929-5588 APPLICATION FOR SECTION 8 ... - City of Norwalk

NORWALK HOUSING AUTHORITY12035 Firestone Bl.Norwalk, CA 90650(562) 929-5588For Office Use Only:Date Received:Preference Code: ________Date Entered: _______________Print first letter of last nameAPPLICATION FOR SECTION 8 RENTAL ASSISTANCEApplicant Name: _____________________________________________Telephone No._________________Address of Current Residence: __________________________________________ Apt. No.______________City, State, Zip Code: ______________________________________________________________________Mailing Address (If different): __________________________________________ Apt. No. _____________City, State, Zip Code: ______________________________________________________________________Family Composition: List all persons who will be living in assisted unit (include yourself).NameRelationto self SexDate ofBirthDisabled?Y/NSoc. Sec. No.1. SELF2.3.4.5.6.7.8.General Information:1. Is your current residence located in the City of Norwalk? Yes No(If yes, attach a copy of your lease, utility bill or children’s school registration as proof of residency)2. Are you displaced from a Norwalk residence as a result of government action or natural disaster?(If yes, attach copy of displacement notice) Yes No3. Is any member of the household a U.S. Veteran? Yes NoIf yes, who is a veteran? ____________________ (Attach copy of discharge papers. Form # DD214)4. Is any member of the household a spouse or minor child of a deceased U.S. Veteran? Yes No5. Are you attending college either full-time or part-time? Yes No(PLEASE TURN OVER)

Race of head of household: White Black/African American American Indian/Alaskan Native(check one) Asian Native Hawaiian/Other Pacific IslanderEthnicity (check one): Hispanic Non-HispanicLanguage of head of household:I Understand English: Well Not Well Not at all The language that I understand is: ______________I Speak English: Well Not Well Not at all The language that I speak is: _______________I Read English: Well Not Well Not at all The language that I read is: _______________I Write English: Well Not Well Not at all The language that I write is: _______________Sources of income: Write in amount of total monthly gross income in each category. Be sure to include allsources of income for your household.Social Security $_____________SSI (Supplemental Social Security) $_____________Retirement benefits/Pension $_____________Employment/Wages $_____________Welfare $_____________Veterans benefits $______________Disability/Workers compensation $______________Child Support/Alimony $______________Unemployment $______________Other______________________ $______________Employment Information: If any household members are employed, list employer’s name and full address:Name of household member Name of employer Work location street address and cityI certify under penalty of perjury that all information that I have provided is accurate and complete. I understand thatmaking false statements or providing false information is punishable under federal and/or state law.Signature of Head of Household ________________________________________ Date________________Signature of Spouse or Co-Head ________________________________________ Date________________RETURN COMPLETED APPLICATION BY MAIL ONLY TO:NORWALK HOUSING AUTHORITYATTN: APPLICATION DESK12035 FIRESTONE BOULEVARDNORWALK, CA 90650APPLICATION MUST BE POSTMARKED BETWEENMAY 7 - 25, 2007OR IT WILL NOT BE ACCEPTED.DON’T FORGET TO ATTACH PROOF OF VETERAN STATUS AND/OR NORWALK RESIDENCY. YOU WILLNOT RECEIVE A PREFERENCE IF THE INFORMATION IS NOT SUBMITTED.THIS APPLICATION WILL ONLY BE ACCEPTED IF RECEIVED BY MAIL.IF YOU WOULD LIKE A RECEIPT,INCLUDE A SELF-ADDRESSED STAMPED ENVELOPE WITH YOUR APPLICATION.IT IS IMPORTANT THAT YOU NOTIFY THE NORWALK HOUSING AUTHORITY IN WRITING IF THERE IS A CHANGE TOYOUR MAILING ADDRESS. IF WE ARE UNABLE TO CONTACT YOU BY MAIL AT ANY TIME, YOUR APPLICATIONWILL BE REMOVED FROM THE WAITING LIST.