Section 8 Pre-Application and Supplement One third of all applications are dropped from the waiting list due to unreported address changes. Do not let this happen to you. Report any change of address in writing to one of the regional agencies listed on the reverse of this form.
Head of Household Information Social Security Number*
Date of Birth*
Telephone Number*
Cell Phone Number
Name*
First
Middle
Last
Email Address*
Mailing Address*
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Shelter Name
Shelter Address
Physical Address (if different from Mailing Address)
Co-Head/Spouse of Household Information A co-head is an adult individual in the household who is equally responsible with the head of household for ensuring that the family fulfills all of its responsibilities under the program. A family may have a co-head or spouse but not both. What this means is that if you choose to be listed as the co-head you cannot also be listed as spouse. You are not required to select a co-head.
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Co-Head
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Spouse
Social Security Number
Date of Birth
Phone (include area code)
Name
First
Middle
Last
Household and Demographic Information How many people will live in the unit, including yourself?* Gross annual household income*
Write in the approximate amount of your family’s
gross (before taxes) annual income. Include all
sources for all family members.
Check if the head of household, spouse or co-head: This field is hidden when viewing the form
Is 62 years old or older
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Has a disability
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Has been displaced by government action
Are there other members of the household who have a disability? This field is hidden when viewing the form
Disability (Yes)
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Disability (No)
Is there another member of the household who has a disability and is between 18 and 61 years old?* This field is hidden when viewing the form
Disability between 18-61 (Yes)
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Disability between 18-61 (No)
If yes, what is that person’s date of birth?
Is the head of household, spouse, or co-head working or about to start working? This field is hidden when viewing the form
Working (Yes)
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Working (No)
If yes, enter the name of the city/town where working:
Which city/town would you like to use for a residency preference? Your application will receive an admission preference in the area where you live or work. You must select whether you wish to have your residency preference applied to your home address or your work address. For example, if you live in Framingham but work in Worcester and you select Framingham as your residency preference, your application will be ordered by date and time with all other applicants in the Framingham region.
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Where I live
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Where I work
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Where I last had a permanent residency
Specify city/town
We collect data on race and ethnicity in accordance with federal regulations. People of various races may also be of Hispanic ethnicity. Please indicate if you are Hispanic. Your answers will not affect your application.
Is the head of household (Select as many as appropriate) This field is hidden when viewing the form
Head of household - White
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Head of household - Black/African American
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Head of household - American Indian/Alaskan Native
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Head of household - Asian
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Head of household - Native Hawaiian/Other Pacific Islander
Is the head of household This field is hidden when viewing the form
Head of household - Hispanic
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Head of household - Non-Hispanic
Is the head of household a veteran?* This field is hidden when viewing the form
Veteran - Yes
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Veteran - No
What is your current housing situation? (Check one box that best applies) This field is hidden when viewing the form
Current Housing - Homeless
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Current Housing - Substandard Housing
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Current Housing - Involuntarily Displaced
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Current Housing - 50% Rent & Utilities
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Current Housing - Nursing Home
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Current Housing - Doubled Up
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Current Housing - Public Housing
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Current Housing - Transitional Housing
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Current Housing - Subsidized Housing
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Current Housing - Other
Other
What is the language you prefer for communication This field is hidden when viewing the form
Spanish
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Portuguese
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Vietnamese
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Haitian Creole
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Chinese
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Khmer
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Russian
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English
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Other
If other please specify:
Supplement to Application for Federally Assisted Housing This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.
Name of Additional Contact Person or Organization
First
Additional Contact Address
Additional Contact Telephone Number
Additional Contact Cell Phone Number
Additional Contact Email Address (if applicable)
Relationship to Applicant
Reason for Contact (Check all that apply) This field is hidden when viewing the form
Reason for Contact - Emergency
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Reason for Contact - Unable to Contact
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Reason for Contact - Rental assistance termination
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Reason for Contact - Eviction
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Reason for Contact - Late rent
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Reason for Contact - Recertification assist
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Reason for Contact - Lease terms change
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Reason for Contact - House rules change
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Reason for Contact - Other
Other
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.
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Do not provide contact info
Certification of Applicant Please read this statement very carefully. By signing, you are agreeing to its terms.
I hereby certify that the information I have provided in this pre-application is true and accurate. I understand that
any misrepresentation or false information will result in my application being cancelled or denied, or in termination of housing assistance;
this is a pre-application for tenant-based rental assistance through the Executive Office of Housing and Livable Communities (EOHLC) and its regional administering agencies and is not an offer of housing;
at the time I rise to the top of the waiting list(s), I will be required to provide verification of the information I have provided here, in accordance with federal housing regulations and EOHLC policy;
it is my responsibility to notify any one of EOHLC’s regional administering agencies of any change of address in writing and I understand that my application may be cancelled if I fail to do so;
my participation in the Section 8 housing program is subject to my being eligible and in compliance with
HUD and EOHLC regulations; and that I will be subject to a criminal history check.
I agree that EOHLC can share my information with other state agencies for the purposes of determining program
eligibility.
Signature of head of household* CAPTCHA
EOHLC manages a limited number of project-based Section 8 apartments in or near most major cities and towns throughout the state. To find out more contact one of the agencies on the reverse of this form or visit the Housing Consumer Education Center website at www.masshousinginfo.org.
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.
