050158 BA 120221
WAITING LIST STATUS FORM
Check here if you are reporting new information
Check here for Waiting List Status
Use this form to update your information (including address) or verify your Waiting List status. When the Housing Authority receives
your completed form, we will mail you a letter confirming we have received your information and verifying your Waiting List status.
Please be aware that you must keep us informed, in writing, of any address change so we can contact you when it is your turn for a final
eligibility determination. If letters are returned as undeliverable, no further attempts will be made to contact you and your name will be
cancelled from the Waiting List.
WAITING LIST: Santa Cruz Section 8 HCV Program
Hollister / San Juan Bautista Section 8 HCV Program Other: _________________
I request a verification of my placement date or change of address on the Waiting List shall be sent to the address provided below.
PLEASE PRINT THE INFORMATION REQUESTED BELOW.
1. First Name: _______________________ 2. Middle Initial: ___ 3. Last Name: _________________________
4. Social Security Number: _____- _____ - _________ 5. Date of Birth: __________________________
6. Telephone: ( ___ ) ______ - __________ 7. Other Telephone: ( ___ ) ____ -______Email:__________________
8. Current Resident Address: _________________________________________________________________________
9. Current Mailing Address: _________________________________________________________________________
Are you currently homeless? No Yes (Please note that a mailing address must still be provided.)
10. Total annual household income $ _______________ 11. Total number of members in household _______
12. Number of adults in the household (18 and older) Males: ________ Females: ________
13. Number of children in the household (under 18) Males: ________ Females: ________
14. In which language do you prefer to communicate? English Spanish TDD Other: _____________
15. Ethnicity: Hispanic or Latino Not Hispanic or Latino
16. Race: African American / Black American Indian / Alaskan Native Asian
White Native Hawaiian / Pacific Islander
17. Please indicate any special features you would require to accommodate a member of your household with disabilities:
Wheelchair accessibility.
18. Name at the time I placed my name on the list: ________________________________________________________
19. Date or approximate date I placed my name on the list: Month: ______________________ Year: _____________
Information Regarding Eligibility for Special Programs
20. Do you or your spouse work in the county of Santa Cruz? No Yes
21. Do you or your spouse work in the county of San Benito? No Yes
22. Are you or your spouse aged 62 or older? No Yes
23. Do you or your spouse wish to claim disability status? No Yes
24. Are you, or any members of your household, a person who is between the ages of 18-62 who wishes to claim disabled status?
No Yes
25. If yes to question 24, is any of the following applicable to the non-elderly disabled adult?
At risk of homelessness Transitioning out of institutional care At serious risk of institutionalization
26. Are you, or any member of your household, a current military serviceperson or a veteran who has been separated under
honorable conditions from any branch of the United States armed forces or the surviving spouse of a veteran?
No Yes
Print Name (Head of Household): ____________________________ Signature: _____________________________
Date: ______________________
ST
VENUE
APITOLA
95010-2040
PHONE: (831) 454-9455 FAX: (831) 469-
