SENIOR CITIZEN HOUSING APPLICATION

unlinked 3/4/03 from SC Hsg.htm

Last Name ______________________________________________________ First Name__________________________________________

Street Address _______________________________________________________________________ PO Box ________________________

Town _______________________________________________________State ______________________ Zip Code ___________________

Home Phone: ____________________________________ Emergency Contact: ___________________________________________________

Work Phone: _____________________________________ Phone:____________________________________________________________

Landlord’s Name and Address: __________________________________________________________________________________________

__________________________________________________________________________________________Phone: ___________________

Rent charged: __________________ Rent you pay: _____________________ Number of Bedrooms: ___________________________________

PROPERTY

Do you own any property / real estate? Yes __________ No __________

If "yes", list all addresses:_______________________________________________________________________________________________

Market Value: _______________________ Income Received: ____________________________

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Are you the parent of a Madison resident?     Yes _______      No _____

If "Yes", please answer the following:

           What is your child's name?   ____________________________________________________________

            What is your child's address?  __________________________________________________________

                            Telephone number?  _________________________________________________________

            How long has he/she lived in Madison?  ___________________________________________________

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Do you need a wheelchair accessible unit? ____________

LIST ALL PERSONS WHO WILL LIVE IN THE RENTAL UNIT:

         FULL NAME      RELATIONSHIP        BIRTH DATE                AGE                 SEX
         
Social Security #   xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxx
         
Social Security #   xxxxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxx xxxxxxxxxxxxxxxxxxxxxxxxxx

INCOME  

List all ALL SOURCES OF INCOME such as Social Security, SSI, pensions, disability, employment, self-employment earnings, unemployment, interest from assets, baby sitting, caretaking, alimony, child support, annuities, dividends, income from rental property, etc.

Household Member Source of Income/Job Title GROSS Amount per month

Does anyone outside of your household pay for any of your bills or give you money? Yes ___________ No ___________

If "yes", explain: ______________________________________________________________________________________________________

ASSETS

Checking: Bank _____________________________________________________________ Amount ____________________________

Account # __________________________________________________________

Savings: Bank _____________________________________________________________ Amount ____________________________

Account # __________________________________________________________

Bank _____________________________________________________________ Amount ____________________________

Account # __________________________________________________________

Credit Union: Bank ______________________________________________________________ Amount ____________________________

Address ______________________________________________________________________________________________________

Account # __________________________________________________________________

Stocks and Bonds, CDs, 401K, Mutual Funds, IRA accounts, etc.: List on a separate sheet of paper. Include name of company/bank, number of shares, present value, dividends (income received) and rate of interest.

MEDICAL EXPENSES

 Medical Insurance you pay for:___________________________________________________________________________________________

Amount paid per year: ________________________________

Medical Conditions for which you are being treated:__________________________________________________________________________

_________________________________________________________________________________________________________________

AUTOMOBILES

Make, model and year: _______________________________________

License number: ____________________________________________

Make, model and year: _______________________________________

License number: ____________________________________________

OTHER ASSISTANCE

Have you ever received either rental assistance or public housing? Yes ___________ No ____________

If "yes", which Housing Authority?_________________________________________________________________________________________

Beginning ______________________________ Ending ___________________________________

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For HUD record-keeping we request that you indicate your race / ethnicity:

White ____________                Asian/Pac Islander ____________                Native American _____________

Black ____________                Hispanic ___________

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WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL FALSE STATEMENTS OR MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.

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CERTIFICATION BY APPLICANT: BY SIGNING THIS APPLICATION, I / WE DECLARE THAT ALL OF MY / OUR RESPONSES ARE TRUE AND COMPLETE AND I / WE AUTHORIZE THE MADISON HOUSING AUTHORITY TO VERIFY THIS INFORMATION. ANY FALSE STATEMENT ON THIS APPLICATION CAN LEAD TO REJECTION OF YOUR APPLICATION OR IMMEDIATE TERMINATION OF YOUR LEASE. I / WE UNDERSTAND THAT IN ORDER FOR MY / OUR APPLICATION TO REMAIN CURRENT I / WE MUST NOTIFY THE HOUSING AUTHORITY OF ANY CHANGE IN ADDRESS.

                                                                                                        __________________________________________________________

                                                                                                        Signature of Applicant                                                                    Date

In the selection of all tenants the Housing Authority does not discriminate on the basis of sex, race, creed, national origin or against persons with disabilities.