Housing Assistance Program

To properly assist you, we must have accurate and complete information. All questions must be answered. If a question does not apply, please type in “N/A” or place an “X” through that portion of the form. Failure to answer all questions may delay your eligibility determination and placement on the waiting list. Incomplete applications will be returned to the applicant to be completed.

1. HEAD OF HOUSEHOLD INFORMATION

Social Security Number:

Date of Birth:

Male Female

Mailing Address:

Phone Number:

2. CO-HEAD INFORMATION (OPTIONAL)

Social Security Number:

Date of Birth:

Male Female

Mailing Address:

Phone Number:

3. HOW MANY PEOPLE IN YOUR HOUSEHOLD? (PLEASE INCLUDE YOURSELF):

4. INCOME INFORMATION

Please indicate, using the chart below, the TOTAL MONTHLY HOUSEHOLD INCOME for ALL members of this applicant household.

Source	Monthly Amount	Source	Monthly Amount
Wages		Other Disability
General Assistance		Pension
Social Security		Unemployment
SSI/SDI		Child Support
Self-Employment		Other

Total Monthly Household Income (Before Deductions)

5. WOULD YOU LIKE YOUR NAME PLACED ON THE PUBLIC HOUSING WAITING LIST? (Income-based, 1-BR apartments in Mora, MN – heat, electricity, water & sewer included)
Yes No

6. DO ANY PERSONS WHO WILL LIVE IN THE UNIT HAVE A DISABILITY?

         Yes No

7. DO YOU REQUIRE FUTURE CORRESPONDENCE IN A FORMAT OTHER THAN      WRITTEN ENGLISH?
      Yes No

     If yes, please specify:

8. PLEASE EXPLAIN IF THERE ARE ANY OTHER ACCOMMODATIONS WHICH YOU OR      ANYONE IN YOUR HOUSEHOLD WILL NEED TO FULLY UTILIZE THE HOUSING      AUTHORITY’S PROGRAMS AND/OR SERVICES:

9. FOR HUD STATISTICAL PURPOSES ONLY

“The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service that the Federal laws prohibiting discrimination against tenant applications on the basis on race, color, national origin, sex, familial status, age and disability are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and sex of individual applicants on the basis of visual observation or surname.

Ethnicity:

Hispanic or Latino

Non Hispanic or Latino

Race: (mark one or more)
Black or African American

American Indian/Alaska Native
Native Hawaiian or Other Pacific Islander

Asian
White

The HRA of Mora prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital or familial status. To file a complaint of discrimination, write: Office of Civil Rights, Washington, D.C., 20250-9410.

10. APPLICANT CERTIFICATION

Giving True and Complete Information: I certify that all the information provided on this application is accurate to the best of my knowledge. I have reviewed my application and certify that the information shown is true and correct.

Composition: I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true circumstances. Cooperation includes, but is not limited to, attending pre-scheduled meetings and completing and signing needed forms. I understand failure or refusal to do so may result in delays, termination of assistance, or eviction.

Reasonable Accommodation: I understand that if I am disabled, I have the right to request a reasonable accommodation to make services and programs accessible.

Criminal and Administrative Actions for False Information: I understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information may be considered fraud and is grounds for denial of assistance, termination of housing assistance and/or eviction from public housing.

I certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability.