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Home For Residents Government Online Services Online Housing Choice Voucher Waiting List Questionnaire
Online Housing Choice Voucher Waiting List Questionnaire PDF Print Email

Housing Authority of the City of Napa

1115 Seminary Street  PO Box 660  Napa CA 94559

(707)257-9543

HOUSING CHOICE VOUCHER RENTAL ASSISTANCE WAITING LIST QUESTIONNAIRE

HEAD OF HOUSEHOLD NAME    

MAILING ADDRESS

RESIDENCE ADDRESS

Include city, state and zip code in mailing and residence address

EMAIL ADDRESS   (Optional)

PHONE NUMBER         MESSAGE PHONE NUMBER

GENDER FEMALE MALE DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO     U.S. VETERAN NO YES SURVIVING SPOUSE      DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

NUMBER OF PEOPLE LISTED WHO WILL BE LISTED ON THIS APPLICATION

If you are applying for only yourself,  CLICK HERE   to go to the next section of the Questionnaire.

If you are applying for other family members,   - Complete the following for each family member who will be living with you.

FAMILY/HOUSEHOLD MEMBERS

FAMILY MEMBER #2 NAME    RELATIONSHIP CO-HEAD OR SPOUSE SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD

GENDER FEMALE MALE DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO       DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

If this is the last family member you are applying for, click here to go to the next section of the Questionnaire.

FAMILY MEMBER #3 NAME    - SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD CO-HEAD OR SPOUSE

GENDER - MALE FEMALE DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO     DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

If this is the last family member you are applying for, click here to go to the next section of the Questionnaire.

FAMILY MEMBER #4 NAME    RELATIONSHIP - SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD CO-HEAD OR SPOUSE

GENDER - MALE FEMALE DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO      DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

If this is the last family member you are applying for, click here to go to the next section of the Questionnaire.

FAMILY MEMBER #5 NAME    RELATIONSHIP - SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD CO-HEAD OR SPOUSE

GENDER - MALE FEMALE   DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO      DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

If this is the last family member you are applying for, click here to go to the next section of the Questionnaire.

FAMILY MEMBER #6 NAME    RELATIONSHIP - SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD CO-HEAD OR SPOUSE

GENDER - MALE FEMALE   DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO      DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

If this is the last family member you are applying for, click here to go to the next section of the Questionnaire.

FAMILY MEMBER #7 NAME    - SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD CO-HEAD OR SPOUSE

GENDER - MALE FEMALE   DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO      DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER    ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME    SOURCE OF INCOME

If this is the last family member you are applying for, click here to go to the next section of the Questionnaire.

FAMILY MEMBER #8 NAME RELATIONSHIP - SON DAUGHTER OTHER ADULT OTHER CHILD HEAD OF HOUSEHOLD CO-HEAD OR SPOUSE

GENDER - MALE FEMALE   DATE OF BIRTH     SOCIAL SECURITY NUMBER  

LEGAL US RESIDENT? YES NO      DISABLED NO YES

RACE WHITE BLACK/AFRICAN AMERICAN AMERICAN INDIAN/ALASKA NATIVE ASIAN NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER ETHNICITY NOT HISPANIC OR LATINO HISPANIC OR LATINO

GROSS MONTHLY INCOME SOURCE OF INCOME

If you have additional family members, please enter information in the Comments section at the end of this Questionnaire.

Has any member of your household ever received Rental Assistance?  NO YES

If YES, provide: Address where you received rental assistance

Date of Occupancy  From to Agency

Under what name?    and Social Security Number?

Has any member of your household ever been detained or arrested for violent crime, sex offences or drug-related activity? NO YES

If YES, provide:  Name(s) of Person(s)

Location and date of arrest(s)/convictions(s)

Charges

COMMENTS OR ADDITIONAL INFORMATION:

WARNING:  Section 1001 of Title 18 of the US Code makes it a criminal offense to make willful false statements or misrepresentation to any department or agency of the US as to matters within its jurisdiction.  

I have read the above and, under penalty of perjury, certify the information given is true and complete.  I authorize the Housing Authority to verify information on this Questionnaire.  I understand that providing false information is grounds for denial of this application.   I understand verification of information contained herein may be verified utilizing computer matching.  I understand that information contained herein may be shared with the County of Napa HMIS system. 


HOUSING SURVEY FORM

Please complete this section to tell us about where you live now

Owner Information:

Owner/property manager name

Phone

Email

Unit Information:

Unit Address

City/Town Select a City Napa American Canyon Angwin Calistoga Lake Berryessa St. Helena Yountville

Other City or Area in Napa County: 

Date  rented

Current Rent Amount

Security Deposit :

Unit Type Select House (Single Family Detached Unit) Apartment (Row House/Garden Apt) Mobile Home Duplex/Triplex Condominium

# of Bedrooms 1 2 3 4 5 6 0

# of Bathrooms 1 1.5 2 2.5 3

 Pets Allowed? Yes No

Other Amenities:
(Choose all that apply)

Yes No Balcony, Patio, Deck, or Porch

No Yes Fireplace 

No Yes Garage or covered parking

No Yes Large yard

No Yes pool and/or hot tub

No Yes dishwasher

Utility payment and appliances responsibility 

 

Electricity: Tenant Owner

Gas: Tenant Owner

Water: Owner Tenant

Sewer Owner Tenant

Trash Owner Tenant

Stove provided by Owner Tenant

Refrigerator provided by Owner Tenant

COMMENTS, ADDITIONAL INFORMATION

 

Date Completed    09/27/2006

You are submitting an online application for the Housing Choice Voucher Waiting List.

We suggest that you keep a copy of your submission by saving a copy of your Sent Email.  You can access this by going to your email program and looking in the "Sent Mail" folder.

You should receive written confirmation of your Waiting List status within two weeks.

PLEASE NOTE:  We have received information that this form will not submit from some internet providers such as AOL.  After you press "Submit", if you do not see a message that says this form is being emailed, please print out a copy and mail it to us at PO Box 660, Napa CA 94559.