Application Update Form
You must use the correct legal name for each member of your household as it appears on the Social Security card.
Choose One:
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Affordable Housing
Housing Choice Voucher
Name of Applicant:
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Date:
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Address:
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City/State:
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Zip:
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Home Phone:
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Work or Cell:
E-Mail:
Family Member 1:
Birthdate:
SS#:
Relation:
Family Member 2:
Birthdate:
SS#:
Relation:
Family Member 3:
Birthdate:
SS#:
Relation:
Family Member 4:
Birthdate:
SS#:
Relation:
Family Member 5:
Birthdate:
SS#:
Relation:
Family Member 6:
Birthdate:
SS#:
Relation:
Name & Address of Father(s) of Children:
Martial Status:
Single
Married
Divorced
Separated
Widowed
Are you pregnant:
Yes
No
If yes, due date:
Total Household Income
Please list all money earned or received by EVERYONE in your household. This includes money from wages, self-employment, child support, contributions, Social Security, disability payments, Workman's Compensation, retirement benefits, AFDC, Veteran's Benefits, rental property income, stock dividends, oil royalties, interests from bank accounts and any other income.
Member # (1-6 from above):
Source of Income:
Amount:
I do hereby swear and attest that all of the information above is true and complete. I understand that any false statements made intentionally can jeopardize my eligibility for low-income housing.
Signautre:
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Date:
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Local Preference Election
Please read the below preferences and select which apply, if any, apply to you by check the corresponding box. If none apply, simply sign the bottom of the form.
Prefences:
Applicants with an adult family member who is working full-time employment with a minimum of twenty (20) hours per week. This preference is also extended equally to all applicant households whose head, spouse or sole member is age 62 or older or is receiving social security disability benefits, supplemental security income, disability benefits, or any other payment based on the individual's inability to work.
Displaced person(s): Individuals or families displaced by government action or whose dwelling has been extensively damaged or destroyed as a result of a disaster declared or otherwise formally recognized pursuant to Federal Disaster Relief laws. (Displaced action must be verifiable.)
Currently living in substandard housing (including homeless families).
Currently paying more than 50% of their income for rent and utilities ("Rent Burden").
Certification:
I certify that the above election is true to the best of my knowledge.
Signauture:
*
Date: