Involuntary Displacement: Have you been (or are you being) displaced because:
check the situation that applies to you and your family
Substandard Housing
Paying more than 50% of Income for Rent
Check the situation that applies to you or your family
Project-based or tenant-based subsidy:
Family Composition
Income
Current Assets
Assets Recently Disposed Of
Medical Expenses
This allowance is permitted only for households whose HEAD or SPOUSE is age 62 or older, handicapped, or disabled. consider only medical expenses that will not be paid by an outside source - e.g. insurance, Medicare, or grants by a State agency or charitable organization.
Handicap Expenses
The allowance applies only if a member is Handicapped or Disabled. Consider only handicap expenses that will not be paid or reimbursed by an outside source such as insurance, Medicare, or grants by a State agency or charitable organization; and not paid to a family member living in the household.
Child-Care Expenses
This allowance applies only to amounts paid for the care of children (including foster children) UNDER AGE 13.
If "Yes" list babysitters name, address, and telephone number
Race and Ethnic Data Reporting Form
There is no penalty for persons who do not complete this form.
Supplement to Application for Federally Assisted Housing
Supplement 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.
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.
The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.
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.
