Number of other adults:
Number of children:
Other Household Member
Giving True and Complete information.
I/we certify that all the information given on household, composition, income and family assets is accurate and complete to the best of my/our knowledge. I/we have reviewed this Application Form and certify that the information shown is true anmd correct.
Reporting on Prior Housing Assistance
I/we certify that I/we have disclosed where I/we have received any previous Federal housing assistance and whether or not any money is owed. I/we certify that for the previous assistance , I/we did not commit any fraud, or knowingly misrepresent any information, or vacate the unit in violation of the lease.
Criminal and Administrative Actions for False Information
I/we understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal and State criminal law. I/we understand that knowingly supplying false, incomplete or inaccurate information is grounds for denial of this application or termination of housing assistance or termination of tenancy.
Determination of Eligibility
I/we understand that this is only my/our “initial application” and that I/we shall be required to update at a later time, so that the Housing Authority can determine my/our eligibility for the housing assistance program.
Release of Information
I/we do hereby consent and authorize the release of any and all information to the Concord Housing Authority from the sources listed on this application for the purpose of verifying my/our eligibility and benefit level. I/we do hereby release, remise and forever discharge from any action whatsoever, in law and equity, all Concord Housing Authority employees and agents in connection to the processing, investigation or credit checking of this application and will hold harmless from any suit or reprisal whatsoever.
By signing below, I/we attest that all the information contained in this application is true and accurate to the best of my/our knowledge. I/we have read and understand all sections of this application.
Please type the names of all adult household members
Concord Housing Authority does not discriminate against any person because of color, religion, handicap, familial status, sexual orientation, sex, race, marital status, age or national origin.
Applicant must notify CH+R of any address and/or telephone changes immediately. Failure to do so may result in termination from the wait list.
Completed applications will be added to the wait list on the date they are received. Incomplete applications will not be processed.