PLEASE RETURN THIS PRE-APPLICATION TO THE HOUSING AUTHORITY OF THE COUNTY OF SANTA CRUZ.
MAIL THIS PRE-APPLICATION TO: HOUSING AUTHORITY OF THE COUNTY OF SANTA CRUZ – 2160 41
AVENUE – CAPITOLA CA 95010. PRE-APPLICATIONS RECEIVED BY FAX WILL NOT BE ACCEPTED.
8/2015 050180 JP
15. Do you wish to claim disability status? Yes No
Please note that you are not required to answer this question or to reveal any information about the disability status of any
Person with disabilities defined as individuals with mental or physical impairments that substantially limit one or more major life
activities. The term mental or physical impairment may include conditions such as blindness, hearing impairment, mobility
impairment, HIV infection, mental retardation, alcoholism, drug addiction, chronic fatigue, learning disability, head injury, and
mental illness. The term major life activity may include seeing, hearing, walking, breathing, performing manual tasks, caring for
one's self, learning, speaking, or working. The definition also includes persons who have a record of such an impairment, or are
regarded as having such an impairment. Current users of illegal controlled substances, persons convicted for illegal manufacture or
distribution of a controlled substance, sex offenders, and juvenile offenders are not considered disabled by virtue of that status.
To help assess special housing needs, please indicate any specific features you would require to
accommodate any family member.
Wheelchair accessibility Unit Adapted for the Hearing Impaired Grab Bars
Ground Floor Unit Adapted for the Visually Impaired Other
By completing and submitting this form I am requesting that my name be placed on the Waiting List for Project
Based Voucher assistance at the El Centro Residential Apartments in downtown Santa Cruz. I understand that
placing my name on the Waiting List does not give me any right to be admitted to the program, guarantee my
future eligibility, or assure that subsidy funds will be available. Additionally, by signing below, I give the
Housing Authority my authorization to share my application information with El Centro management so that
they may consider my eligibility for housing.
I understand that I must inform the Housing Authority, in writing, within 30 days of any change to my
name and / or mailing address. I understand that if I do not respond to any information or appointment
request from the Housing Authority, or if any letter sent to me is returned to the Housing Authority as
undeliverable, my name will be removed from the Waiting List.
WARNING – TITLE 18 SECTION 1001 OF THE UNITED STATES CODE STATES THAT ANY PERSON WOULD BE
GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS
TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
Printed Name of Applicant _____________________________________________________________
Signature of Applicant _____________________________________________________________