Public Housing Application

This application is intended for individuals or families seeking affordable housing through government-assisted programs. Please complete all relevant sections accurately. Additional documents or verifications may be required depending on your specific circumstances.

Applicant Information

Full Name: {fullName}

Date of Birth: {dateOfBirth}

Social Security Number: {socialSecurityNumber}

Phone Number: {phoneNumber}

Email Address: {emailAddress}

Current Address: {currentAddress}

Preferred Language: {preferredLanguage}

Household Members

Housing Preferences

Preferred Housing Type: {preferredHousingType}

Number of Bedrooms: {bedroomCount}

Do you require accessible accommodations? {requiresAccessibility}

{#accessibilityDetails}

Please describe your accessibility needs: {details}

{/accessibilityDetails}

Employment and Income Information

Employment Status: {employmentStatus}

Monthly Household Income: {monthlyIncome}

{#incomeSources}

• {type}: {amount}

{/incomeSources}

Assistance and Benefits

Are you currently receiving any of the following assistance programs?

{#assistancePrograms}

• {programName}

{/assistancePrograms}

Criminal Background Disclosure

Have you or any member of your household ever been convicted of a felony? {hasFelony}

{#felonyExplanation}

Explanation: {explanation}

{/felonyExplanation}

Previous Housing History

Have you previously applied for or lived in public housing? {previousHousing}

{#previousHousingDetails}

Location/Agency: {housingAgency}

Dates of Residency: {residencyDates}

Reason for Leaving: {reasonLeaving}

{/previousHousingDetails}

Documentation Checklist

Please ensure you submit copies of the following documents along with this application:

{#documentsRequired}

• {documentName}

{/documentsRequired}

Consent and Signature

I, {fullName}, certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in disqualification.

Signature: _______________________

Date: {submissionDate}