Read and sign warning before completing this application!

WARNING

Misrepresentation is a serious dwelling lease violation that may result in an eviction. If it is found that an applicant or tenant has misrepresented the facts upon which his/her rent is based so that he/she is paying less than he/she should be paying, the dwelling lease and/or housing assistance will be terminated. In addition, the applicant/tenant may be subject to civil and criminal penalties.

The applicant/tenant is advised that any person who, by means of a false statement, failure to disclose information, impersonation or other fraudulent scheme or device: 1) obtains or attempts to obtain, or 2) establishes or attempts to establish eligibility for, and/or 3) knowingly or intentionally aids or helps such person obtain or attempt to obtain housing or a reduction in public housing rental charges or any rent subsidy to which such person would not otherwise be entitled, shall be guilty of a misdemeanor. Upon conviction, the person shall be punished by a fine of not less than $300 nor more than $500, be punished at hard labor for the county not to exceed 60 days, or both fined and imprisoned, at the discretion of the court. (24-1-10, Code of Alabama, 1975)

I understand that this is not a contract and does not bind either party. I certify that the foregoing information is full, true, and complete to the best of my knowledge.

Enter your full legal name as your signature:(Required)

Date(Required)

*** Documents you will be required to provide:

Birth certificates for all members of household
Social Security cards for all members of household
All final divorce decrees, proof of separation, and widow decree
Marriage certificate
Most current landlord’s name and complete mailing address, and phone number
Employer’s name and complete mailing address, and phone number

Most recent Social Security/SSI award letter
Child support print-out
Unemployment verification
Veterans benefit award letter

Applicant Name

First Name(Required)

M.I.

Last Name(Required)

Racial Group(Required)

(check all that apply)

White

Black / African

Asian

Native

Other

Other Racial Group

Ethnicity

Hispanic / Latino

Current Address(Required)

Street Address Apt./Unit # City State ZIP Code

Mailing Address (if different from above)

Street Address Apt./Unit # City State ZIP Code

Home Phone

Work Phone

Other Phone

Name of Current Landlord(Required)

Mailing Address of Landlord

Street Address Apt./Unit # City State ZIP Code

Present Monthly Rent

Number of Bedrooms

Number of Persons Presently in Household(Required)

Utilities

If f you pay for your utilities, indicate the amount paid by you for each. If you do not pay for a listed utility, enter N/A.

Electricity(Required)

Enter Amount Paid Monthly:

Gas(Required)

Enter Amount Paid Monthly:

Water(Required)

Enter Amount Paid Monthly:

Phone(Required)

Enter Amount Paid Monthly:

Cable TV(Required)

Enter Amount Paid Monthly:

How long have you lived at the address above?

Years

Months

Do you owe any money to the landlord listed above?

Amount Owed:

List Locations where you have lived for the past 5 years:

City

State

Year(s)

Household Composition (Start with Head of Household)(Required)

List all persons who will live in the rental unit while you are on this program.

Full Name

Relationship to Head

Birthdate

Age

Sex

SSN

Occupation / Name of School Attending

U.S. Citizen? (Yes/No)

Do you anticipate any changes in your family composition?(Required)

Explanation of Anticipated Change

Military Service(Required)

Is there any member of your hosehold (listed above) now serving in military service (Army, Navy, Air Force, Marines, Coast Guard, etc.)?

Military Information

Please provide the following information on each military service person in your household:

Name

Rank

Address

Service Branch

Household Income(Required)

List all employment income (including self-employment) for each household member.

Household Member

Name & Address of Employer

Annual Income

Other Sources of Income

(Examples: welfare, Social Security, SSI, pensions, disability compensation, unemployment compensation, baby-sitting, alimony, child support, annuities, interest, dividends, income from rental property, Armed Forces, Military Reserves, cash contributions from individuals, scholarships, grants) Include alimony and/or child support entitled to but not received.

Household Member

Source

Amount

Bank Information(Required)

List any checking, savings, credit union and/or certificate of deposit accounts.

Type of Account

Bank

Account Number

Amount

Stocks and Bonds?(Required)

Current Stock Value

Savings Bonds?(Required)

Current Savings Bond Value

Do you own Real Estate?(Required)

Current Real Estate Value

Have you EVER owned real estate?(Required)

When?

Do you have a life insurance or retirement account?(Required)

Current Insurance/Retirement Amount

Childcare Expenses

Do you pay for baby-sitting while a family member is employed?(Required)

Childcare Provider's Name

Childcare Provider's Address

Street Address Apt. / Unit # City State ZIP Code

Childcare Provider's Phone

Baby-sitting Cost

Baby-Sitting Cost Frequency

Weekly

Monthly

Medical Expenses

Are you receiving Medicare benefits?(Required)

Monthly Benefit Amount:

Are you receiving medical assistance through the welfare department (DHR)?(Required)

Monthly Medical Assistance Amount:

Do you pay for medical/hospitalization insurance (such as BlueCross)?(Required)

Indicate amount of premium paid and how often paid:

Insurance Premium Frequency

Weekly

Bi-weekly

Monthly

Are you making payments on outstanding medical bills?(Required)

Monthly Medical Bill Amount:

Do you take prescription drugs on a regular basis?(Required)

Monthly Prescription Costs:

Special Needs

For the purpose of determining allowable income deductions, does any member of your household have a disability?(Required)

Does any member require any special accommodations?(Required)

Description of Special Accommodations

Do you pay for a care attendant or for any equipment for any member with a disability in order to permit that person or someone else in the family to work?(Required)

Description of Care Attendant or Equipment Expense

Program Information

Have you or any family member listed above in this application ever been arrested for any offense against the law?(Required)

Have you or any family member listed above in this application ever had a warrant issued for an arrest?(Required)

Have you or any family member listed above in this application ever been in trouble with the law? For example, traffic citation or any other situation?(Required)

Legal / Arrest Explanation

Notice!!!!! You are reminded that all your answers will be verified. Giving false information is considered fraud.

Absent Parent Information

Family Member

Father's/Mother's Name

Street Address

City, State

Comments/Last Contact

Marital Status / History

Have you ever been married?(Required)

How many times?

Maiden Name

Have you ever been separated?(Required)

Separation Information

Date Separated

From Whom?

Street Address

City, State

Zip

Comments

Have you ever been divorced?(Required)

Divorce Information

Date Divorced

From Whom?

Street Address

City, State

Zip

Comments

Have you ever been widowed?(Required)

Information on Deceased Spouse:

Name

Social Security Number

Have you ever used a name or Social Security Number other than the ones you are using now?(Required)

Explanation of Alias/SSN

Additional Information

Have you ever applied for Public Housing or Section 8 Housing?(Required)

Have you ever lived in Public Housing or Section 8 Housing?(Required)

Have you ever lived in housing described as the "PROJECTS"?(Required)

Housing History

If you have lived or currently live in Public Housing (Projects) and/or Section 8 Assisted Housing or housing where the amount of rent you paid was based on your income, complete the following:

Where (Address)

When (Dates)

Do you owe any money to the Public Housing Project and/or Section 8 Housing?

Amount Owed for Housing:

WARNING: Section 1001 of Title 18 of the U. S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.

I/We certify that all information given to the Hobson City Housing Authority in this application is correct. I/We understand that if these facts are not true, housing assistance or housing will not be provided, and I/We will be declared ineligible. I understand that after the information in this application is verified that the information will be submitted to the U.S. Department of Housing and Urban Development (HUD) on Form HUD-50058 (The Federal Privacy Act Statement contains additional information concerning the authorized use of this information.) I also understand that staff of the Hobson City HA will verify this information, and I authorize the Hobson City HA to submit inquiries necessary for the purpose of verifying the facts herein stated.

Enter full legal name of the Head of Household as your signature(Required)

Date(Required)

Enter full legal name of Spouse/Other Adult as your signature

Date

Note: If you believe you have been discriminated against, you may report the incident by calling the Fair Housing and Equal Opportunity toll-free hotline at 1-800-669-9777, or by asking the Anniston HA to provide you with a HUD Housing Discrimination Complaint form, HUD-903.

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Hobson City Housing Application

Read and sign warning before completing this application!

WARNING

*** Documents you will be required to provide:

Applicant Name

Utilities

How long have you lived at the address above?

Childcare Expenses

Medical Expenses

Special Needs

Program Information

Notice!!!!! You are reminded that all your answers will be verified. Giving false information is considered fraud.

Marital Status / History

Additional Information

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