(Print clearly or Type). HOUSING AUTHORITY of the TOWN of MANCHESTER 24 BLUEFIELD DRIVE MANCHESTER, CT 06040 4702 This application form MUST be completely filled out and signed by all adults. Upon completion please present in person or mail the application to the above address. Anyone requiring assistance in filling out this application need only ask any MHA employee for help. PRIVACY ACT NOTICE Family income and other information is being collected by MHA to determine an applicant s eligibility and the recommended unit size. MHA will conduct a computer match to verify the information you provided ONLY AT THE TIME OF SELECTION. This information may be released to appropriate Federal, State, and local agencies, when officially requested. However, the information will not be otherwise disclosed or released outside of MHA, except as permitted or required by law. You must provide all the information requested by MHA, including all social security numbers you, and all other household members age six (6) years and older, have and use. Giving the social security numbers of all household members 6 years of age and older is mandatory, and not providing the social security numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval. Authority for information collection: The following laws authorize the collection of this information by HUD or the public housing agency: 1) the U.S. Housing Act of 1937 (42 U.S.C., 1437 et seq.), 2) Title VI of the Civil Rights Act of 1968: The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and residents to submit the social security numbers of all household members at least six (6) years old. Effective March 31, 2013, all MHA properties will be smoke free. Federal/State Public Housing Section 8 Housing Choice Vouchers Any Available This application is for (check one): Page 1
APPLICANT NAME (HEAD OF HOUSEHOLD) Last Name First Name MI Social Security # Birth Date Race/Ethnicity We are required to perform a demographic survey of all housing applicants. This information is voluntary. This data will be kept confidential and will only be used as required by government law or regulation. CODES TO USE: Race AN AS AA PI CA Ethnicity HL NH American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Not Listed or do not wish to disclose Hispanic or Latino Not Hispanic or Latino Not Listed or do not wish to disclose ADDRESS / Apt. #, Street, Town, Zip Code TELEPHONE NUMBER: HOME MOBILE WORK E Mail ALTERNATIVE CONTACT: Page 2
HOUSEHOLD MEMBERS: List all other persons who are part of your application. Print clearly. Last Name First Name MI Social Security # Birth Date Race/Ethnicity 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. We are required to perform a demographic survey of all housing applicants. This information is voluntary. This data will be kept confidential and will only be used as required by government law or regulation. CODES TO USE: Race AN AS AA PI CA Ethnicity HL NH American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Not Listed or do not wish to disclose Hispanic or Latino Not Hispanic or Latino Not Listed or do not wish to disclose. Page 3
INCOME: Does anyone receive or expect to receive money from any source listed below? Check Yes or No for each item. If yes, list who and the estimated amount received monthly. Item Yes No Who/Brief Explanation Monthly Amount Social Security SSI Pension/Retirement Veteran s Benefit Railroad Retirement Military Allotment Rental Property Spousal Support Workers Compensation State Disability Unemployment Benefits SNAP (Food Stamps) TANF Child Support Grants, Scholarships Work Study or Training Other, Explain Page 4
12. Do you have a live in aide? If yes, complete the following: Name Social Security # Do you pay for this service yourself? If no, please explain. Is anyone in the household a veteran? If yes, please identify. Does anyone in the household require any type of service or accommodation? If yes, please explain. Does anyone receive any income from any other source, including someone outside your household paying for any of your bills or giving you money? If yes, please explain. EMPLOYMENT: Is anyone working or expecting to work in the next 6 months at an employer who will verify their employment? Yes No Does anyone receive contributions, gifts or loans from any source? Yes No If yes, please explain: Does anyone own or is anyone buying real estate, such as land and/or buildings, mobile homes, etc., anywhere? If yes, please explain: PLEASE ANSWER THE FOLLOWING QUESTIONS TRUTHFULLY. YOUR ANSWERS DO NOT AUTOMATICALLY RULE OUT YOUR ELIGIBILITY FOR THE WAITING LIST. Have you or any member of your household (listed above) ever been arrested for any drug related criminal activity? Page 5
Have you or any member of your household (listed above) ever been arrested/convicted for any felonious crime or violent criminal activity that has as one of its elements the use, attempted use, or threatened use of physical force against a person or property of another? Have you any other adult member ever been arrested for/convicted of any crime involving fraud or dishonesty? Are you or any member of your household (listed above) subject to a lifetime registration requirement under a state sex offender registration program? Do you or have you or any other adult household member live in/lived in any rental assisted housing? Have you ever been evicted from or committed any fraud in any housing assistance program or been requested to repay money for knowingly misrepresenting information for such housing programs? Have you or any other adult member ever used any name(s)/social security number(s) other than the one you have listed? Have you or any other adult household member sold any business or asset in the last 2 years for less than its full value? By signing this application I (we) understand that this is not a contract for housing assistance and that no commitment has been made by MHA to provide such. I (we) understand that the information that has been provided will be used for waiting list purposes only and that selection for housing assistance provided by MHA will take place by lottery at a place and time and according to a method determined by MHA for its purposes. I (we) certify that the information provided is accurate and truthful and that failure to provide such may be cause for MHA to refuse to consider the application for further processing and/or selection for housing assistance. SIGNATURES OF ALL ADULT MEMBERS OF THE HOUSEHOLD LISTED ON THIS APPLICATION DATE & TIME STAMP Page 6