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.
* Does anyone help you pay bills regularly?:
YesNo* If yes, who?
* How often?
* How much?
Do any household members have or receive income from assets? (Check all that apply)
Real EstateStocks/BondsSavings AccountsCompany Retirement
Pension FundInsurance SettlementsCertificate of DepositsTrusts
Checking AccountOther
* If other, itemize:
* Has any member of the household given away or sold any asset for less than fair market value in the past 2 years?
YesNo* If yes, what?
* How much did you actually receive:
* 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 TotalMedical ExpenseYearly TotalMedical ExpenseYearly TotalMedical ExpenseYearly TotalMedical ExpenseYearly TotalMedical ExpenseYearly TotalCurrent Landlord:
Address:
Phone:
Previous Landlord:
Address:
Phone:
* Have you or any household member ever lived on public housing assistance?
YesNo* If yes, under whose name?
* Where?
From?
To?
* Do you owe money on any type of claim to any Housing Authority in the United States where you or any household member has lived after age 18?
YesNoIf yes, where?
How much?
* Does any household member 18 years or older have a debt with a utility company or previous landlord?
YesNoIf yes, where?
How much?
* Have you or any household member ever used any other name or social security number than the one used on this application?:
YesNo* If yes, list:
* Are you or any household member required to report to a probation or parole officer?:
YesNo* If yes, please provide officer's name and telephone number:
* Have you or any household member ever been arrested before?:
YesNo* If yes, please explain:
* Have you or any household member ever been arrested for drug or alcohol related activity, or violent criminal activity?:
YesNoIf yes, give name of household member(s):
* If yes, please explain:
* Do you own vehicle(s)?:
YesNoIf yes, please list:
Make:
Model:
Color:
Tag #:
Make:
Model:
Color:
Tag #:
Make:
Model:
Color:
Tag #:
* Have you ever lived in assisted housing before?:
YesNoIf yes, Who was the head of the household?:
When?:
Where?:
Under what name?:
* Have you ever used a name other than the one you are now using?:
YesNo* If yes, what name?:
* Have you ever used a social security number other than the one listed above?:
YesNo* If yes, What is it?:
* Have you ever been evicted?:
YesNoIf yes, Who?:
When?:
For What?:
* Has anyone in your household ever been arrested?:
YesNoIf yes, who?
When?
For what?
* Has anyone in your household (regardless of age) been arrested or convicted for the use, sale, manufacture or distribution of controlled substances (drugs)?:
YesNoIf yes, Who?:
When?:
For What?:
* Have you or any household member ever been arrested or charged for drug, alcohol related activity or violent criminal activity?:
YesNo* If yes, please explain:
* Have you or any household member participated in drug rehabilitation during the past 12 months?:
YesNo* If yes, please explain:
* Have you or any family member been the victim or assailant in a domestic violence case?:
YesNo* If yes, please explain:
* Has anyone in your household applied for any benefits or money which is in the process of being approved?:
YesNo* If yes, please explain:
* Does anyone outside of your household pay any of your bills or give you regular gifts (food, clothing, cigarettes, etc.)?:
YesNoIf yes, who?
How much?
How often?
* Do you receive child support, alimony, or maintenance?:
YesNoIf yes, from whom?
Amount?
* Does anyone in your household receive an educational scholarship or grant?:
YesNoIf yes, name of source, amount, and how often:
Household member who receives it:
* Does anyone in your household currently use a controlled or illegal drug?:
YesNo* If yes, please explain:
* Have you ever been evicted from Public or Assisted Housing for violent criminal or drug-related activity?:
YesNo* If yes, please explain:
* Do you owe any money to another Public Housing Authority, a Section 8 Agency or other subsidized housing program?:
YesNoIf yes, who?
Amount?
* Are you or any household member required to report to a probation or parole officer?:
YesNoIf yes, which family member(s)?Name of probation or parole officer:
Officer's phone #:
* Have you ever lived in public housing before?:
YesNoIf yes, where?Lessee Name
From
To
* Do you owe money to the Housing Authority?:
YesNoIf yes, how much?:
* Do you have any past due utility bills (gas, water or electricity)?:
YesNo* If yes, please describe and give amount owed:
* Have you, or any member of the applicant household ever been arrested or convicted of a crime other than a traffic violation?:
YesNo* If yes, please explain the nature of the problem and who was involved:
* Do you own a pet?:
YesNoIf yes, what kind?:
Size?:
Weight?:
* Are you entitled to Child Support?:
YesNo* Are you entitled to Alimony?:
YesNo* Are you entitled to Maintenance?:
YesNoI 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.