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PRELIMINARY APPLICATION

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Dear Applicant: The application you are about to complete is for Public Housing units in Tulsa, Oklahoma. The approximate waiting period for Public Housing is 6 to 12 months. You may visit our website at www.TulsaHousing.org for additional program information.

By submitting this application, you authorize the Tulsa Housing Authority to complete a criminal background check and verify information and current accounts from the local gas utility company.

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Waiting List:

Public Housing

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Part 1: Head of Household

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Applicant

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First Name:

Last Name:

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Social Security Number:

 ex. xxx-xx-xxxx

Date of Birth:

 ex. mm/dd/yyyy

Sex:

Female

Male

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Telephone Number:

 ex. (xxx) xxx-xxxx

Other Phone/E-mail:

 

Other Phone Type:

Ethnicity (Check one box)

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Hispanic
Not Hispanic

Race (Check all that apply)

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White
Black/
        African American
American Indian/
        Alaska Native
Asian
Native Hawaiian/
        Other Pacific Islander

Racial and ethnic data for statistical purposes only.

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Yes

No

Do you qualify for a reasonable accommodation due to a disability?

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Part 2: Household Information

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Legal Address 
(Where you currently live)

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Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

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

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Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

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

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Household Members

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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.

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First Name


Last Name

Social
Security # 


Date of Birth 


Sex


Disabled 


Relationship

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        Head
                 
                 
                 
                 
                 
                 
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Part 3: Family Income and Assets

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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.

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First Name

   Gross
   Income

How Often

If Income is from Wages
List Name and Address of Employer

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

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Type of Asset

Cash Value of Asset

Annual Income Received from Asset

Checking Accounts

Savings Accounts

Stocks, Bonds, CDs, Investment

Real Estate

Other

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Part 4: Supplemental and Optional Contact Information

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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 during your tenancy or to assist in providing any special care or services you may require should you become a tenant. 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.

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

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Part 5: U.S. Citizenship Notification and Certification

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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.

Use the fields below to confirm the information entered in Part 1.

Head of Household Social Security Number:

 ex. xxx-xx-xxxx

Head of Household Date of Birth:

 ex. mm/dd/yyyy


By submitting this form, I certify that the information provided 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
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