PHA Paperwork Pilot

Applicant — Personal Identifiers

First Name

Last Name

Date of Birth

SSN (or Alternate ID)

Gender (optional)

Marital Status (optional)

Contact & Residency

Street Address

City

State

ZIP

Phone

Email

Homelessness Status (optional)

Race & Ethnicity (Voluntary for HUD Reporting)

Ethnicity

Race (select one or more)

Providing race/ethnicity is voluntary and used for civil rights and reporting compliance.

Income & Assets

Employment Income (monthly)

Benefits (SSI/SSDI/TANF) (monthly)

Other Income (child support, etc.)

Assets: Checking/Savings

Assets: Retirement/Securities

Assets: Other

Current Housing Situation

Monthly Rent / Housing Cost

Estimated Totals: Monthly $0 · Annual $0

Preferences & Priority Status (Local Policy)

Veteran Status

Elderly/Disabled Household

Accessibility Needs / Reasonable Accommodation

Describe mobility, sensory, or other accommodation needs.

VAWA Optional Disclosure

Domestic violence, dating violence, sexual assault, or stalking (if applicable for protections/preferences per policy).

Certifications

I declare the information on citizenship/eligible non-citizen status is true for each household member. (Adults sign; parents/guardians sign for minors.)Consent to criminal background screening (per PHA policy).Consent to release income and benefit information for verification.I certify that all statements are true and complete. I understand providing false information may result in denial or termination of assistance.

Applicant Signature (type full name)

Date