Preliminary Application Housing Type*SelectNorthridge ManorPublic HousingPublic Housing Waiting List*Select1 Bedroom Elderly/55 Plus2 Bedroom Elderly/55 Plus2 Bedroom3 Bedroom4 BedroomNorthridge Manor Waiting List*Select2 Bedroom3 Bedroom4 BedroomSection 8 Waiting List*Select2 Bedroom3 Bedroom4 BedroomPart 1: Head of HouseholdName* First M.I. Last Social Security Number*ex. xxx-xx-xxxxDate of Birth* Sex*FemaleMaleTelephone Number*Secondary Phone NumberEmail* Ethnicity*Ethnic data for statistical purposes only.HispanicNot HispanicRace* White Black / African American American Indian / Alaska Native Asian Native Hawaiian / Other Pacific Islander Racial data for statistical purposes only.Do you qualify for a reasonable accommodation due to a disability?*YesNoPlease notify the housing authority of the type of accommodation need once your application is successful update in our records.Income*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer WeeklyEvery 2 WeeksMonthlyYearlyPart 2: Household InformationAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code*Zip CodeIs your mailing address different from the address above? Yes Mailing Address (if different from legal)* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code*Zip Code Note: If your legal or mailing address changes, you must notify the Housing Authority in writing to maintain your waiting list status.How many household members? (Not including head of household)*012345List information for adults first, then children under age 18. Be sure to list the relationship of each person to the Head of Household.1st Household MemberName* First M.I. Last Social Security No.*Date of Birth*Sex*MaleFemaleDisabled*NoYesRelationship to Head of Household*SpouseCo-headFoster child/adultYouth under 18Full-time student 18+Live-in aidOther adultEthnicity*HispanicNon-hispanicRace*WhiteBlack/African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderIncome*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer WeeklyEvery 2 WeeksMonthlyYearlyList total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18. At least one source of income must be specified. If you do not have any income, select the Head of Household from the "First Name" dropdown, enter 0 for "Gross Income", and select "Yearly" for "How Often".2nd Household MemberName* First M.I. Last Social Security No.*Date of Birth*Sex*MaleFemaleDisabled*NoYesRelationship to Head of Household*SpouseCo-headFoster child/adultYouth under 18Full-time student 18+Live-in aidOther adultEthnicity*HispanicNon-hispanicRace*WhiteBlack/African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderIncome*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer WeeklyEvery 2 WeeksMonthlyYearlyList total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18. At least one source of income must be specified. If you do not have any income, select the Head of Household from the "First Name" dropdown, enter 0 for "Gross Income", and select "Yearly" for "How Often".3rd Household MemberName* First M.I. Last Social Security No.*Date of Birth*Sex*MaleFemaleDisabled*NoYesRelationship to Head of Household*SpouseCo-headFoster child/adultYouth under 18Full-time student 18+Live-in aidOther adultEthnicity*HispanicNon-hispanicRace*WhiteBlack/African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderIncome*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer WeeklyEvery 2 WeeksMonthlyYearlyList total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18. At least one source of income must be specified. If you do not have any income, select the Head of Household from the "First Name" dropdown, enter 0 for "Gross Income", and select "Yearly" for "How Often".4th Household MemberName* First M.I. Last Social Security No.*Date of Birth*Sex*MaleFemaleDisabled*NoYesRelationship to Head of Household*SpouseCo-headFoster child/adultYouth under 18Full-time student 18+Live-in aidOther adultEthnicity*HispanicNon-hispanicRace*WhiteBlack/African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderIncome*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer WeeklyEvery 2 WeeksMonthlyYearlyList total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18. At least one source of income must be specified. If you do not have any income, select the Head of Household from the "First Name" dropdown, enter 0 for "Gross Income", and select "Yearly" for "How Often".5th Household MemberName* First M.I. Last Social Security No.*Date of Birth*Sex*MaleFemaleDisabled*NoYesRelationship to Head of Household*SpouseCo-headFoster child/adultYouth under 18Full-time student 18+Live-in aidOther adultEthnicity*HispanicNon-hispanicRace*WhiteBlack/African AmericanAmerican Indian/Alaska NativeAsianNative Hawaiian/Other Pacific IslanderIncome*Gross Income ($)How OftenIf Income is from Wages, List Name and Address of Employer WeeklyEvery 2 WeeksMonthlyYearlyList total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18. At least one source of income must be specified. If you do not have any income, select the Head of Household from the "First Name" dropdown, enter 0 for "Gross Income", and select "Yearly" for "How Often".Part 3: Family Income and AssetsList total cash value and total income received for assets owned by all family members.Checking AccountChecking Account ValueAnnual Income ReceivedSavings AccountSavings Account ValueAnnual Income ReceivedStocks, Bonds, CDs, InvestmentsStocks, Bonds, CDs, Investments ValueAnnual Income ReceivedReal EstateReal Estate ValueAnnual Income ReceivedOther AssetsOther Assets ValueAnnual Income ReceivedEligibility and PreferencesYour response to the following statement will help determine your eligibility for rental assistance and if you are entitled to a preference when placed on the program's waiting list. Select the appropriate responses for each question below.Are you active US Military, the spouse of Active US Military, a US Military Veteran, the spouse of US Military Veteran, or a widow of a US Military person killed in Action?*YesNoPart 4: Supplemental and Optional Contact InformationYou have the right to include as part of your application contact information for a person or organization that may be able to help you resolve any issues that may arise during your tenancy or to assist in providing any special care or services you may require should you become a tenant. You are not required to provide this contact information, but if you choose to do so, please click the "Add Contact" button below to complete the form.Add Contact Yes Optional and Supplemental Contact Information for HUD-Assisted Housing ApplicantsSUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSINGThis form is to be provided to each applicant for federally assisted housing Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form. Applicant Name* First Last Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code*Zip CodeTelephone Number*Secondary Phone NumberName of Additional Contact Person or Organization* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code*Zip CodeTelephone Number*Secondary Phone NumberEmail Address (if applicable) Relationship to Applicant*Reason for Contact* Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent Assist with Recertification Process Change in lease terms Change in house rules Other Please list other reason for contact*Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you. Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law. Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975. The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD's assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.Part 5: U.S. Citizenship Notification and CertificationHousing may be contingent upon the submission and verification of evidence of citizenship or eligible immigration status prior to the time housing is made available. Based on the evidence submitted at that time, assistance may be prorated, denied or terminated following appeals and informal hearing processes. Confirm* I certify that the information provided is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000 or imprisoned up to five years if I furnish false or incomplete information. CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.