THE HUNTINGTON WEST VIRGINIA HOUSING AUTHORITY
ADMINISTRATIVE OFFICES - JOHNSTON CENTRE
300 SEVENTH AVENUE WEST P.O. BOX 2183
HUNTINGTON, WEST VIRGINIA 25701 HUNTINGTON, WEST VIRGINIA 25722
TELEPHONE 304-526-4400 FAX 304-526-4432 TDD 304-526-0022
COMMISSIONERS ADMINISTRATION
DAVID PLANTS, CHAIRMAN VICKIE LESTER
WENDY D. THOMAS, VICE-CHAIRMAN EXECUTIVE DIRECTOR
CAROL WILLIAMSON
JOYCE CLARK CHARLES W. PEOPLES, JR.
SUSAN GILLETTE GENERAL COUNSEL
APPLICATION FOR HOUSING ASSISTANCE
(Including any site based application)
1. HEAD OF HOUSEHOLD INFORMATION
Last Name First Name Middle Initial Maiden Name
Mailing Address______
Street City State Zip Code
Telephone Number______Alternate Telephone Number______
2. INFORMATION ABOUT SPOUSE(Wife or Husband)
Last Name First Name Middle Initial Maiden Name
Social Security Number_____-__ _-______Date of Birth______
3. LIST ALL MEMBERS INCLUDING YOURSELF WHO WILL BE LIVING IN THE UNIT
Member Full Legal Name / Income / Relationship to Head of Household / Date of Birth / Sex / M/F / Race(see code below) / Social Security Number
(Head)
FOR HUD STATISTICAL PURPOSE ONLY
Race Code: 1 = White 2 = African American 3 = American Indian/Alaska Native 4 = Asian
5 = Native Hawaiian/Other Pacific Islander 6 = Multi-Racial
Please Check One: Hispanic or Latino Non-Hispanic or Non-Latino
4. Do you or any member of the household have any of the following assets such as, (please check all that apply) checking account , savings accounts , stocks , bonds , certificates of deposit (CD’s) , real property , or Insurances policies , other ______.
5. Is there a household member with disabilities that requires reasonable accommodation so that they may have full access and utilize the housing programs and other related services? Yes No
6. Would you like your name placed on all waiting lists that you may be eligible for? Yes No
7. SOURCE(S) OF ALL HOUSEHOLD MEMBERS INCOME
(check all that apply and enter the amount received) Wages ______SSI ______
Social Security ______TANF/Welfare ______Food Stamps ______
Railroad Retirement ______Veterans Benefits ______Other ______
8. Have you or any member of the household ever engaged in drug-related criminal activity or violent criminal activity or other criminal activity? Yes No
9. Have you or any member of the household ever received any type of housing assistance? Yes No
If yes, please provide the following information:
Household members name: ______
Address of assisted unit: ______
10. Have you or has any member of the household been in the military? Yes No
11. Do you or any member of the household qualify for any of the following preferences? (must be able to provide proof): Working, Student; or receiving Social Security or SSI Involuntary Displacement
Victim of Domestic Violence, substandard Housing Homeless or High Rent Burden
12. Do you or any member of the household currently owe any money to the Huntington Housing Authority or any other Housing Authority? Yes No If yes, please provide the following information: how much is owed? $______and which household member owes the money ______Name of Housing Authority owed ______
13. I understand that it is my responsibility to contact the Huntington West Virginia Housing Authority of any changes that may effect this application. This pre-application will be applied to all housing waiting lists that I may be eligible for. I also, understand this application will not be placed on any waiting list that is closed at the time of this application. I further understand I must submit another application when a closed waiting list opens.
I CERTIFY THAT THE INFORMATION ON THIS PRE-APPLICATION IS ACCURATE AND COMPLETE
I certify that the information given to the Huntington Housing Authority on household
composition and characteristics, drug and criminal activity, income and assets are
accurate and complete. I understand the false statements of information are punishable
under Federal Law and grounds for denial or termination of housing assistance.
I understand that I am to report in writing all changes in household composition, income
and assets of any member of the household to the Huntington Housing Authority within
thirty (30) days of the change. I also understand that any attempt to obtain Public Housing,
any rent subsidy or rent reduction by false information, impersonation, and failure to disclose
information or other fraudulent behavior, and any act of assistance to such attempt are a crime.
Signature of Head of Household: ______Date: ______
Signature of Co-Applicant: ______Date: ______
***WARNING***Title 18, Section 1001 of the United States Code, states that a person who knowingly and willingly makes a false or fraudulent statement to any Department or Agency of the U.S. Government is guilty of a felony.
In compliance with Section 504 of the Rehabilitation Act of 1973 as amended, The Huntington West Virginia Housing Authority (THWVHA) does not discriminate on the basis of a disability, (physical or mental), in the admission of or access to The Huntington West Virginia Housing Authority and its programs, or the treatment of employees or applicants for employment. Any discrimination on this basis is illegal.
Mr. Larry Ellis is the Section 504 Coordinator for this agency.
Office – 300 West 7th Avenue
Huntington, WV 25701
Phone – 304-526-4400
TDD – Tele-communication Device for the Deaf
304-526-0022
______
William Dotson,
Executive Director
DO NOT WRITE BELOW THIS LINE – FOR PHA ONLY
I have reviewed this Application in it’s entirety with the applicant. Verified by my signature the application is complete. This Application will be entered, on this date and time as initialed by the head of household/spouse.Signature of THWVHA Representative: ______
Date of the Pre-Application: ______
Time of this Pre-Application: ______
Head of Household/Spouse Initial: ______
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Effective 11-15-2010