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Working together to provide quality affordable housing and community development services for all
Attach form HUD – 92006 (05/09) - Pre-app update 02/17/11
Yes No
7. Will you require an accessible unit? [ ] [ ]
8. Will you require a reasonable accommodation? [ ] [ ]
If yes to 8 – Please specify required reasonable accommodation**
___________________
_____________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
* *The term “reasonable accommodation” means a change, modification, alteration, or adaptation in policy
procedure, practice, program, or facility that provides a qualified individual with a disability the opportunity to
participate in, or benefit from, a program (housing or non-housing) or activity. If requested, this form can be
made available in appropriate alternative formats to persons with a disability. Persons seeking an alternative
format should contact the YCH 504 Coordinator at 530-662-5428 for further information.
CURRENT WAITING LIST PROGRAMS
Please mark the box for each
of the waiting lists you wish to apply;
□ USDA Farm Labor Housing – Davis
Low Income Public Housing
□ Esparto (2&3 Bedrooms) □ Winters
□
Knights Landing (2&3 Bedrooms)
□ Woodland □ West Sacramento
□
Yolo (2&3 Bedrooms)
I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE.
I understand that submission of false information or misrepresentation may result in loss of eligibility to
participate in any assisted housing programs.
WARNING! Title 18, Section 1001 of the United States Code, states that a person who knowingly and willingly
makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or
fraudulent statement or entry; shall be fined under this title, imprisoned not more than 5 years or, if the
offense involves international or domestic terrorism (as defined in section
2331), imprisoned not more than 8
years, or both.
Head of Household Signature: ________________________________________ Date: ________________
Spouse/Co-Head Signature: __________________________________________ Date: ________________
NONDISCRIMINATION
Yolo County Housing prohibits discrimination in employment, services, and activities on the basis of race, color,
creed, religion, sex, ancestry, familial status, marital status, national origin, sexual orientation, age, disability, source
of income or other legally protected status. YCH affirms its commitment to equal opportunity and equal access to
services. For additional information, contact the 504 Coordinator, Janis Holt at 530-662-5428;
TDD 1-800-545-1833, ext. 626.
LANGUAGE SERVICES
YCH offers free language services. If you need this document translated, please contact us at 530-662-5428;
TDD 1-800-545-1833, ext. 626.
USDA FARM LABOR HOUSING DAVIS – NON DISCRIMINATION
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, age, disability, religion, sex, and familial status. (Not all
prohibited bases apply to all programs). To file a complaint of discrimination, write USDA, Director, Office of Civil
Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-
6382 (TDD).”
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