Washington County Housing Authority
100 Crumrine Tower, Franklin Street Washington, PA 15301-6995



Washington County Housing Authority Use Only
Date of Application:_________________                                                        Time of Application:___________________

1. Name of head of household:

Last: First:

2. Name of adult co-head of household:

Last: First:

3. Current address, Street, Apt#:

Street Address:    

   Current City, Sate and Zip Code:

City: State:      Zip Code:

   Current Area Code and Telephone Number:

Telephone Number:

4. Race of Head of Household: 

African American/Black    Asian or Pacific Islander    American Indian/Alaskan Native  


5. Ethnicity: Hispanic/Latino    Non-Hispanic/Non Latino

Emergency Contact Person:


Address: City: State: Zip Code:


Family Information

 First Name & Last Name
 if different from Head's

 Date of Birth


 Social Security Number

 Relationship to Head

 Disabled Person?

 Full Time Student








6. Is the applicant family displaced by natural disaster, such as a flood, hurricane, earthquake, tornado, etc.?       Yes     No

7. Is the applicant family displaced by governmental action through no fault of their own?      Yes     No

8. Is the applicant family displaced by domestic violence?      Yes     No

9. Is any adult family member employed?       Yes     No

10. Is any adult family member enrolled in a job-training program, including on required under the welfare  program?          

     Yes      No
11. Are you a resident of Washington County?       Yes     No

12. Have you or anyone in your household been evicted from public or assisted housing for drug related activity
      within the past 3 years?       Yes     No

13. Is any adult family member enrolled in an education program full-time?       Yes     No

14. Family Income Information: Please list the source and amount of all current income received by all members, including you.
      Include all earnings and benefits received from AFDC/TANF, VA, Social Security, SSI, SSID, Unemployment, Worker's
      Compensation, Child Support, etc.

Family Member Name

Income Source

Amount $

Frequency - Per

Week Month Year

Week Month Year

Week Month Year

15. Current Landlord's name and phone #:
       Date family moved into this location:

16. Most recent former address, Street, Apt#:
      Most recent former City, State,  and Zip:
      Most recent former Area code and Phone#:

17. Most recent prior landlord's name, phone #:
      Date family moved to this location:

Authorizations, Representations and Certifications

I do hereby authorize Washington County Housing Authority to obtain a "consumer report" as defined in the Fair Credit Reporting Act, 15 U.S.C. Sec. 1681a(d), seeking information on the credit worthiness, credit standing, credit capacity, general reputation, or mode of living of applicants.

I understand that any misrepresentation of information or failure to disclose information requested on this application may disqualify
me from consideration for admission or participation, and may be grounds for eviction or termination of assistance.

WARNING: Title 18, Section 1001 of the U.S. Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any Department or Agency of the U.S. or the Department of Housing and Urban Development.

NOTICE: Any attempt to obtain any rent subsidy or rent reduction by false information, impersonation, failure to disclose or other fraud, and any act of assistance to such attempt is a crime subject to the penalties of Title 18, Crimes and Offenses of the Pennsylvania Consolidated Statutes, Chapter 49, Subchapter A, Perjury and Falsification in official matters, Section 4904: (unsworn falsification to authorities).

NOTICE: You are required to notify the housing Authority (in writing) of any change of address. If we cannot contact you at the above address, your name may be removed from the waiting list, and you will have to re-apply.

Washington County Housing Authority will be contacting all former landlords for the period of three years from the date of application.

I/we certify that the statements on this application are true to the best of my knowledge and belief and understand that they will be
verified.  I/we authorize the release of information to the Housing Authority by my/our employer(s), the Department of Public
Assistance, the Social Security Administration, and/or other business or government agencies.  I/we understand that any false
statement made on this application will cause me/us to be disqualified for admission.

Applicant Signature  _________________________________     Date__________________
Co-Applicant Signature________________________________   Date___________________

WARNING:  18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingly makes or uses a document or
writing containing false, fictitious or fraudulent statement or entry in any matter within the jurisdiction of a department or agency of
the United States shall be fined not more than $10,000 or imprisoned for not more than five years or both.

"If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the Housing Authority."

Waiting List Choices

Family Areas
Elderly Areas








North Charleroi






Monongahela Manor





Washington County Housing Authority
Copyright 2009 Lauren Friedman