Child Support 6-8

Massachusetts Section * Centralized Waiting list

V1.7 Massachusetts Section 8 Centralized Waitlist Page 1 of 4 Head of Household

* First name: Middle: * Last name:

Primary Email: * Date of Birth: Gender:

* SSN or

Alien ID #:

I have no SSN or Alien ID # (temporary

* Disabled: Yes No number will be provided by PHA) Primary Phone Number:

May we send text message to this number (rates may apply) Yes No Phone Type: Mobile Home Work Other

Home Address

In Care of:

* Address 1:

* City:

Is this the best place to send mail? If not, please provide a mailing address:

* State: * Zip Code:

Address 2:

Mailing Address

In Care of:

Address 1:

City: State: Zip Code:

Address 2:

Emergency Contact

Phone: Relationship: Parent Child Sibling Other

Please provide additional contacts in case we need to get in touch with you about your waitlist status. These contacts can be homeless shelters, friends, family members etc. First Name: Last Name:

* How many people live in your household? * #

Household

* How many bedrooms does the household require? * # Curent Living Situation

* What is your household's living condition?

Living in a permanent residence

Living in a shelter or hotel/motel

Living in a temporary residence

Living in a place that is not normally used for housing Housing Costs

* What is your current monthly rent or

mortgage payment? * $

* What is your total monthly cost for utilities?

(heat, hot water and electricity only) * $

* Is your household at risk of losing Yes No

your current residence?

Please complete all fields marked with an asterisk or your application will be considered incomplete. Complete information on every member of your household. If your household is over 4 members please provide additional sheets. For more information about the application please refer to the Pre-Application Information Document available at www.gosection8.com/MassCWL.

Massachusetts Section 8 Centralized Waiting list

V1.7 Massachusetts Section 8 Centralized Waitlist Page 2 of 4 Employment 1: Type: Full Time Part Time Seasonal

Employment & Other Income

City: State: Zip Code:

Approximate Monthly Income from Employment 1: $ Pay Cash: Yes No

* Other total monthly income (Including SSI, SSDI, alimony, child support, pensions, etc.): * $

* Student: Yes No If Yes, School Name: Full Time Part Time School Type: Kindergarten Elementary (K-6) Middle (6-8) High (9-12) College or University Training City: State: Zip Code:

School

Race

Optional: Asked solely for HUD reporting purposes. White

Alaska Native or Indian American

Black or African American

Asian

Pacific Islander

Other

Ethnicity

Asked solely for HUD reporting purposes:

Hispanic or Latino

Would not like to disclose

Not Hispanic or Latino

Have you ever served on active duty in the U.S. armed forces, reserves, or National Guard? * Yes No Are you an ex-spouse, widow, or widower of a person who is no longer a member of the household * Yes No but who had ever served on active duty in the U.S. armed forces, reserves, or National Guard? Veteran Status

If yes to a question above, please indicate years served: Employment Monthly Income: $ Type: Full Time Part Time Seasonal Employment & Other Income

City: State: Zip Code:

Pay Cash: Yes No * Other total monthly income: (SSI, Child Support, Pensions, Etc.) $ Household Member 2 Co-Applicant (one per household)

* First name: Middle: * Last name:

* Date of Birth:

* SSN or Alien ID #: I have no SSN or Alien ID # (temporary number will be provided by PHA) Gender: * U.S. Citizen: Yes No * Disabled: Yes No

* Relationship to Head of Household: Spouse/Partner Parent Child Sibling Foster child Live in Aid Other

* Student: Yes No If Yes, School Name: Full Time Part Time School Type: Kindergarten Elementary (K-6) Middle (6-8) High (9-12) College or University Training City: State: Zip Code:

Have you ever served on active duty in the U.S. armed forces, reserves, or National Guard? * Yes No Are you an ex-spouse, widow, or widower of a person who is no longer a member of the household * Yes No but who had ever served on active duty in the U.S. armed forces, reserves, or National Guard? Veteran Status

If yes to a question above, please indicate years served: School

* Required Field

V1.7 Massachusetts Section 8 Centralized Waitlist Page 3 of 4

* Required Field

Employment Monthly Income: $ Type: Full Time Part Time Seasonal Employment & Other Income

City: State: Zip Code:

Pay Cash: Yes No * Other total monthly income: (SSI, Child Support, Pensions, Etc.) $ Household Member 3 Co-Applicant (one per household)

* First name: Middle: * Last name:

* Date of Birth:

* SSN or Alien ID #: I have no SSN or Alien ID # (temporary number will be provided by PHA) Gender: * U.S. Citizen: Yes No * Disabled: Yes No

* Relationship to Head of Household: Spouse/Partner Parent Child Sibling Foster child Live in Aid Other

* Student: Yes No If Yes, School Name: Full Time Part Time School Type: Kindergarten Elementary (K-6) Middle (6-8) High (9-12) College or University Training City: State: Zip Code:

Have you ever served on active duty in the U.S. armed forces, reserves, or National Guard? * Yes No Are you an ex-spouse, widow, or widower of a person who is no longer a member of the household * Yes No but who had ever served on active duty in the U.S. armed forces, reserves, or National Guard? Veteran Status

If yes to a question above, please indicate years served: School

Please provide information on each member of your household. Additional sheets may be included for additional household members and/or additional employment or school information. Employment Monthly Income: $ Type: Full Time Part Time Seasonal Employment & Other Income

City: State: Zip Code:

Pay Cash: Yes No * Other total monthly income: (SSI, Child Support, Pensions, Etc.) $ Household Member 4 Co-Applicant (one per household)

* First name: Middle: * Last name:

* Date of Birth:

* SSN or Alien ID #: I have no SSN or Alien ID # (temporary number will be provided by PHA) Gender: * U.S. Citizen: Yes No * Disabled: Yes No

* Relationship to Head of Household: Spouse/Partner Parent Child Sibling Foster child Live in Aid Other

* Student: Yes No If Yes, School Name: Full Time Part Time School Type: Kindergarten Elementary (K-6) Middle (6-8) High (9-12) College or University Training City: State: Zip Code:

Have you ever served on active duty in the U.S. armed forces, reserves, or National Guard? * Yes No Are you an ex-spouse, widow, or widower of a person who is no longer a member of the household * Yes No but who had ever served on active duty in the U.S. armed forces, reserves, or National Guard? Veteran Status

If yes to a question above, please indicate years served: School

Massachusetts Section 8 Centralized Waiting list

V1.7 Massachusetts Section 8 Centralized Waitlist Page 4 of 4

* Required Field

You must complete all required fields on the pre-application in order to be added to the waitlist. Required fields are marked with an asterik . The fields on this pre-application are used to determine eligibility and your placement on the waitlist. Please note that each housing authority operates under their own local policy and use different methods and preferences to rank applicants on the waitlist. If you have questions or need additional information about completing your pre-application please contact a participating housing authority. Return a completed Pre-Application to ONE of the 101 Participating Housing Authoritites on the Massachusetts Section 8 Centralized Waiting List. For a complete list of PHA’s please see the Pre-Application information document or visit www.gosection8.com/MassCWL.

* Has anyone in your household been displaced or at risk of being displaced due to a natural disaster? * Yes No Name / Disaster Type: Disaster Date: Displacement Date: Disaster City:

* Has anyone in your household been displaced or at risk of being displaced due to an action of a housing owner/landlord? * Yes No

* Has anyone in the household vacated their housing unit because of domestic violence or lives in a unit with a person who engages in violence? * Yes No

*Has anyone in your household been displaced or at risk of being displaced due to hate crimes? * Yes No

* Has anyone in your household been displaced or at risk of being displaced due to a government action? * Yes No State: Zip Code:

Applicant Household Conditions

* Has anyone in your household been displaced or at risk of being displaced due to the inaccessibility of a unit? * Yes No

* Has anyone in your household been displaced or at risk of being displaced to avoid reprisals or due to being in witness protection? * Yes No

* Is anyone in your household fleeing home due to dangerous conditions? * Yes No

* Are you currently living in substandard housing? * Yes No

* Do you currently live at Father Bill's & Mainspring (at 422 Washington St, Quincy, MA 02169) ? * Yes No

* Are you or any household member living in an institution that provides a temporary residence, including congregate shelters and transitional housing, intended for individuals with disabilities?

* Yes No

* Are you or a household member at serious risk of moving into an institution that provides a temporary residence, including congregate shelters and transitional housing, intended for individuals with disabilities? * Yes No

* Signature of Head of Household: * Date:

I understand that submission of false information or misrepresentation may result in loss of eligibility to participate in the Section 8 Housing Choice Voucher Program. I certify that I have attained the age of eighteen and therefore have full legal capacity to act on my own behalf in the matter of contracts.

I CERTIFY THAT THE ENCLOSED INFORMATION IS ACCURATE AND COMPLETE. Application ID: Application Date:

For PHA use only

Contact this candidate