WASHINGTON HOUSING SERVICES

Initial Application For Housing

RETURN COMPLETED APPLICATION TO:

Housing Authority of Sedro-Woolley

830 Township Street, Sedro-Woolley, Washington 98284-1340

PHONE (360) 855-0404 FAX (206) 574-1241

THIS SPACE IS FOR OFFICE USE ONLY:

Pref. Date: ________________________ Pref. Date: ________________________

Client #: ________________________ App. Date: ________________________ Time: __________________

Bedroom Size: ________________________ R/C: ________________________

Preference 50%: ________________________ Dis: ________________________ Sub: __________________

Cert. By: ________________________ Cert. By: ________________________

Part I. Application Information

A. NAME: ____________________________________________________ HOME PHONE: ____________________

(Last) (First) (Middle Initial)

ADDRESS: ___________________________________________________ MESSAGE NO.: ____________________

CITY, STATE, ZIP: ______________________________________________ WORK PHONE: ____________________

PLEASE LIST ANY OTHER NAMES YOU HAVE USED (If Applicable): _______________________________________

B. EMERGENCY CONTACTS (Please list two people we may contact if you are not available)

NAME: ________________________________________ NAME: _______________________________________

ADDRESS: ____________________________________ ADDRESS: _______________________________________

CITY, STATE, ZIP: _______________________________ CITY, STATE, ZIP: _________________________________

PHONE NO.: ____________________________________ PHONE NO.: ____________________________________

RELATIONSHIP: _________________________________ RELATIONSHIP: __________________________________

Part II. Household Information

A. Please list ALL HOUSEHOLD MEMBERS who will be living in the assisted unit, including Head of Household on line #1 (list additional Members on a separate page):

MBR#	LAST NAME	FIRST NAME	MI	AGE	SEX	RELATION TO HEAD	BIRTH DATE	BIRTH PLACE	SOCIAL SECURITY #
1
2
3
4
5
6
7
8
9

B. FAMILY STATUS: (Select all that apply)

(1) Head of House or Spouse age 62 or over: ____________

(2) Head of Household or Spouse Disabled or Handicapped: ____________

(3) Other Family Member Disabled: ____________

(4) None of the above: ____________

Office Use Only

Reasonable Accommodation Form Given

(HAR Initials) ____________

C. DISABILITY STATUS:

IF YOU HAVE A DISABILITY as outlined under Section 504 of the Americans With Disabilities Act or State or Local Fair Housing Laws, and you need:

*A structural change or repair in your apartment, or a special type of apartment;

*A change or repair in some other part of the housing development; or Housing Authority facilities; or.

*A change in our rules, policies, or how we do things (ie: how we communicate with you or give you information),

that would allow you to live and use your apartment or access our facilities in a manner equal to that of a non-disabled tenant; YOU CAN ASK for the Housing Authority to make a Reasonable Accommodation to your disability by requesting a Reasonable Accommodation Form.

D. Please answer the following questions by placing a Check in the correct box:

(1) Are there any children living in the household age six or under with an Elevated Lead Blood Level?

YES ( ) NO ( ) If YES, please list name(s): __________________________________________________________

(2) Does anyone live with you who is not listed in PART II. (A) above?

YES ( ) NO ( ) If YES, please list the name(s) and explain the circumstances: _______________________________

(3) Have you ever committed fraud, misrepresentation or been evicted from any housing program?

YES ( ) NO ( ) If YES, please explain where and when: ________________________________________________

(4) Do you presently owe money to any previous Landlord or Housing Authority for rent or unpaid damages?

YES ( ) NO ( ) If YES, please provide name(s) and amount owing: _______________________________________

(5) Do you and any adult family member have a Criminal Record? A Criminal History background check will be run on you and your family members.

YES ( ) NO ( ) If YES, please list any criminal history which will appear on your records and where it occurred:

____________________________________________________________________________________________

(6) Do you presently have a pet?

YES ( ) NO ( ) If YES, list the following: Type: _________________________ License #: ______________________

(7) The following information is being requested to comply with Equal Opportunity requirements and will not affect your selection position:

Race: _________________________________________ Hispanic: YES ( ) NO ( )

Primary Language: ______________________________________ Translation Services Needed: YES ( ) NO ( )

E. HOUSING PREFERENCE QUALIFICATION (Please mark the Correct Box):

( ) Involuntarily Displaced

*By Natural Disaster

* By Government Action

*To Avoid Reprisal

*By Domestic Violence

*Due to Hate Crimes

*Due to Owner Action

*Due to Unit Inaccessibility

( ) Living In Substandard Housing

*Homeless Family

*Dilapidated Home

*No Plumbing

*No Toilet

*No Tub/Shower

*No Electricity

*No Heat

*No Kitchen

( ) Rent Burden (paying more than half of your gross income. Gross income is the amount you make before taxes are taken out.)

*towards rent and utilities (Utilities do not include phone or cable)

**for at least 90 days

Part III. Family Income

A. Please list ALL Sources and Gross Amounts of Money received by All Members of your household.

MBR#	Employee Wages		Unemployment Benefits	Welfare (P.A.)	Child Support	Social Sec (S.S.I)	Other Explain
MBR#	$/hr	# of hrs/wk	Unemployment Benefits	Welfare (P.A.)	Child Support	Social Sec (S.S.I)	Other Explain
			PER	PER	PER	PER
			PER	PER	PER	PER
			PER	PER	PER	PER
			PER	PER	PER	PER
			PER	PER	PER	PER

B. Please complete Employer Information:

EMPLOYER’S NAME: ___________________________________________________________________

FAMILY MEMBER’S NAME: ______________________________________________________________

ADDRESS: ____________________________________________________________________________

CITY, STATE, ZIP: _______________________________________________________________________

TELEPHONE NO.: _______________________________________________________________________

EMPLOYER’S NAME: ___________________________________________________________________

FAMILY MEMBER’S NAME: ______________________________________________________________

ADDRESS: ____________________________________________________________________________

CITY, STATE, ZIP: _______________________________________________________________________

TELEPHONE NO.: _______________________________________________________________________

Part IV. Family Assets

A. PLEASE LIST ALL ASSETS (including Checking/Savings Accounts, IRA’s, Keough Accounts, CD’s, Stocks/Bonds, Dividends, Homes, Mobile Homes, or any other form of Real Estate):

MBR #	Type of Assets	Bank Name	Account #	Current Balance	Interest Rate

B. Please answer the following questions by placing a Check in the correct box:

(1) Have you disposed of, sold, or given away any assets for less than the Fair Market Value during the past two (2) years?

YES ( ) NO ( )

If YES, please complete the following:

(a) Type of Asset: ____________________________________________________

(b) Date of Disposal: __________________________________________________

(d) Market Value of Asset at time of Disposal: $_____________________________

(2) Does anyone else help you pay your bills or give you money?

YES ( ) NO ( ) If YES, how much: $________________________________________

I/we hereby certify that the information provided in this application is TRUE and ACCURATE. I/we understand that any MISREPRESENTATION on my/our part will result in the APPLICATION BEING REJECTED, or if I/w are housed based on misrepresented information given on this form, I/we understand that the housing assistance will be TERMINATED at a late date. I/we also understand I/we must report any changes in the above information to the housing office in writing. I/we certify I/we have read and understand this declaration and understand I/we will be required to provide verification of this information in accordance with federal housing regulations at the time I/we am offered assistance.

_____________________________________________________________________ ____________________

Signature of Head of Household Date

_____________________________________________________________________ ____________________

Signature of Spouse or Other Adult Date

_____________________________________________________________________ ____________________

Signature of Adult Date

_____________________________________________________________________ ____________________

Signature of Other Adult Date