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Criminal Activity (Please check “yes” or “no” for each question)

INCOME AND ASSET INFORMATION

ELDERLY FAMILIES ONLY

RENTAL HISTORY (minimum 3 years needed)

Do any of the following apply to your household?

MARKETING

*NOTE-If you are applying for one of our active waiting lists, in order for your application to remain on the active waiting list, you must update your application a MINIMUM of every six months. Failure to contact the office and update your application in writing will result in the application being removed from the active list. We are not responsible for undeliverable mail; please make sure we have a correct mailing address. You will be contacted when your name comes up on the waiting list. Management will offer the first available unit; if you decline the unit your application will be cancelled. If you wish to reapply, you may if our waiting lists are open. If the applicant requires a fully accessible unit and prefers to wait for an accessible unit to become available, the household will remain at their position on both the conventional and Accessible unit waiting lists until accepting a housing unit that meets the household's needs. I/We certify that the foregoing information is true, complete and correct. Inquiries may be made to verify the statements herein. I/We also understand that false statements or omission are grounds for disqualification and/or prosecution under the full extent of the law. I/We certify that all of the statements heretofore are true and correct as of the date shown below and authorize verifications of statements and references and agree to provide additional credit references on request. I/We further recognize that submission of more then one application will cause rejection of all my/our application. I/We understand that this application will be immediately rejected if I or any individual offers the management a bribe for consideration to advance my name on the waiting list for the purpose of obtaining preferential treatment in securing housing. I/We authorize Pico Union Housing Corporation, and any agent allowed to do so to verify Credit and Criminal Background.

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.