Transitional Housing Application

This is a secured pre-application for the Transitional Housing Program.

Fill in your correct full name, address, including apartment number, city, state, zip and telephone number. If you would prefer to mail in your application, you can download it here to print.

PROGRAM APPLICATIONS
You are applying for -

 

1. HEAD OF HOUSEHOLD INFORMATION

 
  Middle 
 
 
 
 
 
 
 
  Male   Female
 

(If you do not have a phone number, please give phone number of nearest relative or friend.)

2. RESIDENTS
List all members of your family that will be living with you.

 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 


 
 
 
 
  Male   Female
 

3. INCOME & DEBTS

List all sources of income and debts that apply to you and indicate the GROSS amount you receive per month.
















Assets:







Debts: (Monthly amount)









Other Rural Housing Services Loan/Grant?  Yes   No


All above information must be verified when your application is processed.

CERTIFY

APPLICANT CERTIFICATION: I/We certify that the information given to the Housing Authority on household composition, income, and all other information as listed above is accurate and complete to the best of my/our knowledge and belief. I/We understand false statements or information are punishable under federal law.

Head of Household Signature:

Spouse/Co-Head Signature:

Date:

Note to applicant: If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll-Free Hot Line at 800-669-9777.