Pre-Public Housing Application
Counter
Elizabethton Housing & Development Agency
Elizabethton Housing & Development Agency, Inc.
Pre-Application (bring with you when you come in)

PERSONAL DECLARATION FOR PUBLIC HOUSING PROGRAM
Name
(Last) (First) (MI)
Place of
Birth
Sex
(M/F)
Social
Security
Number
Date of
Birth

Age

Relationship
(optional)
Race/
Ethnic
(optional)
Doe, John W.
Carter
County
M
111-11-1111
1/1/1937
75
Head
White/Non
Hispanic
Example:

Race:    Black   White    American Indian/Native Alaskan        Asian/Pacific Islander
Ethnicity:          Hispanic            Non-Hispanic

HOUSEHOLD MEMBERS:  USE LEGAL NAMES ONLY
List all persons who will be living in your home, list oldest to the youngest.
INCOME: List all money earned or received by everyone in your household.  This includes, but is not
limited to money from wages, self-employment, child support, contributions, social security, disability,
worker’s compensation, retirement, Families First, Veteran benefits, rental property income, stock
dividends, interest from bank accounts, alimony and all other sources.   If you draw a check off of a
different social security number than your own, please provide us with the appropriate number or
claim number.
Do you owe any money to a Housing Assistance Program?____________________________


Please list the name and address of at least two previous
private landlords.  If you have never
rented, you may list a past or present job supervisor, case worker, social worker, counselor,
probation officer, preacher, teacher or other people of this nature.
Name
Company Name
Address
Telephone Number
       
       
Emergency Contact Name & Number:_________________________________

Emergency Contact Name & Number:_________________________________

I/We do hereby swear and/or attest that all of the information above about me/us is true and
correct.  I/We also understand that all changes in income, assets and deductions of any member
of the household as well as any changes in the household members must be reported to the
Housing Agency in writing.

WARNING! Title 18, Section 1001 of the United States Codes states that a
person is guilty of a felony for knowingly and willingly making false or
fraudulent statement to any department or agency of the United States.
__________________________________             _________________________________
Signature of Head of Household                                       Signature of Spouse/Co-head

_________________________________
Date
Name
(Last)  (First)  (MI)
Place
of
birth
Sex
(M/F)
Social
Security
Number
Date
of
Birth
Age
Relationship
(optional)
Race/
Ethnic
(optional)
              ------
              ------
              ------
              ------
              ------
              ------
Present Living Address: _______________________________________________
                                   (Street)                          (City)                     (State & Zip)

Present Mailing Address:_______________________________________________

Telephone Number:___________________________________

Circle the bedroom size apartment you require:  
0  1  2  3  4  5

D
o you require a specific accommodation to fully utilize our programs and services?  
__Yes___No
If yes, please explain (mobility, hearing, vision_________________________________
_____________________________________________________________________

Are you currently living in government assisted housing? ____Yes  ___No

Have you been charged with or convicted of any crime or offense? ___Yes  ___No
If yes, please explain__________________________________________________
Household
Member
Name
Wages-List
Employer
Name
TANF
Child
Support
SS/SSI/
Pension/VA
Unemployment
Bank Acct.
Information
Food
Stamps
Other
                 
                 
                 
                 
                 
                 
REFERENCES:  Please list the name and address of all previous and current
government housing assistance you have received:
Housing Agency or landlord's Name
Address
City & State