PUBLIC HOUSING and/or SECTION 8 WAIT LIST PREFERENCE

/ REASONABLE ACCOMODATIONAPPLICATION

RACIAL GROUP:
( ) White
( ) Black/African American
( ) Asian
( ) Native American
( ) Pacific Islander
( ) Other
ETHNICITY:
( ) Hispanic/Latino
( ) Non Hispanic/Latino / WAITLIST PREFERENCES:
Please indicate if you meet one of the following preferences
( ) Federally Displaced Person (FEMA documentation)
( ) Veteran (with DD-214 documentation)
( ) Displaced Person by Government Action (Letter from agency)
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( ) Reasonable Accommodation Requested
PROPERTY PREFERENCE:
( ) Southward Village ( ) Bonair Tower ( ) Royal Palm Tower
( ) Horizons Apartments
SECTION 8
( ) Housing Choice Voucher ( )Project Based Voucher
1. APPLICANT HEAD OF HOUSEHOLD:
Applicant Name: ______
Last Name, First Name M.I.
Current Address: ______
Street Address and Apt #, City, State Zip
Mailing Address: ______
Mailing Address (PO Box) City, State Zip
Home Phone # ______Cell # ______

2. HOUSEHOLD COMPOSITION: List all persons that will live in the unit.

Full Name (s) / Relation to
Head of
Household / Birth Date / Age / Sex / Social Security Number / Legal
Status
Yes or No
1 / HEAD
2
3
4
5
6
7
8

Do you or does anyone in your household, require any modifications or accommodations in order to fully utilize the unit or the program and its services? Yes No. If yes explain:______

3. HOUSEHOLD INCOME: List all household income including employment, unemployment, Social Security, SSI, pensions, child support, babysitting, help from family members, TANF Cash Assistance, etc..

Household Member / Source of Income / Amount of Income and
Frequency ((weekly, bi-weekly,

4. MEDICAL EXPENSES: Only applicable if Head, Spouse or Co-Head are elderly or disabled

1. Are you receiving Medicare benefits? Yes  No  If yes, monthly cost of premium amount $______
2. Do you pay for any medical insurance such as Blue Cross or AARP? Yes  No 
If yes, monthly amount of premium $______
3. Are you making monthly payments on outstanding medical bills? Yes  No 
If yes, monthly amount paid $ ______
4. Do you take prescription drugs on a regular basis? Yes  No 
If yes, your cost paid per month $______

5. PROGRAM INFORMATION:

  1. Have you or any family member in the household been arrested in the last five years? Yes  No 
  2. Have you or any family member in the household ever been subject to a lifetime registration under the state sex offender registration program? Yes  No
  3. Have you ever lived in Public Housing? Yes  No If yes, where? ______
  4. Have you ever participated with the Section 8 Program before? Yes  No  If yes, where? ______
  5. Have you ever lived or currently live in a unit where the amount of rent you pay is based on your income? Yes  No. HUD__ LIHTC__ HOME__ Other__  If yes, where? ______
  6. Do you owe any money to any Public Housing Agency and/or Section 8 Housing Program? Yes  No  If yes, name of Housing Agency______Amount owed $______.
  7. Have you lived anywhere other than Lee County, Florida? Yes__ No ___
If yes where______

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make false statements or misrepresentation to any department or agency of the U.S. as to any matter within its jurisdiction.

CONSENT: By submitting my application, I do hereby certify that all of the above information is true and correct to the best of my knowledge. I understand that false statements or information is punishable under Federal Law and may cause my application to be denied. I hereby authorize the Housing Authority of the City of Fort Myers to obtain any information necessary to process my Public Housing Application.

______

Applicant Signature/DateCo - Applicant Signature/Date

TO BE COMPLETED BY HOUSING AUTHORITY REPRESENTATIVE
Date Application Received:______Time Received: ______
Application Received by: ______
Date Inputted in SACS: SACS Application #:

Effective 11/05/2014