Preliminary Application

City of Kenosha Housing Authority

PRELIMINARY APPLICATION	English \| Español

This application must be submitted electronically using this system to create a receipt of application. Paper copies of this form cannot be accepted.

Waiting List:

S8 Housing Choice Voucher

Part 1: Head of Household

Applicant

First Name:
Last Name:

Social Security Number:
Date of Birth:
Sex:	Female	Male

Telephone Number:
Other Phone/E-mail:
Other Phone Type:

Ethnicity (Check one box)

	Hispanic Not Hispanic
Race (Check all that apply)

	White Black/ African American American Indian/ Alaska Native Asian Native Hawaiian/ Other Pacific Islander
Racial and ethnic data for statistical purposes only.


Yes	No	Do you qualify for a reasonable accommodation due to a disability?

Part 2: Household Information

Legal Address (Where you currently live)

Address Line 1:
Address Line 2:
City:
State:
ZIP Code:

Mailing Address (If different from Legal) (Where you currently receive mail)

Address Line 1:
Address Line 2:
City:
State:
ZIP Code:

Note: If your legal or mailing address changes, you must notify the Housing Authority in writing to maintain your waiting list status.

Household Members

List information for adults first, then children under age 18. Use "F" or "M" to indicate sex. If a household member qualifies for a reasonable accommodation due to a disability select "Y", if not, select "N". List relationship of each person to the Head of Household.

First Name

Last Name

Social
Security #

Date of Birth

Sex

Disabled

Relationship

Head

Part 3: Family Income and Assets

List total gross income (before taxes) and payments received by each family member age 18 or older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members age 18 or older on behalf of other family members under age 18.

First Name	Gross Income	How Often	If Income is from Wages List Name and Address of Employer


	$
	$
	$
	$
	$
	$

List total cash value and total income received for assets owned by all family members.

Type of Asset	Cash Value of Asset	Income Received from Asset
Checking Accounts	$	$
Savings Accounts	$	$
Stocks, Bonds, CDs, Investment	$	$
Real Estate	$	$
Other	$	$

Part 4: U.S. Citizenship Notification and Certification

Housing may be contingent upon the submission and verification of evidence of citizenship or eligible immigration status prior to the time housing is made available. Based on the evidence submitted at that time, assistance may be prorated, denied or terminated following appeals and informal hearing processes.

I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000 or imprisoned up to five years if I furnish false or incomplete information.