RENTAL  ASSISTANCE  PROGRAM APPLICATION

unlinked 3/4/03 from Voucher.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: __________________________________

Do you need a wheelchair accessible unit? ____________ If "yes", explain: _______________________________________________________

______________________________________________________________________________________________________________________________________________________ 

Are all members of your household U.S. citizens or permanent residents of the United States? Yes no

Is anyone in your household employed in Madison? Yes ___________ No _________________

LIST ALL PERSONS WHO WILL LIVE IN THE RENTAL UNIT:

List all full and/or part-time employment for all household members. Include self-employed earnings. List other sources of income such as Welfare, Social Security, SSI, pensions, disability compensation, unemployment, interest from savings, CDs, etc., providing child care, caretaking, alimony, child support, annuities, dividends, etc.

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

If "yes", explain: ____________________________________________________________________________________________________

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

If "yes", list all addresses:______________________________________________________________________________________________

Market Value: _______________________ Income Received: ____________________________

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 Insurance you pay for:_________________________________________________________________________________________

Amount paid per year: ________________________________

Medical Conditions for which you are being treated:__________________________________________________________________________

If all adult family members are employed or attending school, you may be eligible for a child care deduction for children 13 years old or younger.

Child Care Provider’s Name & Address: ________________________________________________________________________

_______________________________________________________________________________________________________

Phone: ________________________________________

Cost: _________________________________________

Make, model and year: _______________________________________

License number: ____________________________________________

Make, model and year: _______________________________________

License number: ____________________________________________

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

If "yes", which Housing Authority? _______________________________________________________________________________________

Beginning ______________________________ Ending ___________________________________

Have you or anyone in your household ever been convicted of any crime other than traffic violations? yes no

If "yes", explain: _________________________________________________________________________________________________

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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.