Application VHA

We are accepting applications at this time. All waiting lists are open EXCEPT 1 Bedroom.

SECTION 1: FAMILY COMPOSITION

Please list all other members of the Household who will be living with you.
Head of Household
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Sex

Male Female
Address

Street Address

Apartment #

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
Phone Number

SECTION I: FAMILY COMPOSITION
Member 2

If you have no other family members living with you, skip to Section II
Full Name

First Name Last Name
Relation to Head of Household
Birth Date

Month Day Year
Sex

Male Female

YOU QUALIFY FOR A ONE BEDROOM UNIT.

OUR ONE BEDROOM WAITING LISTS ARE CLOSED AT THIS TIME.

SECTION II: INCOME

All income entered must be Gross Income (before taxes), NOT Net Income.
Member 1 Income Description
Name of Business
Member 1 Type of Income
Amount per Month
in dollars
Member 2 Income Description
Name of Business
Member 2 Type of Income
Amount per Month
in dollars

SECTION II: INCOME

Deductions
How much do you pay in childcare/daycare expenses per month?
per month
How much do you pay in medical expenses per month?
per month
Are any family members currently enrolled in school?

Yes No
If you or any of your family members are in school, please list how many members are enrolled.
SECTION II: INCOME

Assets
What is the current value in all family members checking accounts?
What is the current value in all family members savings accounts?
What is the current value in all family members stocks/bonds?
What is the current value of any real property you own?
If you currently disposed of any assets within the past two years for less than fair market value, please list the amount you recieved for those assets here.

SECTION IV: Displaced, Handicapped, Disabled, Veteran Service Data

If you are not disabled, handicapped, or a veteran, please skip to the next section.
Are you or any of your family members disabled or handicapped?

Yes No
Please list any special accommodations you or any of your family members may need.
Have you or any of your family members ever been in the military?

Yes No
If yes, please list the branch, date served, date dishcarged, and rank

SECTION V: Disclosure

Please place your initials as your signature
I understand that this is not a contract and does not bind either party. The above information is full, true and complete to the best of my knowledge. I have no objections to inquiries being made for the purpose of verifying the statements made herein.
APPLICANT'S SIGNATURE *
Applicant's Initials
Date:
Should be Empty:

SECTION 1: FAMILY COMPOSITION