Tenant Name:
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NOTE TO TENANT: In order for us to determine your eligibility or continued eligibility, you must provide all information included in this questionnaire. This information is considered confidential and will only be used as necessary in determining your eligibility for a federal affordable housing program. Providing false information may result in loss of your housing.
First Name
Last Name
Apartment Number:
Home Telephone Number
Alternate Telephone Number
Household Composition
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List yourself and anyone who will live with you within the next 12 months. Be sure to include members temporarily away from home, including (but not limited to): dependents away at school, military persons stationed away from home that have a spouse or dependent in the home.
Please list household members starting with the head of household on line 1, then in order of oldest to youngest.
Last Name, First Name | Relationship to Head of Household | Birth Date | Age | Social Security Number | Student Status (Full-Time, Part-Time, N/A)
Do you anticipate any changes in the size of your household within the next 12 months?
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If yes, please describe any changes.
Will anyone under the age of 18 listed above live in the unit less than 50% of the next 12 months?
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If yes, please explain here:
Does any member of your household have a disability and require a live-in care attendant?
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Is any adult member of your household separated, but not divorced?
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Does your household receive, or is it applying to receive, Section 8 rental or voucher assistance?
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Are all members of your household full-time students?
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Will all members of your household be full-time students during any 5 months of this year?
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Will all members of your household be full-time students during any 5 months of next year?
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Is any adult member of your household a part or full-time student in an institute of higher education?
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If yes, who is enrolled?
Which school are they enrolled in?
How do they pay for their education?
What is the cost of tuition per semester?
Does any adult member of your household intend to become a student within the next 12 months?
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If yes, who will be enrolling in school?
If yes, will they be enrolling as a full-time or part-time student?
Has any member of your household ever been court ordered to receive child support or alimony payments, even if no child support or alimony is being received?
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Does any member of your household receive child Support or Alimony payments that are not court ordered?
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Is any member off the household employed?
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Job 1: Who is employed? What Company? Phone number? Amount Paid?
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Job 2: Who is employed? What Company? Phone number? Amount Paid?
Check if there are any additional jobs in the household?
Are any household members self-employed?
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If yes, Who is self-employed? What type of work? Amount Paid?
Are any adult members of your household unemployed?
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Which adult members are unemployed?
Does any household members receive pay from the military?
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If yes, who is paid by the military? Which branch? Contact person & Phone?
Amount $?
Does any household member receive any payments from the Social Security Administration?
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If yes, which type:
Amount $?
Who receives payments from Social Security Office?
Does any household member receive severance pay or worker's compensation?
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Who is receiving severance pay or worker's compensation? What company pays them? Contact Person & Phone? Amount paid?
Is the household member unemployed and receiving payments from an Unemployment Agency?
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Who is receiving unemployment benefits? Contact Person & Phone? Amount paid?
Does any household member receive Public Assistance payments such as TANF or AFDC?
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Please do not include food stamp benefits here.
Who is receiving TANF or AFDC benefits? Casework? Phone? Amount paid?
Does any household member receive periodic payments from a pension, annuity or retirement benefit account?
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Please check one:
If yes, who receives these benefits? What company pays them? Contact Person & Phone? Amount paid?
Does anyone outside of your household provide you with cash or contributions to help pay expenses that a household would normally pay, such as rent, utility payments or groceries?
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If yes, What is the name of that person? What is their address? Phone Number? Amount Paid?
Is there any other source of income we haven't already asked about above that you receive?
If yes, please describe? Amount paid?
Does your household expect any changes in their income within the next 12 months?
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Please describe:
Does your household receive long-term care insurance payments, in excess of $180 per day, for a daily member residing in a long-term care facility?
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If yes, which household member is in a long-term facility? Which household member are the payments made to? What company pays this person? Contact Person & Phone? Amount paid?
Do any adult members of your household have zero income?
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Which adult members have zero income?
Does any household member have any accounts or assets that were not described above?
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Please do not include personal use vehicles, furniture, clothing, etc.
If yes, what type of account or asset is this? What is the estimated value of this asset if you were to sell it today?
In the past two years, has any household member given away any asset(s) for less than they were worth?
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Examples: property, transferring an asset account into someone else's name, charitable contributions, etc.
What was the estimated value of this asset?
Head of Household Date of Signature
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Co-Head of Household Signature (Electronic)
Co-Head of Household Signature Date
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DD
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Other Adult Member Signature (Electronic)
Other Adult Member Signature Date
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Other Adult Member Signature (Electronic)
Other Adult Member Signature Date
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