* REQUIRED

First Name *
 

M.I.
 

Last Name *
 

City *
 

State *
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Zip code *
 

Are you related to any Current Employee or Commissioner of the Arlington Housing Authority?

Yes    No

If yes, enter Relative's name Relative's Relationship

Part 1: Head of Household

Social Security # * (no dashes)
 

Date of Birth * (i.e. mm/dd/yyyy = 01/01/1900)
 

Sex *
 Female    Male

Are you willing to move when offered assistance? *

Yes    No

Are you disabled? *
 Yes    No

Email Address (if any)

Home Telephone
 

Other Telephone
 

Other Telephone Type

  Other Telephone Type Work Cell Phone Relative Friend Other

Are you currently employed? *

 Yes    No

If yes, please enter your employer's name and address below:

Employer's Name

Employer's Address

Race (Check One Box) *
White (If Hispanic or Latino, check here)

Black/African American

Native Hawaiian/Other Pacific Islander

Asian

American Indian/Alaska Native

Ethnicity (Check One Box) *
 Hispanic or Latino    Not Hispanic or Latino

Racial and ethnic data for statistical purposes only.

Part 2: Household Information

Provide the total number of members for this household *
 

Provide the total number of minors for this household (17 years or younger) *
 

Part 3: Family Income

List total income (before taxes) and payments received by each family member age 18 and older from wages, military pay, pensions, social security, SSI, SSDI, welfare, child support, unemployment, business, profession or any other source.

1) Family Member First Name (Head of Household)

Gross Income
 $

How Often are you Paid?
Weekly    Biweekly    Semi-Monthly   Monthly    Yearly

List Source or Description of Income
 

2) Family Member First Name
 

Gross Income
 $

How Often are you Paid?
Weekly    Biweekly    Semi-Monthly    Monthly    Yearly

List Source or Description of Income
 

3) Family Member First Name
 

Gross Income
 $

How Often are you Paid?
Weekly    Biweekly    Semi-Monthly    Monthly    Yearly

List Source or Description of Income
 

Part 4: Eligibility and Preferences

Select each option that applies to your current Status

I live in Arlington and have documentation of my current address. *Yes    No

I or my spouse work in Arlington. * Yes    No

Do you or your spouse have an SSI or SSID verified disability or currently receive some type of payment based on an inability to work. I understand that I will be required to provide documentation of the disability prior to acceptance on the Housing Choice Voucher program. *  Yes    No

Either I or my spouse is sixty-two years of age or older. *  Yes  No

I understand my birth date will be verified prior to certification for the Housing Choice Voucher program.

Application certification and submission

I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000 or imprisoned up to five years if I furnish false or incomplete information.

  I Disagree I Agree *