Public Housing Application - Concord Housing

Subsidized Housing Application
Please check the programs you are applying for:
- Pitman Place*
- Thompson Square*
- Public Housing
- Housing Choice Voucher Program
Name*
Household Information
First Last Suffix
Social Security Number*
Date of Birth*
MM slash DD slash YYYY
Birthplace*
Sex*
- Male
- Female
Race*
Ethnic Group*
Mailing Address*
Mailing Address City State Zip
Physical Address*
Physical Address City State Zip
Phone Number*
Are there more household members?*
- Yes
- No
If YES, click the add entry button below for each household member and fill in their complete information.

Untitled

Last Name	First Name	Relationship to HOH	Social Security #	Date of Birth	Birthplace	Sex	Disabled:	Full-time Student?	Actions

There are no Entries.

Number of adults (over age 18):
Number of other male adults
Number of other female adults
Number of children:
Number of boys
Number of girls
What is the bedroom size you are requesting:
- Studio/1
- 2
- 3
- 4
Are you or another adult member of the household disabled:
- Yes
- No
If YES, and you are in need of a “Reasonable Accommodation”, please describe your request:
Are you in need of interpreter services:
- Yes
- No
If YES, what language do you speak

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Household’s Annual Income
Head of Household
Employment Employer Name Address
Employment
Gross Amount (Before deduction) $
$ weekly # Hours per week: Hourly Rate $
Other Household Member
Other Household Member
Employment Employer Name Address
Employment
Gross Amount (Before deduction) $
$ weekly # Hours per week: Hourly Rate $
Income Source
Source Who Collects? Amount (Monthly) Amount (Weekly) Company name
Who Collects?
Any other income sources/types not listed
Source Who Collects? Amount (Monthly) Amount (Weekly)
Who Collects?
DO NOT INCLUDE DIVIDENDS/INTEREST: THEY SHOULD BE LISTED IN THE ASSET SECTION OF THIS APPLICATION

Employment	Employer Name	Address
Employment

Employment	Employer Name	Address
Employment

Source	Who Collects?	Amount (Monthly)	Amount (Weekly)
	Who Collects?

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Assets type	Balance $	Account Number	Bank name
Assets type

Assets type	Balance $	Account Number	Bank name
Assets type

Assets type	Balance $	Account Number	Bank name
Assets type

Assets type	Balance $	Account Number	Bank name
Assets type

Life Insurance	Cash Value $
Life Insurance

Do you own any pets?	Type	Weight
Do you own any pets?

Address	Property	Cost per month $
	Property

Applicant Certification
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
Head of Household
Head Date
MM slash DD slash YYYY
Spouse or Co-Head of Household
Spouse Date
MM slash DD slash YYYY
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.
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CONCORD, NEW HAMPSHIRE

Subsidized Housing Application

Household’s Annual Income

Household Assets

Housing History

Emergency Contact

Applicant Certification

Stock name	Total Value $	Number of Shares

Total Value $	Total Value $	Total Value $

#1 Name	Address	Phone 000-000-0000