Worthington Public Housing Application

Public Housing Application

Applicant

*Must NOT be declared a dependent of Parent/Guardian*

Name*

First NameMiddle NameLast Name

Other Names Used in the Last 10 Years

First NameMiddle NameLast Name

Social Security #*

Sex:*

MaleFemale

Date of Birth*

Date

Place of Birth*

Race:*

WhiteBlackAmerican Indian/Alaska NativeAsian

Ethnicity:*

HispanicNon-Hispanic

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County*

Main Phone*

Area CodePhone Number

Additional Phone

Area CodePhone Number

Email*

example@example.com

Note: You are required to notify the Housing Authority in writing of any change in address. If we cannot contact you at the listed address, your name will be removed from the waiting list.

Family

List all additional members of your family that will be living with you. (Use comments box if more than 6 additional family members are in your household)

First, Middle, Last Name

Relationship To Applicant

Date of Birth

Date

Place of Birth

Sex

Race

Social Security #

*Required for each family member*

First, Middle, Last Name

Relationship To Applicant

Date of Birth

Date

Place of Birth

Sex

Race

Social Security #

*Required for each family member*

First, Middle, Last Name

Relationship To Applicant

Date of Birth

Date

Place of Birth

Sex

Race

Social Security #

*Required for each family member*

First, Middle, Last Name

Relationship To Applicant

Date of Birth

Date

Place of Birth

Sex

Race

Social Security #

*Required for each family member*

First, Middle, Last Name

Relationship To Applicant

Date of Birth

Date

Place of Birth

Sex

Race

Social Security #

*Required for each family member*

First, Middle, Last Name

Relationship To Applicant

Date of Birth

Date

Place of Birth

Sex

Race

Social Security #

*Required for each family member*

Comments or additional family members

Household Income

Fill in all sources of income that apply to your household and indicate the GROSS amount you receive per month. THIS SECTION MUST BE COMPLETED.

If not complete the application will be returned. If none, indicate "0".

Public Aid*

(TANF, General Assistance, Food Support, CASH)

Social Security*

Who receives this benefit?

Pension*

Who receives this benefit?

Employment*

Please list employer

Child Support*

Other (please specify what and amount)

Background

Veteran's Status*

YesNo

Have you ever been subsidized by any HUD program in the past?*

YesNo

If you answered Yes, which Public Housing Authority?

If you answered Yes, under what program

Section 8Public HousingOther

Do you owe any money to a Public Authority?*

YesNo

Have you or anyone in your household ever been convicted or are currently being prosecuted for a crime?*

YesNo

If you answered Yes, please explain:

Have you ever engaged in the felonious use or possession of drugs?*

YesNo

Do you have any pets?*

YesNo

The Following information is REQUIRED:

Are you homeless?*

YesNo

If yes, this information must be verified.

If yes, please explain:

What do you currently pay for rent?*

Do you currently have a lease?*

YesNo

How many bedrooms in your unit?*

What utilities do you pay?*

How long at your current address?*

Landlord's Name?*

Landlord's Phone #*

Area CodePhone Number

WARNING: Title 18, Section 1001 of the United State code, state that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.

I/we certify that the information given is complete and accurate. I/we hereby authorize the Worthington Housing Authority to verify any information regarding rental history or criminal activity, including obtaining a consumer or investigative credit report. I/we declare under penalty or perjury under the laws of the United States of America and the State of Minnesota that the information contained in this statement of facts is true, correct and complete. I/we understand that any false statements made on this application will cause me/us to be disqualified for admission.

Required*

I accept the above statement

Please list all adults 18 and over in the household

Required*

On behalf of all the adults in the household I/we accept the above statement

If non-citizen, please give Alien Identification Number

WORTHINGTON HOUSING AND
REDEVELOPMENT AUTHORITY

NOTICE TO ALL APPLICANTS:
REASONABLE ACCOMMODATIONS FOR APPLICANTS
WITH DISABILITIES OR HANDICAPS

The Worthington Housing Authority is a public agency that provides low rent housing to eligible families. The Housing Authority is not permitted to discriminate against applicants on the basis of their race, religion, sex, national origin, disability or handicap. In addition, the Housing Authority has a legal obligation to provide "reasonable accommodations" to applicants if they or any family member have a disability or handicap.

A reasonable accommodation is some modification or change the Housing Authority can make to its apartments or procedures that will assist an otherwise eligible applicant with a disability to take advantage of the Housing Authority's programs. Examples of reasonable accommodations would include:

Making alterations to a unit so it could be used by a family member with a wheelchair;
Installing strobe type flashing light smoke detectors in an apartment for a family with hearing impaired member;
Permitting a family to have a support animal necessary to assist a family member with a disability in a Housing Authority development where animals are not usually permitted;
Making large type documents or a reader available to a vision-impaired applicant during the application process;
Making a sign language interpreter available to a hearing impaired applicant during the interview;
Permitting an outside agency assist an applicant with a disability to meet the Housing Authority's applicant screening criteria.

An applicant family that has a member with a disability must still be able to meet essential obligations to tenancy - they must be able to pay rent, to care for their apartment, to report required information to the Housing Authority, to avoid disturbing their neighbors, etc., but there is no requirement that they be able to do these things without assistance.

If you or a member of your family have a disability, you may request a reasonable accommodation at the time of application or after admission.

Required*

I have read and accept the above statement on reasonable accommodations

I accept the below statement*

Applicant represents that all information given on this application is true and correct. Applicant hereby authorizes verification of all references and facts, including but not limited to current and previous landlords and employers, and personal references. Applicant hereby authorizes owner/agent to obtain Unlawful Detainer, Credit Reports, Telechecks, and/or criminal background reports. Applicant agrees to furnish additional credit and/or personal references upon request. Applicant understands that incomplete or incorrect information provided in the application may cause a delay in processing which may result in denial of tenancy. Applicant hereby waives any claim and releases from liability any person providing or obtaining said verification or additional information.

I accept the below statement*

I authorize the Worthington Housing Authority/Prairie Acres/Rising Sun Estates to obtain a Consumer Credit Report and/or a Background Report on me. This authorization is valid for purposes of verifying information given pursuant to employment, leasing, rental, business negotiation, or any other lawful purpose covered under the Fair Credit Reporting Act (FCRA). The Background Check may contain information available in the Public Domain but may not include interviews with persons other than previous employers or their agents. By accepting above, I hereby authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county and federal courts and agencies, military services and persons to release all information they may have about me including criminal and driving history. This authorization shall be valid in original or copy form.

Worthington Housing & Redevelopment Authority