The Housing Authority of the City of Fort Lauderdale, Florida

The Housing Authority of the City of Fort Lauderdale, Florida

Affordable Housing Division

Application: Initial___ Renewal___

If this is an initial application, address of unit applying for:

Head of Household Information

Name:Home Phone:

Current

Address: Work Phone: City, State, Zip: Cell Phone:

Email Address:

MAIDEN NAME, NICKNAME OR ALIAS (if applicable): ______

Household Information

LEGAL NAME
Last, First, Middle Initial / Social Security
Number / Date of
Birth / Relationship
To Head / Sex
M/F / Marital
Status / Race
(see #
Below) / Ethnicity
(see #
Below)
HEAD
RACE: (1) Black (2) White (3) American Indian/Alaskan Native (4) Asian or Pacific Islander (5) Multi Racial
ETHNICITY: (1) Hispanic (2) Non- Hispanic

Rental History

Current Landlord name, address and phone number:

Have you or any household member ever been evicted?Yes No

If yes, how many times and when:

Name of Landlord(s):

Are you or any household member now living or have ever lived in Public Housing, received Section 8 assistance or any other form of governmentassistance? Yes No

If yes, where and what agency:

Do you owe them money?YesNo If yes, how much: $

Are you related to anyone currently employed by The Housing Authority of the City of Fort Lauderdale or any of its affiliates, including the Affordable Housing Division? Yes No

Criminal History

Have you or any member of your household ever engaged in, been cited, arrested, indicted, convicted, placed on probation/parole, had an adjudication withheld, had charges dropped or nolleprossed in connection with any criminal activity? Yes No

If yes, who:

When? What was the charge? What was the outcome?

Are you or any member of your household required to register as a sex offender or predator? YesNo

If yes, who? What was the charge: ______

When? What state did the offense occur: ______

Emergency ContactBeneficiary

Name: Name:

Telephone: Telephone:

Relationship: Relationship:

THE RESIDENT DESIGNATES THE ABOVEADULT PERSONAS THE RESIDENT'S BENEFICIARY TO BE RESPONSIBLE FOR REMOVAL OF THE RESIDENT'S PERSONAL PROPERTY IN THE EVENT OF DEATH OR INCAPACITY OF RESIDENT. RESIDENT FURTHER DESIGNATES HIS/HER BENEFICIARY TO BE THE RECIPIENT OF ANY FUNDS DUE TO RESIDENT IN THE EVENT OF RESIDENT'S DEATH OR INCAPACITY. THIS EMERGENCY CONTACT BENEFICIARY NOTICE SUPERCEDES ANY AND ALL PRE-EXISTING EMERGENCY CONTACT BENEFICIARY NOTICES.

Household Income

Please provide one (1) month of income receiving now and/or expect to receive in the next twelve (12) months for all members of your household. Proof of income such as:

Employment / Retirement Fund
Unemployment / Social Security
Workmen’s Compensation / TANF / Food Stamps
Self Employment Verification / Child Support
Tax Return with W-2 attached for the past 2 years / Alimony
Veterans Benefits / Annuity Payments
Contribution / Money received from: (i.e. gifts, family members, friends, etc.) Notarized letter ONLY
Member Name / Type of Income / Agency / Contributor Name
Address and Phone Number / Monthly Income
$
$
$
$

Household Expenses

Please provide twelve (12) months of your most recent expenses paid out of pocket. Proof of expenses such as:

(Only applicable for Project Based Units)

Childcare / Prescriptions/Medications / Doctor/Dental / Hospital
Adult care / Nurse Aide / Supplemental Insurance / Insurance / Other
Member Name / Type of Expense / Agency Name
Address and Phone Number / Monthly Expenses
$
$

Household Assets

Please provide your most recent assetstatement. Proof of assetsuch as:

Checking Account / Life Insurance Policy / Money Market / IRA/ Retirement Pension
Savings Account / Trust / Stocks / Bonds / CD / Other
Member Name / Type of Asset / Agency Name
Address and Phone Number / Value or Balance
$
$
$

Vehicle Information

Member Name / Year, Make, Model / Tag Number / Monthly Vehicle Payment / Monthly Insurance Payment
$
$

Are you or any household member disabled?YesNo

Is yes, who:

Do you require any reasonable accommodations based on the disability?YesNo

If yes, please specify what or explain:

By signing below I understand that there is a $25.00 non-refundable initialapplication fee per adult. I further understand that any security deposit given to The Housing Authority of the City of Fort Lauderdalewill only be refunded if denied. If I decide to cancel after being approved, security deposit paid will NOT be refunded.

I hereby authorize The Housing Authority of the City of Fort Lauderdale to perform background checks, including credit and criminal background checks, for the purposes of determining my suitability as an initial or continuing tenant. I understand and agree that any initial or renewal lease agreement entered into by the parties is conditional upon the receipt of cleared background checks. Said checks will be performed after this Application has been completed. The Housing Authority of the City of Fort Lauderdale reserves the right toterminate any lease if the background checks are not approved. Tenant will be given a 7-Day Notice to Cure/NonCompliance if their background check(s) are not approved. Tenant’s lease will be terminated in the event they are unable to cure the noncompliance.

WARNING: Title 18, Section 1001 of the United States Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States.

I/we read and understand all questions asked of me and certify the all information given is true. I/we further understand any false information given will result in denial of my application

Signature:Date:

Signature:Date:

Signature:Date:

Stamp date/time received: