Pre-Public Housing Application
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Elizabethton Housing & Development Agency
| Elizabethton Housing & Development Agency, Inc. Pre-Application (bring with you when you come in) PERSONAL DECLARATION FOR PUBLIC HOUSING PROGRAM |
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Use legal names only
CIRCLE ONE FOR HEAD OF HOUSEHOLD
Race: Black White American Indian/Native Alaskan Asian/Pacific Islander
Ethnicity: Hispanic Non-Hispanic
Race: Black White American Indian/Native Alaskan Asian/Pacific Islander
Ethnicity: Hispanic Non-Hispanic
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HOUSEHOLD MEMBERS: List all person who will be living in your home, list oldest to the youngest
Present Living Address: _______________________________________How long? ______
(Street) (City) (State & Zip)
Present Mailing Address:
_________________________________________________________________________
(P.O. Box or Street address)
Previous Mailing Address: ______________________________________How long? ______
Telephone
Number:_________________________________________________________________
Emergency Contact Name & Number: __________________________________________
(Street) (City) (State & Zip)
Present Mailing Address:
_________________________________________________________________________
(P.O. Box or Street address)
Previous Mailing Address: ______________________________________How long? ______
Telephone
Number:_________________________________________________________________
Emergency Contact Name & Number: __________________________________________
INCOME: List all money earned or received by everyone in your household. This includes, but is not limited to money from wages, self-
employment, child support, contributions, social security, disability, worker’s compensation, retirement, Families First, Veteran benefits, rental property
income, stock dividends, interest from bank accounts, alimony and all other sources. If you draw a check off of a different social security number than your
own, please provide us with the appropriate number or claim number.
employment, child support, contributions, social security, disability, worker’s compensation, retirement, Families First, Veteran benefits, rental property
income, stock dividends, interest from bank accounts, alimony and all other sources. If you draw a check off of a different social security number than your
own, please provide us with the appropriate number or claim number.
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NOTICE: You are required to notify the Housing Agency in writing of any changes 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 reapply.
contact you at the above address, your name may be removed from the waiting list and you will have to reapply.
Do you owe any money to a Housing Assistance Program?____________________________
Are you currently living in government assisted housing? ______Yes _____ No
Please list the name and address of at least two previous private landlords. If you have never
rented, you may list a past or present job supervisor, case worker, social worker, counselor,
probation officer, preacher, teacher or other people of this nature.
Are you currently living in government assisted housing? ______Yes _____ No
Please list the name and address of at least two previous private landlords. If you have never
rented, you may list a past or present job supervisor, case worker, social worker, counselor,
probation officer, preacher, teacher or other people of this nature.
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Have you or anyone in your household ever been convicted of any crime? _____ Yes _____ No
If yes, please explain:
_____________________________________________________________________
Have you ever engaged in felonious use/possession of drugs? _____ Yes _____ No
List any name(s) other than the one you are currently using, that you have used (maiden name,
previous married
name)____________________________________________________________________
List previous spouse:
______________________________________________________________________
Do you require a specific accommodation to fully utilize our programs and services? ___ Yes
___ No
If yes, please explain (mobility, hearing,
vision)_______________________________________________
I/We do hereby swear and/or attest that all of the information above about me/us is true and
correct. I/We also understand that all changes in income, assets and deductions of any member
of the household as well as any changes in the household members must be reported to the
Housing Agency in writing.
If yes, please explain:
_____________________________________________________________________
Have you ever engaged in felonious use/possession of drugs? _____ Yes _____ No
List any name(s) other than the one you are currently using, that you have used (maiden name,
previous married
name)____________________________________________________________________
List previous spouse:
______________________________________________________________________
Do you require a specific accommodation to fully utilize our programs and services? ___ Yes
___ No
If yes, please explain (mobility, hearing,
vision)_______________________________________________
I/We do hereby swear and/or attest that all of the information above about me/us is true and
correct. I/We also understand that all changes in income, assets and deductions of any member
of the household as well as any changes in the household members must be reported to the
Housing Agency in writing.
__________________________________ _________________________________
Signature of Head of Household Signature of Spouse
_________________________________
Date
WARNING! Title 18, Section 1001 of the United States Codes states that a person is guilty of a
felony for knowingly and willingly making false or fraudulent statement to any department or
agency of the United States.
Signature of Head of Household Signature of Spouse
_________________________________
Date
WARNING! Title 18, Section 1001 of the United States Codes states that a person is guilty of a
felony for knowingly and willingly making false or fraudulent statement to any department or
agency of the United States.