WFHA Pre-Application Form

!!!DO NOT USE THIS !!!!
THIS IS TEMPORARILY UNDER CONSTRUCTION PLEASE DO NOT USE UNTIL THE ISSUE IS RESOLVED 

Head of Household   Phone   Alternate 
Mailing Address     Apt# 
City   State   Zip 

FOR STATISTICAL PURPOSES ONLY

Ethnicity of Head:  African American/ Black |  Asian |  Native American / Alaskan Native |  White |
Native Hawaiian/Other Pacific Islander

Race of Head:   Hispanic/Latino |  Non•Hispanic/Latino

HOUSEHOLD FAMILY MEMBERS

Person One (Head of Household)

Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country 

Person Two
Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country

Person Three
Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country

Person Four
Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country

Person Five
Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country

Person Six
Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country

Person Seven
Full Name   Date of Birth   Age   Sex   
Monthly Income   Income Source (wages, SSI, Child Support etc)
Last Four of SS#   Relation to Head   Birthplace/Country

*Disabled Person- has a disability determined to be continuous, and/or long term, (more than 12 months)


LOCAL PREFERENCE

Q01: Are you currently displaced due to a disaster-fire, flood, hurricane, earthquake, or governmental action such as Modernization or property disposition (housing is inaccessible or uninhabitable)? Yes |  No
Q02: Are you currently residing in a shelter from being a victim of domestic violence? Yes |  No
Q03: Is the Head of household or Co-Head/Spouse Elderly (62 years or older)? Yes |  No
Q04: Is the Head of household or Co-Head/Spouse Disabled? Yes |  No
Q05: If you answered yes to either question above, do you wish to reside at an Elderly/Mix property Yes |  No
Q06: Do you or anyone in the household need a wheelchair accessible apartment? Yes |  No
Q07: Is any family member's mobility, hearing or visually impaired? Yes |  No
Q08: Is the Head of household 51-61 years of age and if so do you wish to reside at on Elderly/Mix property?Yes |  No
*Elderly/Mix Property-All residents must be 62 years of age or older or be a disabled individual of any age.
Q09: Have you ever violated a previous obligation in connection with a HUD Program? Yes |  No
Q10:  Do you owe any low income Housing programs (PHA, Section 8 or other Program)? Yes |  No

B. Please check the bedroom size you require:
1 BEDROOM | 2 BEDROOM | 3 BEDROOM | 4 BEDROOM

I/ certify that the statements on this application are true to the best of my/our knowledge and belief and understand that they will be verified and understand that any false statements made on this application will be cause for me/us to be disqualified for admission. I/we authorize the release of information to the Housing Authority by the Social Security Administration. and/or other business or government agencies.

Head of Household Signature
Date

Co-applicant Signature
Date

WAITING LIST POLICY
I understand that I am on the active Waiting List for a _ bedroom apartment. In order to stay on the active Waiting List, I must visit or contact the Housing Authority office immediately to report any changes in family size, income, address, telephone, etc.

Applicant Signature
Date