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SOUTHERN NEVADA REGIONAL HOUSING AUTHORITY Admissions Department: 5390

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PRELIMINARY APPLICATION The Southern Nevada Regional Housing Authority shall not discriminate against anyone because of race, color, sex, religion, familial status, disability, gender identification, national origin,
marital status, or sexual orientation in providing housing assistance. Information provided to SNRHA will be kept confidential and used solely to determine housing eligibility and unit type. Please be advised that
results of criminal screening (which may include FBI checks) may be grounds for denial of housing. The Southern Nevada Regional Housing Authority 5390 E. FLAMINGO ROAD, LAS VEGAS, NV 89122 (702) 477-3100
TTY# (702) 387-1898
SOUTHERN NEVADA REGIONAL HOUSING AUTHORITY
Admissions Department: 5390 East Flamingo Road, Las Vegas, NV 89122-5335
Phone: (702) 477-3100 TTY: (702) 387-1898 Visit our website at: www.snvrha.org
DATE: ________________ APPLICATION ACCEPTED & REVIEWED BY: __________________________ APPLICATION # ________________________ INPUT BY: _________________
INITIAL PRELIMINARY APPLICATION
Do you require future correspondence in a format other than written English, such as: SPANISH, LARGER FONT, OTHER? ____ Yes ____ No
If yes, what format do you require? ___________________________________________
THIS FORM MUST BE COMPLETED IN INK. We will not accept applications completed in pencil. To properly assist you, we MUST HAVE ACCURATE AND COMPLETE INFORMATION. ALL questions
must be answered. If the question does not apply, write “N/A” or “NONE”. Failure to answer all questions may delay your interview and/or eligibility determination.
MAILING ADDRESS: ________________________________________________________________________________________________________________________________________________
Number Street Apt. # City State Zip Code
Home Phone Number: (______) ______________________ Work Phone Number: (_______) ____________________Ext. _______ Cell Phone Number: (_______) _____________________
ABOUT YOUR FAMILY: List each member, including yourself, that will be living in your household.
LAST NAME
FIRST NAME
MIDDLE
INITIAL
SEX
M / F
SOCIAL SECURITY
NUMBER
RELATIONSHIP
TO HEAD OF
HOUSEHOLD
RACE
1= White
2= Black
3=American
Indian/
Alaskan Native
4= Asian
5= Native
Hawaiian/
Pacific Islander
ETHNICITY
1= Hispanic
2= Non-Hispanic
1
HEAD
2
SPOUSE/
CO-HEAD
Other Household Members:
1) ____Male ____ Female _____Age 2) ____ Male ____ Female _____ Age 3) ____ Male ____ Female _____ Age 4) ____ Male ____ Female _____ Age
5) ____Male ____ Female _____Age 6) ____ Male ____ Female _____ Age 7) ____ Male ____ Female _____ Age 8) ____ Male ____ Female _____ Age
OTHER HOUSEHOLD MEMBER INFORMATION:
Is the Head, Spouse or Co-Head Disabled? Yes ____ No ____ If yes, who? ________________________________
Do you or any member of your household have a disability that requires any of the following (check all that apply):
____Unit for Hearing impaired ____Unit for Visually Impaired ____Wheelchair accessible unit: Name of person requiring the items checked:_______________________________________________
HEAD
PRELIMINARY APPLICATION The Southern Nevada Regional Housing Authority shall not discriminate against anyone because of race, color, sex, religion, familial status, disability, gender identification, national origin,
marital status, or sexual orientation in providing housing assistance. Information provided to SNRHA will be kept confidential and used solely to determine housing eligibility and unit type. Please be advised that
results of criminal screening (which may include FBI checks) may be grounds for denial of housing. The Southern Nevada Regional Housing Authority 5390 E. FLAMINGO ROAD, LAS VEGAS, NV 89122 (702) 477-3100
TTY# (702) 387-1898
Does your household meet the definition of homeless? (Family lacks a fixed regular and adequate night time residence, or has a primary night time residence that is a supervised publicly or privately
operated shelter to provide temporary living accommodations, such as welfare voucher hotels, congregate shelters or transitional housing designed for homeless persons, or a public or private place
not designed for, or ordinarily used as a regular sleeping accommodation for human beings.) ____Yes ____No.
Is anyone in your household a US Citizen? _____ Yes _____ No. If no, does at least one household member have eligible INS status? _____ Yes _____ No
INCOME: Please indicate the TOTAL MONTHLY OR ANNUAL HOUSEHOLD INCOME for ALL members of this applicant household, from all sources.
Total Monthly/Annual Household Income from all sources for all Household members. $_______________ ___Month ___Annual
PREFERENCES:
Is the Head/Spouse/Co-Head a Veteran? YES ____ NO ____; The Spouse of a Deceased Veteran whose death was service connected? YES ____ NO ____ ;
A Disabled Veteran with a Service Connected Disability? YES ____ NO ____
Is the Head/Spouse/Co-Head a full time student enrolled in an accredited program? YES ____ NO ____, Employed at least 20 hours per week? YES ____ NO ____
Receiving SSI/SSD or any disability pension? YES ____ NO ____, 62 year of age or older? YES _____ NO _____
Does Head/Spouse/Co-Head: Currently live, work, or has been hired to work, in Clark County? YES ____ NO ____
If a balance is owed to any Housing Authority or Subsidized Housing Program, the balance MUST BE PAID IN FULL in order to be eligible for our program(s).
Are you or anyone in your household a registered sex offender? ____ Yes ____ No. If yes, name of household member: _________________________________________________________
Reasonable Accommodations: I understand that if I am disabled, I have the right to request a reasonable accommodation to make services and programs accessible, and request must be
submitted in writing to SNRHA for review and approval.
Criminal and Administrative Actions for False Information: I understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State criminal law. I
understand that knowingly supplying false, incomplete, or inaccurate information may be considered fraud and is grounds for denial of assistance, termination of housing assistance and/or
eviction from public housing. Financial assistance in the form of housing subsidy is contingent upon submission and verification, as appropriate, of the evidence of citizenship or eligible
immigration status. I swear that I have honestly reported the citizenship of myself and anyone whom I am applying for.
I certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability.
Signatures and Date of Head of Household and Spouse/Co-Head:
1) ____________________________________________________ Date ___/___/____ INDICATE IF YOU UNDERSTOOD THIS APPLICATION: YES_____ NO_____
2) ____________________________________________________ Date ___/___/____ INDICATE IF YOU UNDERSTOOD THIS APPLICATION: YES_____ NO_____
If this application was completed by someone other than the Head of Household or Spouse/Co-Head of the applicant household, please complete:
Name (print clearly):_______________________________ Signature: ___________________________________ Date: _______________________
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SOUTHERN NEVADA REGIONAL HOUSING AUTHORITY Admissions Department: 5390

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Completed 22 June 2022

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