Application For Admission

1. Applicant Information (Head of Household)* First Name: Middle Initial: * Last Name: * Phone:

* Address: * City: * State: * Zip:

3. Total Household Income

List all money earned or received by everyone living in the household. This includes, but is not limited to, gross wages, self employment, child support, Social Security, SSI, Worker's Compensation, Unemployment benefits, retirement benefits, TANF, Veteran's benefits, alimony, babysitting, rental property income. Income from banks such as interest on saving bonds, checking accounts, and CDs. Also, include any regular contributions to the household from any person outside the household.

Name of Person
Receiving MoneySource of Income
(any type)How often this income
is receivedGross Income Amount
(cash/check before deductions)Social – List any changes anticipated

* Is the Head of Household, or Spouse of the Head of Household, in the Armed Services? YesNo* Does anyone help you pay bills regularly?: YesNo

* If yes, who? * How often? * How much?

5. Childcare and Medical Information* Do you pay for childcare for children age 12 or younger while you work or attend school?: YesNo* If yes, Name of the child care provider: * How much per month?:

If the Head of Household or Spouse are age 62 or older OR disabled regardless of age, list all medical expenses anticipated for the next 12 months that will not be reimbursed by insurance or other outside source. (This includes but is not limited to: prescriptions, physicians bills, hospital bills, insurance premiums, and over-the-counter medications) Back-up info required.

Medical ExpenseYearly Total

8. ConsentI hereby consent that the Henderson Housing Authority is authorized to order credit reports, criminal background checks, and any other reasonable tenant screening reports from third party providers for all applicant(s) listed on application. The applicant(s) also authorize(s) the Henderson Housing Authority, to contact past and present employers, landlords, creditors, and/or neighbors to verify employment, income, rent payment history, cleanliness, and any other relevant inquiries as the applicant’s likelihood to make regular, timely rent payments and treat the leased premises with care and respect.