who can verify this information: Name of family member:

Name, address & phone of someone who can verify this information:

Driver’s License or State ID: Applicant:

Co-applicant:

Automobile: Year:

Make:

Model:

License:

Do you want an apartment at an all elderly building? (Head or Spouse over 62):

Yes
No

Do you want to have a pet in your apartment?

Yes
No

PHA will be contacting all former landlords for the period three years from the date of application

Name:

I/we certify that the statements on this application are true to the best of my/our knowledge and belief and understand that they will be verified. I/we authorize the release of information to the Housing Authority by my/our employer(s), the Arkansas Health and Human Services Commission, the Social Security Administration, and/or other business or government agencies. I/we understand that any false statement made on this application will cause me/us to be disqualified for admission.

Applicant Signature:

Date:

Co-applicant Signature:

Date:

Warning: 18 U.S.C. 1001 provides, among other things that whoever knowingly and willfully makes or uses a document or writing containing false, fictitious or fraudulent statement or entry in any matter within the jurisdiction of a department or an agency of the United States shall be fined not more than $10,000 or shall be imprisoned for not more than five years or both.

Background Check Authorization

Date:

Signature of Applicant:

Is any Member of your household subject to a life time sex offender registration program in any state?

Yes
No

If yes, what state?

I, hereby authorize Poinsett County Housing Authority and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for housing purposes. I understand that the scope of this report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

Office use only. Do not write below this line

First Name:

Middle Name:

Last Name:

Social Security:

Date of Birth:

Office Verified ID:

Yes
No

Applicant's Present Address:

Street Address:

City:

State:

Zip Code:

Signature of Requesting Personnel:

Date Requested:

Background Attached:

Yes
No

Upload Documents (pdf/docx/doc/jpeg/jpg/png formats only):

APPLICATION for PUBLIC/ PHA-OWNED HOUSING

The Housing Authority is an Equal Housing Provider

APPLICATION for PUBLIC/ PHA-OWNED HOUSING