Who Is The Head Of Household? (Use Legal Name):

Last: First: M.I.:

Sex: M F SSN: DOB: AGE:

RACE: White Black American Indian/Alaska Native Asian or Pacific Islander

Ethnicity: Hispanic Non-Hispanic

Monthly Income:$

Income Source:

What Is Your Present Street Address?:

Street Address:   City: State:

Mailing Address: Street:   City: State:

Home Telephone:   Business Telephone:

Emergency Contact Person: Name:

Address: City: State:

Telephone:

What Other Adults Will Be Living In The Unit?:

Legal Name	Sex M /F	Relationship to Head	SSN	Age	DOB	School Name or Occupation	Monthly Income

What Other Minors Will Be Living In The Unit?:

Do You Claim Any Of The Following Washington County Housing Authority Local Preferences?:

Involuntarily Displaced: Yes No

Resident: Yes No

Do you Require Any Modifications or Accommodations In Order To Fully Utilized The Unit?: Yes No

Have You or Anyone In Your Household Been Evicted From Public or Assisted Housing for Drug Activity Within
The Past 3 Years? Yes No

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 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 attempts a crime subject to the penalties of Title 18, Crimes and Offenses of the Pennsylvania Consonidated Statutes, Chapter 49, Subchapter A, Perjury and Falsification in official matters, Section 4904: (unsworn falsification to authorities).

Signature |Date

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 have to re-apply.

Family Areas			Elderly Areas
Washington/Canonsburg			Washington
Fredericktown			Bentleyville
California			North Charleroi
Donora			California
Monongahela			Monongahela Manor

Washington County Housing Authority© Copyright 2002-2006, Melissa McClure
Last revised: July 23, 2006.