USDA Rural Development Housing

PRE-APPLICATION (HOUSING AUTHORITY)

**** ******** ******, *********, ******* 31791

229-***-**** Office 229-***-**** Fax

Rural Development

Name of Head of Household: Social Security #: Address: City: State: Zip Code: Home #: Work #: Other #: 1. Do any household members require a fully accessible unit due to disability? Yes No 2. Do any household members require a unit with special features or modifications due to disability? Yes No 3. If you have answered yes, please explain the special features required below. Please provide below the name, age, sex and relationship to the head of household for all household members. Name Relationship D.O.B. Age Sex

Head of House

Member 1

Member 2

Member 3

Member 4

Member 5

Member 6

Check all of the following Categories that apply to the head of household or other adult member: __ Stable Work History (20 hours a week over the past 24 weeks.) __ Disabled (receiving SSI) __ Elderly (62 or over) __ Full-Time Student

__ Displaced due to natural disaster or governmental action TOTAL ESTIMATED ANNUAL HOUSEHOLD INCOME: $ Minority Code: __ Black __ White __ American Indian __ Asian __ Native Hawaiian __ Other Ethnicity Code: __ Hispanic __ Non-Hispanic/Latino I certify that the statements made on this form are true and complete to the best of my knowledge and belief. I also understand it is my responsibility to update my application and to advise SHA in writing of address changes.

(The preapplication will not be processed if you fail to complete the entire form, sign the form and provide your SSN.) Signature of Head of Household Date

*IF YOU REQUIRE ASSISTANCE COMPLETING THIS FORM DUE TO A DISABILITY, PLEASE CONTACT MANAGEMENT* For Office Use Only:

Date and Time of Application Date: / / Time: : am or pm Initials: