Please Check All Programs You Are Signing up For

HOUSING APPLICATION

Date ______Time ______

Please check all programs you are signing up for: _____ Low income Housing - Parkside Apartments - one bedroom _____ Low income Housing - Elizabeth Manor - one bedroom _____ Public Housing - Family 2 and 3 Bedroom Units _____ Voucher Program - Rental Assistance

Applicant Name ______

Current Address ______

______

Home Phone ______Cell Phone______

List names, addresses and phone numbers of two relatives or friends who generally know how to contact you.

Name ______Name______Address ______Address ______Phone ______Phone ______

List the head of household and all other members of the household who will be living in the unit. Full Name Relationship Date of Birth Sex S.S.#

______

1 Are any family members 18 or older full-time students? ______If yes, verification is needed.

The City of Shawano Housing Authority has a policy of NO SMOKING at anytime in any of the buildings that have apartments connected by common halls. This will include tenants of Parkside Apartments, Elizabeth Manor and Oak Street. This applies to every apartment in these buildings and every person in the buildings whether a tenant or a guest. Do you smoke? Yes_____ No_____

Verification of social security #’s is mandatory. Documents provided ______

Applicants are required to submit evidence of citizenship or eligible immigration status. For citizens: signed declaration. For eligible immigration status: signed declaration and proof of age.

The following information is required for statistical purposes so HUD may determine the degree to which its programs are utilized by minority families.

White ____ Black ____ American Indian ____ Asian/Pacific Islander ____ Hispanic ____ Non-Hispanic ____

Place of Birth:

Name ______City ______State ______

Current Housing Status

Landlord: Name ______

Address ______

City______Phone # ______

How long have you lived there? ______Amount of rent ______

2 Previous Housing Status

1. Address______

City______

How long in unit? From ______to ______

Address ______

City______Phone # ______

2. Address______

City______

How long in unit? From ______to ______

Address ______

City______Phone # ______

*We request at least a five-year history - if you need additional space, please list on the back of this page.

Has any family member who will be living in the unit ever lived in Public Housing or participated in a Rental Assistance Program? _____ If yes, when and where ______

Does any family member who will be living in the unit owe money for damages, unpaid rent or unpaid utility bills to any current or previous landlord, including a Public Housing Authority or to a utility or gas company (excluding your current monthly bill)? ______If yes, explain amount and circumstances ______

______

Has any family member who will be living in the unit ever been evicted from a housing unit? _____ If yes, explain ______

______

3 Has any family member who will be living in the unit ever been convicted of any drug related criminal activity to include the sale, manufacture, distribution or possession of a controlled substance including drug paraphernalia? ____ If yes, explain ______

______

Has any family member who will be living in the unit ever been convicted of a felony? ______If yes, explain ______

Are any members of the household who will be living in the unit subject to a lifetime sex offender registration program in any state? ______Failure to respond to this question may jeopardize the approval of the application.

Income Information

List all money earned or received by everyone who will be living in your household. This includes money from wages, self-employment, social security, disability payments (SSI), retirement benefits, veteran benefits, W-2, alimony, child support, per-capita, workman’s compensation, unemployment, interest from bank, stock dividends, contributions and all other sources.

Household members Source & address Amount

______

Asset Information

List financial institutions, amounts and type of assets or investments (including stocks, bonds or trusts). Amount & Family member Bank name & address Acct. type Interest rate

______

Real estate income such as rent or land contract payments ______.

Market value of real estate ______Equity ______

Have you disposed of an asset worth more than $2,000 for less than its value in the past two years? ______If yes, what is the current market value of this asset? ______

______

Expenses

List approximate medical expenses annually not covered by insurance or Medicare.

Insurance premiums ______

Prescription drugs ______

Doctor bills/other expenses ______

Family expenses

Do you pay for childcare, which enables you or any other family member to work or go to school? ______If you are not reimbursed by any agency for this childcare, list the name and address of the childcare provider and weekly cost ______

______

**Please review your application for complete information such as addresses and phone numbers on landlord information. We must have complete information to perform a background check. If we are unable to do so, your application will be rejected until we receive the information required.**

Applicant Certification

5 I/We certify that the information given to the City of Shawano Housing Authority on household composition, income, net family assets and allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal law. I/We also understand that false statements or information are grounds for denial of admission or termination of tenancy after admitted.

I/We further certify that this application is true and complete to the best of my/our knowledge and that the City of Shawano Housing Authority and its staff is authorized to contact any agencies, offices, organizations, present and/or past employers, present and/or past landlords to obtain any information or any materials which is deemed necessary to complete my application or annual or interim reexamination.

______Head Spouse/Other adult

PHA Representative ______

Date ______

WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.