Forms - Clifton Meadows - Housing Authority WHA
Application for Admission - Clifton Meadows

 

Application for Admission - Clifton Meadows


Applicant Identification
Full Name: * Email Address: *
Present Address: Unit or Apt. #:
City: State:
Zip: Phone: *
Marital Status: Emergency Contact:

Household Status:
Family Age 62 or Over Familial
Does any family member require an impairment accessible unit?
If yes, what type?
Visual and/or Hearing impaired Wheel Chair Access Ground Floor Unit Other

Anticipated changes in family status?   If yes, which family member?
Where did you hear about our property?


List all household members that will be living with you (Oldest to Youngest):
Name * Social Security #: * - -
Date of Birth * / / Age:
Sex: * Relation to HOH:
Remarks:

Name Social Security #: - -
Date of Birth / / Age:
Sex: Relation to HOH:
Remarks:

Name Social Security #: - -
Date of Birth / / Age:
Sex: Relation to HOH:
Remarks:

Name Social Security #: - -
Date of Birth / / Age:
Sex: Relation to HOH:
Remarks:

Name Social Security #: - -
Date of Birth / / Age:
Sex: Relation to HOH:
Remarks:


Total Family Income:
List Source, Rate, Type of Income for Each Family Member: ie. SS, SSI, Wages, Tips, Child Support, etc..:
Family Member:   Source, Rate & Type: * Anticipated: *
 
 
 
 
 
    Total Family Income:  


Do you participate in Medicare Part D?    
Does any Household member receive money from any education source such as grants or scholarships? **All grants and scholarships must be disclosed for ALL members of the household.

Landlord Information:
Full Name: Phone:
Address: Unit or Apt. #:
City: State:
Zip:    

Have you ever lived in Public Housing? Have you ever lived in Section 8 Housing?
If Yes, where? Do you owe money?

Have you or any family member ever appeared in court, magistrates office, been on probation, or served time in any type of correctional facility?
If so, why and when?

Request for Disabled/Impaired Deduction:
Persons, which meet the definition of disabled or impaired, qualify for a $400 deduction to their annual income when determining rent contribution and certain other deductions. See the addendum, which defined disabled or impaired. If you feel that you qualify and would like to request this adjustment to your income, please indicate by checking the box to the left. If you have indicated your desire to request this adjustment, then we will need only sufficient information (documentation) to confirm your qualification for this status. Failure to provide this information may result in the denial of these deductions.

Request for Medical Expense Deduction:
Person, which qualifies for elderly/disabled deduction, may also qualify for medical expenses deduction. If you have medical expenses not covered by insurance and would like to request this adjustment to your income, please indicate by checking the box to the left. If you have indicated your desire to request this adjustment, then we will need sufficient information (medical bill receipts, prescription receipts, etc...) to confirm your eligibility for this adjustment. Failure to provide this information will result in denial of these deductions.

Request for Childcare Expense Deduction:
Families may request a deduction for childcare expenses when necessary for employment or education of a family member. If you would like to request this adjustment to your income, please indicate by checking the box to the left. If you have indicated your desire to request this adjustment, then we will need sufficient information (receipits/notarized statements of child care provider and proof of employment or education status) to confirm your eligibility for this adjustment. Failure to provide this information will result in denial of these deductions.


Current Housing Information:
Monthly Rent: Monthly Utilities: (Lights, Heat & Water)
Current Address: Length at Residence:
Landlord's Name: Landlord's Address:
Landlord's Phone #:    
Are Monthy Rent & Utilities Paid?    If no, why?

Previous Housing Information:
Monthly Rent: Monthly Utilities: (Lights, Heat & Water)
Previous Address: Length at Residence:
Move-out Date: Reason for Moving:
Landlord's Name: Landlord's Address:
Landlord's Phone #:    
Is there a balance owed to Previous Landlord?    If yes, how much?

Public Housing Information:
Are you a previous resident of public housing? If yes, where?
Was Move-Out voluntary? Were you evicted?
Do you have a civil/criminal record? If yes, where?
Are you a full-time/part-time student? If yes, where?

TENANT(S) I/We certify that the statements given in this form are true and complete to the best of my knowledge and belief. I/We understand that false statements or information are punishable under Federal and State Laws. By checking the box below, you certify that you understand that you cannot maintain two residences while being assisted by this Housing Authority.

NOTE: Sex Offender Screening is required on all members of the household before eligibility is determined.

Race:  National Origin: Sex:


The information regarding race, national origin, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Housing Authority, that Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial staus, age, and handicap are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way.

I have read the above statement and the above information is correct to the best of my knowledge. I have no objection to inquiries for the purpose of verifying the facts herein stated.