Accessible Space, Inc.
IN ORDER TO FILL OUT THE ELECTRONIC HOUSING
APPLICATION PLEASE FOLLOW THESE STEPS:
*Please note that this electronic application does not work on tablets or mobile phones*
1. PLEASE ENSURE THAT YOU ARE USING THE MOST RECENT
VERISON OF ADOBE ACROBAT READER TO FILL OUT THE
APPLICATION. YOU CAN DOWNLOAD IT FOR FREE HERE:
2. PLEASE SAVE THE ELECTRONIC HOUSING APPLICATION TO YOUR
COMPUTER. (YOU CAN DO THIS BY CLICKING THE DISK ICON OR
CLICK FILE\SAVE AS IN THE UPPER LEFT HAND CORNER OF THE
SCREEN.)
FILL OUT THE ELECTRONIC HOUSING APPLICATION COMPLETELY
(BE SURE TO SELECT THE APARTMENT BUILDINGS YOU WISH TO
LIVE AT) AND SAVE IT AGAIN.
3. UPLOAD THE COMPLETED HOUSING APPLICATION HERE. YOU
CAN ALSO ACCESS THIS PAGE BY HITTING THE “UPLOAD
APPLICATION BUTTON” ON THE PROPERTY PAGE.
4. IF YOU NEED ASSISTANCE WITH THE ELECTRONIC HOUSING
APPLICATION PLEASE CALL 800-466-7722 AND ASK TO SPEAK TO
SOMEONE IN HOUSING. THANK YOU.
Date Received Locations: 1.
Accessible Space, Inc.
2.
3.
1 BR ______
4.
2 BR ______
5.
By Mail:
Complete application, save,
2550 University Ave W, Suite 330N
and upload to:
https://
application.accessiblespace.org/
Apartment #:
Work Phone: Cell Phone:
Phone #:
ASI Website
Radio/TV Ad
Brochure
Billboard
Revised November 201
8
www.accessiblespace.or
g
Return your completed housing application in one of the following ways:
By Email:
By Fax:
Attn: Housing
Upon receipt of the completed housing application, Management will make a preliminary determination
of eligibility based on our selection criteria. If eligible, your name will be placed on the waiting list.
FOR OFFICE USE ONLY - DO NOT WRITE IN THIS BOX
Photo ID and Social Security Card
SECTION 1: CONTACT INFORMATION FOR HEAD OF HOUSEHOLD
PRELIMINARY APPLICATION FOR HOUSING WITH ACCESSIBLE SPACE, INC.
Thank you for your interest in Accessible Space, Inc. housing. We provide affordable, accessible housing for
persons with disabilities, as well as for seniors age 62 and better. Please follow the instructions listed below:
In addition to the Preliminary Housing Application, please complete and/or submit the following:
Proof of Guardian, Conservator, Representative Payee, or POA Documentation
The head of household must be at least 18 years old. All co-applicants age 18 or older, other than a
spouse, are required to complete a separate application.
Do not leave any of the 6 sections blank; write "N/A" for those which do not apply. An applicant who
falsifies, misrepresents or withholds information related to program eligibility or submits inaccurate
and/or incomplete information will not be considered for housing nor placed on the waiting list.
Disclosure & Release of Information Authorization
Supplement to Application for Federally Assisted Housing
Race and Ethnic Data Reporting Form
(651) 209-6623
Accessible Space, Inc. Attn: Housing
St. Paul, MN 55114
Page 1
How did you hear about us?
If I can't be reached, contact:
2550 University Avenue W, Suite 330 Nort
h
651.645.7271 (1.800.466.7722) Fax 651.209.662
3
Equal Housing Opportunit
y
Saint Paul, Minnesota 5511
4
TDD/TTY: 1.800.627.352
Equal Opportunity Employe
r
Referral (please list)
Internet (please list)
Newspaper (please list)
Other (please list)
Head of Household Name:
Current Mailing Address:
City, State, Zip Code:
Home Phone:
Email Address:
Relationship Date of Birth Age
Head of
Household
M F
M F
M F
M F
*If you wish not to disclose, choose n/a
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Apt #:
Apt #:
Yes
No
Yes
No
Page 2
SECTION 2: HOUSEHOLD INFORMATION
Applicant's Full Name
For program and eligibility purposes, is the head of household, spouse or co-
head handicapped or disabled?
Have you or any member of your household ever been…
Please list all states you have resided in:
convicted of a drug related criminal activity?
If you answered yes to any of these statements, please explain below:
Name of Landlord or Equivalent
Social Security #
Dates of Occupancy (MM/YYYY through MM/YYYY)
Zip
City State Zip
If you answered yes, please explain below:
Has your housing assistance ever been terminated for fraud, non-payment of
rent or utilities, failure to cooperate with recertification, or for any other reason?
Sex*
n/a
subject to registration under state or federal lifetime sex offender requirements
?
n/a
n/a
n/a
Previous Housing Situation
Are you currently homeless?
convicted of a felony?
Current Housing Situation
SECTION 3: RENTAL HISTORY
Dates of Occupancy (MM/YYYY through MM/YYYY)Name of Landlord or Equivalent
Street Address:
convicted of a misdemeanor other than a minor traffic violation?
Street Address: City State
Applicant #1
$$
$$
$$
$$
$$
$$
Applicant #1 Applicant #2
$$
$$
$$
$$
$$
$$
$$
$$
$$
Have you disposed of any assets at less than fair market value in the last 24 months? Yes No
If you answered yes, please explain:
Applicant #1 Signature
Applicant #2 Signature
SECTION 4: FINANCIAL INFORMATION
Other Income _________________________
Gross Amount per Month
Source of Income
Checking Account
Welfare Assistance
Child Support/Alimony
Employer
Social Security, Disability or SSI
Pension
Applicant #2
Page 3
Date
I/We understand the information in this application will be used to determine eligibility for housing
I/We certify that all information given in this application is true, complete and accurate. I/We understand
I/We authorize management to make any and all inquiries to verify this information, directly or through
application will occupy the unit, that it will be my/our only residence, and that there are no other persons
for whom I/we have, or expect to have, responsibility to provide housing.
assistance and that this information will be verified. I/We understand that any false information may
make me/us ineligible.
that if any of this information is false, misleading or incomplete, management may decline my/our
Direct Express
numbers, income and household composition.
Life Insurance
Date
SECTION 5: SIGNATURE
If my/our application is approved and if I/we move-in, I/we certify that only those persons listed in this
I/We agree to notify management in writing regarding any changes in household address, telephone
application, or, if move-in has occurred, terminate my/our lease agreement.
information exchanged now or later with rental and credit screening services, and to contact previous and
current landlords and other sources for credit and verification information which may be released to
appropriate federal, state or local agencies.
Other Asset __________________________
Savings Account
Certificates of Deposit
Balance/Value of Asset
Assets
Stocks and Bonds
Real Estate
IRA / Retirement Account
State Name of Property Address City Zip Code
Anderson-Fischer Apts. 8479 Jeff Hamilton Road Ext. Mobile 36695
Dogwood Terrace 1502 Marlborough Blvd Florence 35630
Patton Ridge Apts. 2122 Rocky Ridge Road Hoover 35216
Arroyo Terrace 333 North Chippewa Place Chandler 85224
R.J. Piltz Vista Bonita 1140 East 5th Avenue Mesa 85204
Arkansas
Cloverdale Estates Apts. 7009 Baseline Road Little Rock 72209
Becerra Plaza 326 Becerra Way Davis 95618
The Dakota 3245 Clares Street Capitola 95010
Harbor View Terrace 2305 North Harbor Blvd Fullerton 92835
Sky Forest Acres 750 Emerald Bay Road South Lake Tahoe 96150
Casa Libertad 2320 Wedgewood Avenue Longmont 80503
Fox Run Apts. 1300 60th Avenue Greeley 80634
Harmony Road Apts. 301 East Harmony Road Fort Collins 80525
Twin Rivers Apts. 6616 W. 10th Street Greeley 80634
The Harry & Jeanette
Weinberg Hale Kuha'o
Illinois
Heartland Apts. 805 East College Street Carbondale 62901
Blackbird Apts. 1455 Meadowlark Lane Kansas City 66102
Melissa Anne Hanger Apts. 2230 SE 28th Street Topeka 66605
Mid America Commons
1911 North 77th Street Kansas City 66112
Page 4
Waipahu 96797
Kansas
SECTION 6: HOUSING LOCATIONS
Apartment Living (1 & 2 BR)
Each resident rents his/her own apartment. Housing locations italicized and underlined only provide one (1) bedroom
units. ASI supportive services are available in some locations, and some locations offer services from other providers.
Housing locations in bold print indicate housing with ASI Services available. Please contact ASI's Program/Services
Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722. TTY/TDD (800) 657-3529.
Please note: ASI services are available only to qualified applicants and residents, and rent payments do not include
the cost or provision of ASI supportive living services that may be available. In addition, the eligibility for or selection of
ASI services is not required for housing eligibility or occupancy.
Alabama
Instructions: Accessible Space, Inc. (ASI) provides affordable housing for persons with qualifying disabilities and
housing for the elderly. The following pages list the housing communities for each population served. To complete, go
to the page that applies to you. Then select only those housing communities that you are interested in and are willing
to live in that location by checking the box next to the name of the property. Please
note that all locations are
smoke-free.
Nationwide Housing Locations for Persons with Disabilities
Arizona
California
Colorado
Hawaii
94-909 Kau'olu Place
Minnesota
Missouri
Tim O'Brien Apts. 2815 South Nettleton Avenue Springfield 65807
Bruce Blattner Apts. 1225 West Broadway Street Missoula 59802
Eagle Watch Estates 565 Burton Street Missoula 59802
Grandview Apts. 1151 28th Street West Billings 59102
Meadow Lark Apts. 1701 1st Street NW Great Falls 59404
Queen City Estates 2300 North Roberts Street Helena 59601
Southwinds Estates 1615 Oasis Court Great Falls 59405
Spring Run Apts. 1325 North 15th Avenue Bozeman 59715
Accessible Space Apts. 1425 31st Avenue SW Minot 58701
Dewey Apts. 1215 8th Avenue NE Jamestown 58401
Linden Place
2463 South 42nd Street Grand Forks 58201
Northland Apts. 1115 23rd Street South Fargo 58103
Bledsoe Lane Apts. 2306 Bledsoe Lane Las Vegas 89156
Bob Hogan Apts. 5075 Newport Cove Las Vegas 89119
Carol Haynes Apts.
5160 General Miles Way Las Vegas 89122
Dina Titus Estates 5050 Missouri Avenue Las Vegas 89122
Frost Yasmer Estates
1009 East 5th Street Carson City 89701
George & Lois Brown Estates 429 East Van Wagenen Street Henderson 89015
John Butterworth Estates 430 Linden Street Reno 89502
John Chambers Apts. 2030 Camel Street Las Vegas 89115
Major Ave Apts. 600 North Major Avenue Henderson 89015
Mojave Cedar Apts. 2837 Cedar Street Las Vegas 89104
Park Apts. 2312 Bledsoe Lane Las Vegas 89156
Ray Rawson Villa 3420 Lindell Road Las Vegas 89146
Ruby Duncan Manor*
500 W Owens Avenue Las Vegas 89106
Sandy Robinson Apts. 4200 East Bonanza Road Las Vegas 89110
Shelbourne Avenue Apts. 1235 East Shelbourne Avenue Las Vegas 89123
William J. Raggio Apts. 48 Park Street Reno 89502
New Mexico
Homeward Bound Apts. 3454 Cerrillos Road Santa Fe 87507
Key:
Housing Community in bold offers ASI Services
Housing Community in italics and underlined
only offers one (1) bedroom apartments
Page 5
*If selecting this location, please choose your preferred unit size: Studio 1BR
SECTION 6: HOUSING LOCATIONS (CONTINUED)
Nationwide Housing Locations for Persons with Disabilities (Continued)
Montana
North
Dakota
Nevada
Please see Pages 7 and 9 for the list of properties in Minnesota
Oklahoma
Rock Ridge Apts. 808 East Jefferson Avenue McAlester 74501
Crocus Meadow Apts. 4501 East Brennan Drive Sioux Falls 57110
Eastwood Apts. 925 25th Street NE Watertown 57201
Galaxy Apts. 1820 Galaxy Drive Rapid City 57701
Hagy Commons 2737 McCampbell Avenue Nashville 37214
McCullough Place 1456 Gillham Drive Memphis 38134
Welsh Manor 2900 Coleman Road Memphis 38128
Henry Harbour 2421 Cimarron Blvd Corpus Christi 78414
Oak Forest Heights 11801 Toepperwein Road Live Oak 78233
Paul Chase Commons 16440 Moonrock Drive Houston 77058
Pecan Hills 13000 Hymeadow Drive Austin 78729
Rollingbrook Apts. 730 Rollingbrook Drive Baytown 77521
Vista Villa Apts.
3600 Pansy Street Pasadena 77505
Wagon Crossing Apts. 1474 Kitty Hawk Road Universal City 78148
Windvale Pines Apts. 8500 North Windvale Circle The Woodlands 77384
The Anchorage 112 Cromwell Parkway Norfolk 23505
AP's Freedom Apts.
11366 Occohannock Neck Road Exmore 23350
The Sanderling 2809 Parkside Drive Chesapeake 23324
Washington
Eagle Crest Estates 811 South Hatch Street Spokane 99202
Wisconsin
Tribute Commons 123 Heritage Blvd Hudson 54016
Key:
Housing Community in italics and underlined only offers one (1) bedroom apartments
Page 6
SECTION 6: HOUSING LOCATIONS (CONTINUED)
Virginia
Nationwide Housing Locations for Persons with Disabilities (Continued
)
Tennessee
Texas
South
Dakota
Name of Property Address City Zip Code
Becker Avenue Apts. 1409 Becker Avenue SE Willmar 56201
Bostrom Terrace
1680 Eastwood Road SE Rochester 55904
Burke Apts. 720 Maple Grove Road Duluth 55811
Henry Courts I
8650 Aldrich Avenue South Bloomington 55420
Henry Courts II
134 - 154 Western Avenue South St. Paul 55102
Hillcrest Apts. 1370 Curve Crest Blvd Stillwater 55082
Hope Village Apts. 243 Sundance Road Sartell 56377
Kay Knutson Apts. 905 El Dorado Street SE Owatonna 55060
Leah's Apts. 12721 Greenwood Drive Burnsville 55337
Meadow Trails Apts. 21875 129th Avenue North Rogers 55374
Nordic Meadow Apts. 410 34th Avenue East Alexandria 56308
Northern Lights Apts. 511 D Street NE Brainerd 56401
Pine Grove Apts.
4082 Haines Road Duluth 55811
Prairie Sky Apts. 1701 8th Street NW Austin 55912
Quarry Heights Apts.
2051 Quarry Road St. Cloud 56301
Redruth Valley Apts.
6801 Redruth Street Duluth 55807
River Bluff Apts. 1020 Bluff Avenue East Shakopee 55379
River Winds Apts. 303 Jewett Street Marshall 56258
Roselawn Village
1074 Roselawn Avenue West Roseville 55113
Superior View Apts.
1022 Junction Avenue Duluth 55812
West Apts. 1501 West 143rd Street Burnsville 55306
Winston Court 710 East 31st Street Hibbing 55746
Key:
Housing Community in bold offers ASI Services
Housing Community in italics and underlined
only offers one (1) bedroom apartments
Page 7
Please note: ASI services are available only to qualified applicants and residents, and rent payments do not include
the cost or provision of ASI supportive living services that may be available. In addition, the eligibility for or selection of
ASI services is not required for housing eligibility or occupancy.
SECTION 6: HOUSING LOCATIONS (CONTINUED)
Apartment Living (1 & 2 BR)
Each resident rents his/her own apartment. Housing locations italicized and underlined only provide one (1) bedroom
units. ASI supportive services are available in some locations, and some locations offer services from other providers.
Minnesota
Housing locations in bold print indicate housing with ASI Services available. Please contact ASI's Program/Services
Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722. TTY/TDD (800) 657-3529.
Housing for Persons with Disabilities: Minnesota Locations
State Name of Property Address City Zip Code
Arlington Gardens 110 Arlington Avenue West St. Paul 55117
Autumn Trails of Rogers 21845 129th Avenue North Rogers 55374
David F. Day Apts. 1221 22nd Street South Sartell 56377
Kenosha Drive Apts. 3461 Kenosha Drive NW Rochester 55901
Maple Trail Apts. 165 24th Place NW Owatonna 55060
Washington Avenue Apts. 608 Washington Avenue Albert Lea 56007
Aspen Village 615 Janet Street Helena 59601
The Portage 1521 23rd Street South Great Falls 59405
Summer Wood Apts. 1441 North 15th Avenue Bozeman 59715
Van Ee Apts. 420 Grandview Drive Kalispell 59901
Tonopah Lamb Apts. 4250 East Tonopah Avenue Las Vegas 89115
Ruby Duncan Manor*
500 W Owens Avenue Las Vegas 89106
North Dakota
Frontier Apts. 554 23rd Street West Dickinson 58601
South Dakota
Pasque Meadow Apts. 4611 East Brennan Drive Sioux Falls 57110
Texas
Tangle Brush Villa 3300 Tangle Brush Drive The Woodlands 77381
Wisconsin
Heirloom Court Apts. 100 Heirloom Avenue Hudson 54016
Wyoming
Heritage Court Apts. 3912 Gregg Way Cheyenne 82009
Key:
Housing Community in bold offers ASI Services
Page 8
*If selecting this location, please choose your preferred unit size: Studio 1BR
Nevada
Montana
SECTION 6: HOUSING LOCATIONS (CONTINUED)
Minnesota
Each resident rents his/her own one (1) bedroom apartment. Accessible apartments are available. ASI supportive
services are available in some locations, and some locations offer services from other providers. Housing locations in
bold print indicate housing with ASI Services available. Please contact ASI's Program/Services Intake Specialist
with service related questions at (651) 645-7271 or (800) 466-7722. TTY/TDD (800) 657-3529.
Please note: ASI services are available only to qualified applicants and residents, and rent payments do not include
the cost or provision of ASI supportive living services that may be available. In addition, the eligibility for or selection
of ASI services is not required for housing eligibility or occupancy. Some locations offer information and referral
services at no charge to residents. Meal programs are available at some locations from other providers for a
suggested donation.
Apartment Living (1BR)
Nationwide Housing Locations for Seniors Age 62 & Better
Name of Property Address City Zip Code
28th Street Home
2749 11th Avenue South Minneapolis 55407
Camden Home
500 49th Avenue North Minneapolis 55430
Chicago Home
3710 Chicago Avenue Minneapolis 55407
Moses Residence
220 NW 17th Street Grand Rapids 55744
Name of Property Address City Zip Code
Cedar Home
2461 Cedar Avenue White Bear Lake 55110
Flintwood Home
12330 Flintwood Street NW Coon Rapids 55448
Magnolia Home
12455 Magnolia Street NW Coon Rapids 55448
Silver Lake Home
3512 Silver Lake Road NE St. Anthony 55418
Snelling Home
1746 Snelling Avenue N Falcon Heights 55113
Van Buren Home
8706 Van Buren Street NE Blaine 55434
Name of Property Address City Zip Code
Iglehart Home 814 Iglehart Avenue St. Paul 55104
Pesch Place 2000 Mary Hills Drive Golden Valley 55422
Selby Home 825 Selby Avenue St. Paul 55104
Key:
Housing Community in bold offers ASI Services
Page 9
Please note: ASI services are available to qualified applicants and residents. Rent payments do NOT include
the cost or provision of ASI offered services. Eligibility for or selection of ASI services is not required for
housing eligibility or occupancy. Please contact ASI's Programs/Services Intake Specialist with service
related questions at (651) 645-7271 or (800) 466-7722. TTY/TDD (800) 657-3529.
SECTION 7: GROUP HOME SETTINGS
Minnesota
Minnesota
HOMES WITH 24/7 COMMUNITY RESIDENTIAL SETTING (CRS) / CORPORATE ADULT FOSTER CAR
E
ASI offers/provides 24/7, on-site CRS / Corporate Adult Foster Care services to Medicaid eligible residents.
Minnesota
HOMES WITH SERVICES FROM ANOTHER SKILLED NURSING/SUPPORTIVE SERVICE PROVIDER
ASI offers/provides 24/7, on-site Assisted Living services to Medicaid eligible residents.
The locations listed below are NOT apartment buildings. These are accessible
homes where residents rent only a bedroom and share the common areas with other
residents, including the bathroom and kitchen facilities. Most of these locations also
have skilled nursing and supportive care staff on-site 24/7, who attend to residents
receiving services from ASI or another provider.
HOMES WITH 24/7 ASSISTED LIVING SERVICES
Please contact ASI's Programs/Services Intake Specialist with service related questions at (651) 645
-
7271 or (800) 466-7722. TTY/TDD (800) 657-3529.
Signature Date
Zip Code
CityStreet Address State
If you have ever lived in any CITIES or STATES other than those provided above, please list them here
If you have gone by any NAMES other than the one provided above, please list it here
If you, or any member of your household, has used a different SOCIAL SECURITY NUMBER, please list it here
Disclosure and Release of Information Authorization
I authorize Accessible Space, Inc. and the approved vendor Rental History Reports (RHR), a consumer reporting
agency, to retrieve information from all personnel, educational institutions, government agencies, companies,
corporations, credit reporting agencies, law enforcement agencies at the federal, state, or county level, worker's
compensation agencies or individuals, relating to my past activities, to supply any and all information concerning my
background, and release the same from any liability resulting in providing such information. The information
received may include, but is not limited to, academic, residential, achievement, job performance, attendance,
litigation, personal history, credit reports, driving history, worker's compensation records (including medical
information), and criminal history records.
I understand that a consumer report may be prepared summarizing this information. If my prior employers and/or
references are contacted, the report may include information obtained through personal interviews regarding my
character, general reputation, personal characteristics and/or mode of living. I may request a copy of any report
that is prepared regarding me and may also request the nature and substance of all information about me
contained in the files of the consumer reporting agency. I understand that proper identification will be required and
that I should direct my request to: RHR (952) 545-3953.
By my signature below, I hereby release any individual or institution, including its officers, employees, or related
personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may
result to me because of compliance with this authorization and request to release information or any attempt to
comply with it.
I hereby certify that all the statements and answers set forth on the application form and/or my resume are true and
complete to the best of my knowledge, and I understand that if subsequent to employment, any such statements
and/or answers are found false, or that information has been omitted, such false statements or omissions will be
just cause for denial of the housing application.
I acknowledge that a photocopy of this authorization will be accepted with the same authority as the original. This
release expires five (5) years after date of origination.
First Name Middle Name Last Name
Social Security Number Date of Birth Home Phone w/ Area Code
O
MB Control # 2502-0581
Exp. (
02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
I
nstructions: 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:
Address:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
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
Date
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.
P
rivacy 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)
form HUD-27061-H (9/2003)
2
Instructions for the Race and Ethnic Data Reporting (Form HUD-27061-H)
A. General Instructions:
This form is to be completed by individuals wishing to be served (applicants) and those that
are currently served (tenants) in housing assisted by the Department of Housing and Urban
Development.
Owner and agents are required to offer the applicant/tenant the option to complete the form.
The form is to be completed at initial application or at lease signing. In-place tenants must
also be offered the opportunity to complete the form as part of the next interim or annual
recertification. Once the form is completed it need not be completed again unless the head of
household or household composition changes. There is no penalty for persons who do not
complete the form. However, the owner or agent may place a note in the tenant file stating
the applicant/tenant refused to complete the form. Parents or guardians are to complete
the form for children under the age of 18.
The Office of Housing has been given permission to use this form for gathering race and
ethnic data in assisted housing programs. Completed documents for the entire household
should be stapled together and placed in the household’s file.
1. The two ethnic categories you should choose from are defined below. You should check one
of the two categories.
1. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race. The term “Spanish
origin” can be used in addition to “Hispanic” or “Latino.”
2. Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.
2. The five racial categories to choose from are defined below: You should check as many as
apply to you.
1. American Indian or Alaska Native. A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains
tribal affiliation or community attachment.
2. Asian. A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
3. Black or African American. A person having origins in any of the black racial
groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to
“Black” or “African American.”
4. Native Hawaiian or Other Pacific Islander. A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
5. White. A person having origins in any of the original peoples of Europe, the Middle
East or North Africa.
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