Please Complete and Return to:
Independence Housing Authority
811 W Laurel St, Independence, KS 67301
Date:________________ Time:________
Rec’d By:__________________________
Pref:__________________ BR Size: ____
This pre-application is used to request placement on waiting lists for IHA programs and rentals. You may apply for
multiple waiting lists at one time. Income requirements apply. Please read the following to ensure application to
the correct waiting list:
Tenant Based Rental Assistance- Subsidies to pay rent at a unit located within the city limits of Independence.
Cedar Pointe Triplexes- One-bedroom units for person(s) with disabilities or person(s) 62 years and older.
Cedar Pointe Group Home- Group home for person(s) with disabilities or person(s) 62 years and older.
Chaney Duplexes- Two-bedroom units for person(s) with disabilities or person(s) 62 years and older.
South 8th Housing- Four-bedroom unit.
Earl Street- Three-bedroom single family homes.
McKinley- One and two bedroom units on Coffeyville Ave/Cedar; Three bedroom units on 13th and Sycamore
Penn Terrace- High rise apartments, subsidized with Section 8, for person(s) 62 years or older, OR non-elderly disabled
persons who are 18-49 years of age OR near-elderly disabled persons who are 50-61 years of age, in that order.
SEE-KAN- Rental units located in Chanute, Thayer, Neodesha, Cedar Vale, and Sedan.
To apply, completely ll out each section of this application. Do not leave any question blank.
1. Program Choice(s). Check each program applying for.
____________________________________________________________ (____) _______-_________
Last Name First Name Middle Initial Home Phone Number
__________________________________________________________ (____) _______-_________
Mailing address City State Zip Cell Phone Number
Address where you are currently living (if different from mailing address above) City State Zip
I or my spouse is age 62 or older.
I or my spouse is receiving disability benets.
I or my spouse is employed or receiving unemployment benets.
I am homeless (living on street, in car, shelter or safe house; does not include a family doubled up with another family).
None of these apply to me
Other, please specify _______________________________________________________________________
Tenant Based Rental Assistance
Cedar Pointe Triplexes
Cedar Pointe Group Home
Chaney Duplexes
South 8th Housing
Earl Street Single Family Homes
Penn Terrace Apartments
McKinley Housing
(Check all unit sizes applying for)
One-Bedroom Units
Two-Bedroom Units
ree-Bedroom Units
SEE-KAN Properties
(Check all property sites applying for
and write the number of bedroooms
requested below)
# of bedrooms requested _________
Cedar Vale
2. Head of Household Information. IMPORTANT: All correspondence regarding this application will be sent to the
mailing address provided below. Remember to report any change of address to our ofce immediately.
3. Preference Information. Check all that apply. You may qualify for a preference on some waitlists if any of the
following can be veried for your family.
1a. Does your household need an accessible unit? Yes No
If yes, please explain ________________________________________________________________________
4. Household Composition. List the head of household and all other members who will be living in the unit.
5. Income.
5a. What is the household’s
total monthly income?
Include income from all family
members (18 years and older)
Other _______________________________________________________________
Social Security/SSI
Public Assistance
Annuity Income
Child Support
Someone pays my bills/gives me money
Self Employment
5b. Household Income Source(s). Check all that apply.
4a. Lead Based Paint Related Information. Information is collected to ensure compliance with lead based paint policy.
Are any members of the household currently pregnant? Yes No
# Full Name
Relation to Head
of Household
SSN Date of Birth Age
(M or F)
(Y or N)
6. Current Living Situation. Answer the following in regards to your current living and housing situation.
6a. Which of the following best describes your current living situation?
I own my place of residence. I rent my place of residence.
I am living with friends or family. Other:__________________________________________
6c. If you rent your place of residence, complete the following, otherwise continue to section 7
Current monthly rent? $___________/month Current monthly utilities? $_________/month
Do you receive rental payment assistance? Yes No
If yes, list the source of assistance and amount _______________________________________________________
NoHave you or anyone in your household been convicted of a felony in the last 10 years? Yes
Do you currently have an outstanding felony charge that has not yet been settled in a court of law? Yes No
Is any member of the household subject to registration on any State’s Sex Offender list?
Have you ever filed for bankruptcy? Yes No
Have you ever been evicted from another apatment/housing complex before? Yes No
Have you ever left another apartment/housing complex still owing rent or money for damages? Yes No
7. Background Information. Please check yes or no to all questions. You may provide an explanation for any or all of
your answers by attaching it to this application.
CERTIFICATION OF APPLICANT: I hereby certify that the information provided in this application is true and accurate.
I understand that providing false information may result in my application being canceled or denied. I understand that at the
time I rise to the top of a waiting list, I will be required to verify the information I have provided here. I accept responsibility
for keeping the Independence Housing Authority informed of my current address and I understand that my application may be
canceled if I fail to do so.
_______________________________ _____________ _________________________________ ____________
Signature of Head of Household Date Signature, Spouse or Co-head of Household Date
6b. # of bedrooms in the unit you are living in: ______ # of people living in the unit now: ______
ease note, all information listed, including rent, is subject to change at any time and may change before your application is accepted.
* Eligibility: All units are subject to income eligibility requirements. This section shows additional requirements to income, if any.
** Penn Terrace Rent: Apartments come with HUD Subsidy, meaning the rent amount paid by a tenant depends on their annual income.
All utilities includeddesignates the following utilities: Water and Sewer, Trash Removal, Gas and Electricity.
- All units also include Lawn Care and Snow Removal
Appliances Included designates the following appliances are located in the unit: Range and Hood, Refrigerator, Dishwasher, Disposal, Washer and Dryer.
Other Information
- IHA has a smoke-free housing policy.Smoking is not permitted in any of IHA units or buildings.
- IHA has a no-pet policy in all of its properties.
PHONE: (620) 332-2536
Property Name
Rent Amount
Utilities Included in Rent
Energy Efficient
Cedar Pointe Triplexes
- Persons with disabilities; or
- Persons 62 or older
1-BR $383
All utilities included.
Cedar Pointe Group
- Persons with disabilities; or
- Persons 62 or older
All utilities included.
Chaney Duplexes
- Persons with disabilities; or
- Persons 62 or older
2-BR $375
Water, Sewer, Trash
(Tenant pays electric and gas)
Penn Terrace
- Persons 62 or older; or -Disabled
persons aged 18-49; or - Disabled
persons aged 50-61, in that order
See Note**
All utilities included.
South 8
4-BR $625
Water, Sewer, Trash
(Tenant pays electric and gas)
Earl Street 3-BR $467
Water, Sewer, Trash
(Tenant pays electric and gas)
McKinley Housing
Water, Sewer, Trash
(Tenant pays electric and gas)
2-BR $445
3-BR $500
SEE-Kan Properties
Properties vary depending on location and size. Contact the IHA Office for more information.
Map Notes
- McKinley Properties are in two separate locations. 1 and 2 Bedroom units are located at McKinley South. 3 Bedroom Units are located at McKinley North.
- SEE-KAN properties (properties outside of Independence) are not shown. Please contact the IHA office for specific location
PHONE: (620) 332-2536
OMB Control # 2502-0581
Exp. (
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Unable to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
Signature of Applicant
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
click to sign
click to edit
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