Preliminary Application

Vermont State Housing Authority

PRELIMINARY APPLICATION	English \| Español

PLEASE NOTE: THIS IS AN ONLINE APPLICATION ONLY-YOU MUST CLICK THE "SUBMIT" BUTTON AT THE BOTTOM OF THE APPLICATION IN ORDER FOR YOUR APPLICATION TO BE ACCEPTED.

Waiting List:

Section 8 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: Eligibility and Preferences

Your response to the following statement will help determine your eligibility for rental assistance and if you are entitled to a preference when placed on the program's waiting list. Select the appropriate responses for each question below.


Yes	No
		Are you homeless due to domestic violence, or currently living in a situation in which you are being subjected to domestic violence? For purposes of this preference, domestic violence is defined as a pattern of coercive control that may be primarily psychological, economic, or sexual, but that is reinforced by one or more act(s) of frightening physical violence, credible physical threat, or sexual assault. To qualify for this preference, you must have no other option for safe, long-term housing. The number of families admitted under this preference shall be limited to no more than 40 per year. Please provide the name of the agency which can verify your status.
		Are you displaced due to fire, flood, natural disaster, or condemnation by a local, State or Federal agency, or living in housing that has at least one serious defect that threatens your health or safety (such as unusable water or septic system, grossly insufficient heat in winter, severe fire hazard(s) such as grossly defective wiring)? If yes, you must provide us with the name, address and phone number of the agency or shelter that can verify your housing situation.
		Does your family include a child under the age of six who has tested positive for lead paint poisoning ? To qualify for this preference, the child must have an elevated blood level of 15 ug/dl or higher and the household must be occupying a rental unit that contains lead-based paint. If yes, you must provide us with the name, address and phone number of the agency that can verify your housing situation.
		Is the head of your household or the spouse a recent graduate of or participant in an education or training program designed to prepare the individual for the job market? The number of individuals admitted under this preference is limited to not more than 20 households per year. If yes, you must provide the name of an agency which can verify your participation and describe the program.
		Is your household: (a) receiving homeownership education services through a Neighborworks® Homeownership Center or other HUD approved Homeownership Counseling Center; and (b) being referred by that provider to VSHA’s Homeownership Program as needing the voucher to become a homeowner? The number of individuals admitted under this preference shall be limited to no more than 20 families per year. If yes, you must provide the name and contact information of your Homeownership Counseling Agency.
		Are you transitioning from one of the following programs administered by VSHA: (a) Family Unification Program for Youth in Transition, OR (b)The Shelter Plus Care Program? To qualify, an applicant must be in compliance with their lease and with their applicable case management plan. For Shelter Plus Care Program participants, you must have participated in the Shelter Plus Care Program for at least 36 months, and must have met the goals of the Individual Service Plan (ISP). If yes, you must provide the name of the agency that provides your case management services.

Part 4: Supplemental and Optional Contact Information

You have the right to include as part of your application contact information for a person or organization that may be able to help you resolve any issues that may arise or to assist in providing any special care or services you may require in association with this application for housing. You are not required to provide this contact information, but if you choose to do so, please click the "Add Contact" button below to complete the form.

Name of Contact Person

Relationship

Street Address

Check this box if you choose not to provide the contact information.

Part 5: 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.

Equal Housing
Opportunity