TOOELE COUNTY HOUSING AUTHORITY
HOUSING ASSISTANCE APPLICATION
1.
NAME OF HEAD OF FAMILY TELEPHONE SOCIAL SECURITY NUMBER
PRESENT ADDRESS CITY STATE ZIP CODE
2. Current Landlord Telephone Number
How related
3. List names of all persons who will live with you, including yourself, and report all employment and any other income
you and they receive such as welfare, unemployment, alimony, support, G.I. death benefits, Social Security, pension, tips,
value of meals, or from any other source. Also enter name of school each child attends.
NAME AND SOCIAL SECURITY NUMBER
GROSS INCOME
PER MONTH
BEFORE
DEDUCTIONS
4. Have you ever been convicted of a felony? Yes No If yes, when?
5. Name and address of employer – or source of all income______________________________________________
6. Does your family have unusually high medical expenses not compensated for by Insurance? Yes No If yes, give
amount per month and reason
7. Do you have to pay to have your children taken care of so you can work? Yes No If yes, indicate amount paid per
month
8. Do you have any savings, bonds, etc.? Yes No If yes, list amount and type
9. Do you own any real estate or a mobile home? Yes No If yes, state what and give value of equity:
10. Is there more than one motor vehicle in your family? Yes No If yes, give make, model, and year of car of least value:
11. Monthly amount now paid for rent $
Average monthly amount now paid for utilities (not including phone) $
12. Are you a family who has been or is being required to move by a government program? Yes No If yes, give date you
moved or date you are required to move and explain
13. How many people live in the dwelling unit? Number of bedrooms Number of People
14. Does the head of the family consider himself/herself to be:
a. White b. African-American c. Asian/Pacific Islander d. Hispanic e. American Indian
It is illegal to discriminate against any
person because of race, color, religion,
sex, or national origin.
This question is asked for statistical purposes only and can be left blank should the applicant desire.
15. Do you wish to be assisted in the dwelling you now live in? Yes No
If yes, how many bedrooms does your house or apartment have?
If no, do want to move to a place within the Toole County limits? Yes No Undecided
By law, housing assistance cannot be provided to any nonimmigrant student-alien or the alien spouse and minor children of such
alien (Section 1436A of Title 42, U.S.C.).
Definition of nonimmigrant student-alien: (1) An alien having a residence in a foreign country which he or she has no intention of abandoning, who is a bona fide
student qualified to pursue a full course of study and who is admitted to the United States temporarily and solely for the purpose of study at an established
institution of learning or other recognized place of study in the United States, particularly designated by him or her and approved by the Attorney General after
consultation with the Department of Education of the United States, which institution or place of study shall have agreed to report to the Attorney General the
termination of attendance of each nonimmigrant student and if any such institution of learning or place of study fails to make reports promptly the approval shall be
withdrawn, and (2) the alien spouse and minor children of any such alien if accompanying him or her or following to join him or her.
I certify that I have read the information above, and that I am not a nonimmigrant student-alien, and that no others in my household are
nonimmigrant student-aliens.
I herby certify the above information is correct and complete to the best of my knowledge and may be used for the purpose of verification. I
understand that this is not a contract and does not bind either party. I understand false information will constitute grounds for cancellation of this
application or my lease if I should be housed.
Date Signature of Applicant
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any Department or
Agency of the U.S. as to any matter within its jurisdiction.
Please check the program(s) you are applying for:
Public Housing - Westwood Mesa 700 West 770 South Tooele
click to sign
signature
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