Housing Application Form

Floyd County Housing Authority_logo Phone: 606.285.3833 | Fax: 606.285.3835402
John M. Stumbo Drive, Langley, KY 41645
FCHA-KY.org
Equal Housing Opportunity logo, Handicapped Accessible logo, and Website Accessible logo

Fields marked with * must be completed or the form will not be submitted.

Vouchers are issued to qualified participants who live in the jurisdiction of Floyd County Housing Authority.

You will not be added to the waitlist until all required information is provided, either by uploading to this form, or by bringing the information to the office. Please call the office at 606.285.3833 if you have any questions about the information that is needed.

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Address ","name":"Current-Street-Address","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Current City","name":"Current-City","className":"col-md-6","subtype":"text"},{"type":"select","required":true,"label":"Current State","name":"Current-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY","selected":true},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Current Zip Code","name":"Current-Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","subtype":"tel","label":"Home Phone:","name":"Home-Phone","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"tel","label":"Work Phone:","name":"Work-Phone","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"tel","label":"Spouse's Work Phone:","name":"Spouses-Work-Phone","className":"col-lg-4"},{"type":"date","label":"Date of Birth:","name":"Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Sex (Male/Female/Other):","name":"Sex-MFO","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Are you a citizen of the United States?","inline":true,"name":"Are-you-a-citizen-of-the-United-States","className":"col-lg-4","values":[{"label":"Yes","value":"Yes - Citizen of the United States"},{"label":"No","value":"No - not a Citizen of the United States"}]},{"type":"checkbox-group","label":"Race (Select as many as appropriate to best indicate your race):","inline":true,"name":"Race-Select-as-many-as-appropriate-to-best-indicate-your-race","className":"col-lg-4","values":[{"label":" White","value":" White"},{"label":" Asian","value":" Asian"},{"label":" Black/African American","value":" Black/African American"},{"label":" American Indian/Alaskan Native","value":" American Indian/Alaskan Native"},{"label":" Native Hawaiian/Other Pacific Islander","value":" Native Hawaiian/Other Pacific Islander"}]},{"type":"radio-group","label":"Ethnicity:","inline":true,"name":"Ethnicity","className":"col-lg-4","values":[{"label":" Hispanic or Latino","value":" hispanic or latino"},{"label":" Not Hispanic or Latino","value":" not hispanic or latino"}]},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Do you or any member of your Family claim any type of disability for the purpose of qualifying for reasonable accommodation in the PHA rules or policies, modification of the housing unit, or specific housing needs?","inline":true,"name":"Do-you-or-any-member-of-your-Family-claim-any-type-of-disability-for-the-purpose-of-qualifying-for-reasonable-accommodation-in-the-PHA-rules-or-policies-modification-of-the-housing-unit-or-specific-housing-needs","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"textarea","label":"If Yes, Please describe accommodation required:","name":"If-Yes-Please-describe-accommodation-required","subtype":"textarea","className":"d-block"},{"type":"radio-group","label":"Marital status of Head of Household:","inline":true,"name":"Marital-status-of-Head-of-Household","className":"col-md-6","values":[{"label":" Married","value":" married"},{"label":" Single","value":" single"},{"label":" Widow(er)","value":" widow(er)"},{"label":" Divorced","value":" divorced"}]},{"type":"text","label":"Current Spouse Name:","name":"Current-Spouse-Name","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<b>List names, addresses, and telephone numbers of two relatives or friends who generally know how to contact you:</b>","className":"d-block"},{"type":"text","label":"Name of Relative or Friend 1:","name":"Name-of-Relative-or-Friend-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Address of Relative or Friend 1:","name":"Address-of-Relative-or-Friend-1","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of Relative or Friend 1","name":"Telephone-Number-of-Relative-or-Friend-1","className":"col-lg-4"},{"type":"text","label":"Name of Relative or Friend 2:","name":"Name-of-Relative-or-Friend-2","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Address of Relative or Friend 2:","name":"Address-of-Relative-or-Friend-2","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of Relative or Friend 2","name":"Telephone-Number-of-Relative-or-Friend-2","className":"col-lg-4"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Have you or any Family member ever received any type of housing assistance?","inline":true,"name":"Have-you-or-any-Family-member-ever-received-any-type-of-housing-assistance","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Please provide family member name who has received the housing assistance","name":"Please-provide-family-member-name-who-has-received-the-housing-assistance","className":"col-md-6","subtype":"text"},{"type":"text","label":"Public/Assisted Agency Name where the housing assistance was received","name":"PublicAssisted-Agency-Name-where-the-housing-assistance-was-received","className":"col-md-6","subtype":"text"},{"type":"text","label":"Agency Address where the housing assistance was received","name":"Agency-Address-where-the-housing-assistance-was-received","className":"col-md-6","subtype":"text"},{"type":"text","label":"When was the housing assistance received?","name":"When-was-the-housing-assistance-received","className":"col-md-6","subtype":"text"},{"type":"text","label":"Who was Head of Household when the housing assistance was received?","name":"Who-was-Head-of-Household-when-the-housing-assistance-was-received","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Has anyone in the household ever received an earned income exclusion during residency at any housing agency?","inline":true,"name":"Has-anyone-in-the-household-ever-received-an-earned-income-exclusion-during-residency-at-any-housing-agency","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Who received the earned income exclusion?","name":"Who-received-the-earned-income-exclusion","className":"col-md-6","subtype":"text"},{"type":"text","label":"Public/Assisted Agency name that granted the exclusion","name":"PublicAssisted-Agency-name-that-granted-the-exclusion","className":"col-md-6","subtype":"text"},{"type":"text","label":"Who was head of household when the exclusion was granted","name":"Who-was-head-of-household-when-the-exclusion-was-granted","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Do you currently owe any money to any Public or Assisted Housing Agency?","inline":true,"name":"Do-you-currently-owe-any-money-to-any-Public-or-Assisted-Housing-Agency","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"What amount is currently owed to the Public or Assisted Housing Agency","placeholder":"$","name":"What-amount-is-currently-owed-to-the-Public-or-Assisted-Housing-Agency","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Public/Assisted Agency that money is owed","name":"Name-of-PublicAssisted-Agency-that-money-is-owed","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address of Agency that money is owed","name":"Address-of-Agency-that-money-is-owed","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Have you ever used a name other than the one you are using now?","inline":true,"name":"Have-you-ever-used-a-name-other-than-the-one-you-are-using-now","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"textarea","label":"What other name have you used and why?","name":"If-yes-please-explain-","subtype":"textarea","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Have you ever used a social security number other than the one you listed on page one of this form?","inline":true,"name":"Have-you-ever-used-a-social-security-number-other-than-the-one-you-listed-on-page-one-of-this-form","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"What other social security number have you used and why?","name":"If-yes-list-the-other-number","className":"col-md-6","subtype":"text"},{"type":"header","subtype":"h4","label":"List all other members who will be living in this unit. NOTE: Family MUST provide Social Security Numbers of all members before being admitted to FCHA’s Low Rent Public Housing Program - Ref. 24 CFR Parts (5),(92), and (908).","className":"d-block"},{"type":"text","label":"Family Member 1 Full Legal Name","name":"Family-Member-1-Full-Legal-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 1 Relation to Head of Household.","name":"Family-Member-1-Relation-to-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 1 Date of Birth","name":"Family-Member-1-Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Family Member 1 Age","name":"Family-Member-1-Age","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Family Member 1 US Citizen","inline":true,"name":"Family-Member-1-US-Citizen","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Family Member 1 Sex","inline":true,"name":"Family-Member-1-Sex","className":"col-md-6","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"},{"label":"Other","value":"Other"}]},{"type":"text","label":"Family Member 1 Social Security Number","placeholder":"xxx-xx-xxxx","name":"Family-Member-1-Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 1 Occupation or School","name":"Family-Member-1-occupation-or-School","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Family Member 2 Full Legal Name","name":"Family-Member-2-Full-Legal-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 2 Relation to Head of Household","name":"Family-Member-2-Relation-to-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 2 Date of Birth","name":"Family-Member-2-Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Family Member 2 Age","name":"Family-Member-2-Age","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Family Member 2 US Citizen","inline":true,"name":"Family-Member-2-US-Citizen","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Family Member 2 Sex","inline":true,"name":"Family-Member-2-Sex","className":"col-md-6","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"},{"label":"Other","value":"Other"}]},{"type":"text","label":"Family Member 2 Social Security Number","placeholder":"xxx-xx-xxxx","name":"Family-Member-2-Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 2 Occupation or School","name":"Family-Member-2-Occupation-or-School","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Family Member 3 Full Legal Name","name":"Family-Member-3-Full-Legal-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 3 Relation to Head of Household","name":"Family-Member-3-Relation-to-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 3 Date of Birth","name":"Family-Member-3-Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Family Member 3 Age","name":"Family-Member-3-Age","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Family Member 3 US Citizen","inline":true,"name":"Family-Member-3-US-Citizen","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Family Member 3 Sex","inline":true,"name":"Family-Member-3-Sex","className":"col-md-6","values":[{"label":" Male","value":" Male"},{"label":" Female","value":" female"},{"label":"Other","value":"Other"}]},{"type":"text","label":"Family Member 3 Social Security Number","description":"xxx-xx-xxxx","name":"Family-Member-3-Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 3 Occupation or School","name":"Family-Member-3-Occupation-or-School","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Family Member 4 Full Legal Name","name":"Family-Member-4-Full-Legal-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 4 Relation to Head of Household","name":"Family-Member-4-Relation-to-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 4 Date of Birth","name":"Family-Member-4-Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Family Member 4 Age","name":"Family-Member-4-Age","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Family Member 4 US Citizen","inline":true,"name":"Family-Member-4-US-Citizen","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Family Member 4 Sex","inline":true,"name":"Family-Member-4-Sex","className":"col-md-6","values":[{"label":" Male","value":" male"},{"label":" Female","value":" female"},{"label":"Other","value":"other"}]},{"type":"text","label":"Family Member 4 Social Security Number","placeholder":"xxx-xx-xxxx","name":"Family-Member-4-Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 4 Occupation or School","name":"Family-Member-4-Occupation-or-School","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Family Member 5 Full Legal Name","name":"Family-Member-5-Full-Legal-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 5 Relation to Head of Household","name":"Family-Member-5-Relation-to-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 5 Date of Birth","name":"Family-Member-5-Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Family Member 5 Age","name":"Family-Member-5-Age","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Family Member 5 US Citizen","inline":true,"name":"Family-Member-5-US-Citizen-","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Family Member 5 Sex","inline":true,"name":"Family-Member-5-Sex","className":"col-md-6","values":[{"label":" Male","value":" male"},{"label":" Female","value":" female"},{"label":"Other","value":"other"}]},{"type":"text","label":"Family Member 5 Social Security Number","description":"xxx-xx-xxxx","name":"Family-Member-5-Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 5 Occupation or School","name":"Family-Member-5-Occupation-or-School","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Family Member 6 Full Legal Name","name":"Family-Member-6-Full-Legal-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 6 Relation to Head of Household","name":"Family-Member-6-Relation-to-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 6 Date of Birth","name":"Family-Member-6-Date-of-Birth","className":"col-md-6"},{"type":"text","label":"Family Member 6 Age","name":"Family-Member-6-Age","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Family Member 6 US Citizen","inline":true,"name":"Family-Member-6-US-Citizen","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Family Member 6 Sex","inline":true,"name":"Family-Member-6-Sex","className":"col-md-6","values":[{"label":" Male","value":" male"},{"label":" Female","value":"female"},{"label":"Other","value":"other"}]},{"type":"text","label":"Family Member 6 Social Security Number","placeholder":"xxx-xx-xxxx","name":"Family-Member-6-Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 6 Occupation or School","name":"Family-Member-6-Occupation-or-School","className":"col-md-6","subtype":"text"},{"type":"checkbox-group","label":"If there are any additional Family members attach a separate page with application.<br>","inline":true,"name":"If-there-are-any-additional-Family-members-attach-a-separate-page-with-application","className":"d-block","values":[{"label":"Check here if there are additional family members.","value":"check here if there are additional family members."}]},{"type":"file","label":"Please upload information about any additional family members here.","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Additional-Family-Members-information","subtype":"file","multiple":true,"className":"d-block"},{"type":"radio-group","label":"Are any Family members temporarily absent from the home?","inline":true,"name":"Are-any-Family-members-temporarily-absent-from-the-home","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If yes, please state reason they are absent:","name":"If-yes-please-state-reason-they-are-absent","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Violence Against Women Act, Title VI","className":"d-block"},{"type":"radio-group","label":"Are you seeking housing to avoid a domestic violence situation?","inline":true,"name":"Are-you-seeking-housing-to-avoid-a-domestic-violence-situation","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If yes, who is the person(s) you are attempting to avoid?","name":"If-yes-who-is-the-persons-you-are-attempting-to-avoid","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Have you or you on behalf of your children or wards asked for legal protection from the courts?","inline":true,"name":"Have-you-or-you-on-behalf-of-your-children-or-wards-asked-for-legal-protection-from-the-courts","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"file","label":"Please upload information about any EPO, DVO, restraining order or other legal papers.","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Please-upload-information-about-any-EPO-DVO-restraining-order-or-other-legal-papers","subtype":"file","multiple":true,"className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"Are you or anyone who intends to reside with you subject to an EPO, DVO, restraining order or other legal order restraining you from contact with another person?","inline":true,"name":"Are-you-or-anyone-who-intends-to-reside-with-you-subject-to-an-EPO-DVO-restraining-order-or-other-legal-order-restraining-you-from-contact-with-another-person","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"file","label":"Please upload copies of court papers.","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Please-upload-copies-of-court-papers","subtype":"file","multiple":true,"className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<b>Full Time Students: List the Family member name, and school name, address and telephone number of all Family members over the age of 18 who are attending school full-time: </b>","className":"d-block"},{"type":"text","label":"Name of Family Member 1","name":"Name-of-Family-Member-1","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 1 School Name","name":"Family-Member-1-School-Name","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Family Member 1 School Telephone Number","name":"Family-Member-1-School-Telephone-Number","className":"col-md-6"},{"type":"text","label":"Family Member 1 School Address","name":"Family-Member-1-School-Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Family Member 2","name":"Name-of-Family-Member-2","className":"col-md-6","subtype":"text"},{"type":"text","label":"Family Member 2 School Name","name":"Family-Member-2-School-Name","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Family Member 2 School Telephone Number","name":"Family-Member-2-School-Telephone-Number","className":"col-md-6"},{"type":"text","label":"Family Member 2 School Address","name":"Family-Member-2-School-Address","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","label":"If a full time college student, do you receive any financial aid, grants or scholarships?","inline":true,"name":"If-a-full-time-college-student-do-you-receive-any-financial-aid-grants-or-scholarships","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"textarea","label":"Please list any financial aid, grants, or scholarships received","name":"Please-list-any-financial-aid-grants-or-scholarships-received","subtype":"textarea","className":"col-md-6"},{"type":"text","label":"Who may we contact to verify grants, tuition, etc.?","name":"Who-may-we-contact-to-verify-grants-tuition-etc","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Have you maintained a separate residence from your parents for the past 12 months?","inline":true,"name":"Have-you-maintained-a-separate-residence-from-your-parents-for-the-past-12-months","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"file","label":"Please provide evidence of separate households. (Parents tax returns for the last calendar year, students tax return, or any information the Housing Authority determines is necessary.)","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Proof-of-separate-households","subtype":"file","multiple":true,"className":"col-md-6"},{"type":"text","label":"If a full time college student, where have you lived during the past twelve months?","name":"If-a-full-time-college-student-where-have-you-lived-during-the-past-twelve-months","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div><b>For all Family members that are not United States citizens, provide the following information: </b></div>","className":"d-block"},{"type":"text","label":"Name of Non-Citizen Family Member 1","name":"Name-of-Non-Citizen-Family-Member-1","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Non-Citizen Family Member 1 Alien Registration Number","name":"Non-Citizen-Family-Member-1-Alien-Registration-Number","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Name of Non-Citizen Family Member 2","name":"Name-of-Non-Citizen-Family-Member-2","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Non-Citizen Family Member 2 Alien Registration Number","name":"Non-Citizen-Family-Member-2-Alien-Registration-Number","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"PART B:  Drug/Criminal Activity","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Federal regulations require housing agencies to question applicants and participants concerning drug-related or violent criminal activities.","className":"d-block"},{"type":"radio-group","label":"Have you or any Family member ever been evicted from Public or Assisted housing for violent criminal or drug-related activity?","inline":true,"name":"Have-you-or-any-Family-member-ever-been-evicted-from-Public-or-Assisted-housing-for-violent-criminal-or-drug-related-activity","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"When was eviction?","name":"When-was-eviction","className":"col-md-6","subtype":"text"},{"type":"text","label":"What was the reason for the eviction?","name":"What-was-the-reason-for-the-eviction","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Family Member evicted?","name":"Name-of-Family-Member-evicted","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Public/Assisted Agency evicted from:","name":"Name-of-PublicAssisted-Agency-evicted-from","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Have you or any Family member ever been convicted of the manufacture or production of methamphetamine (speed) on the premises of Public or Assisted Housing?","inline":true,"name":"Have-you-or-any-Family-member-ever-been-convicted-of-the-manufacture-or-production-of-methamphetamine-speed-on-the-premises-of-Public-or-Assisted-Housing","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name of Family Member convicted:","name":"Name-of-Family-Member-convicted","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Public/Assisted Housing Agency conviction applies to:","name":"Name-of-PublicAssisted-Housing-Agency-conviction-applies-to","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Are you or any Family member subject to lifetime registration as a sex offender?","inline":true,"name":"Are-you-or-any-Family-member-subject-to-lifetime-registration-as-a-sex-offender","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name of Family Member registered as a sex offender:","name":"Name-of-Family-Member-registered-as-a-sex-offender","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Have you or any family member that will be living in the household, been arrested or received a citation in the past five (5) years for ANY reason, including traffic violations, misdemeanors, and felony arrests?","inline":true,"name":"Have-you-or-any-family-member-that-will-be-living-in-the-household-been-arrested-or-received-a-citation-in-the-past-five-5-years-for-ANY-reason-including-traffic-violations-misdemeanors-and-felony-arrests","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"When, why, and in what county/state charges occurred?","name":"When-why-and-in-what-countystate-charges-occurred","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Have you ever been accused of a crime and had to appear in court? ","inline":true,"name":"Have-you-ever-been-accused-of-a-crime-and-had-to-appear-in-court-","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Have you ever been incarcerated, imprisoned or jailed?","inline":true,"name":"Have-you-ever-been-incarcerated-imprisoned-or-jailed","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"When, for what reason, and in what county/state incarceration occurred?","name":"When-for-what-reason-and-in-what-countystate-incarceration-occurred","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Have you ever been on probation?","inline":true,"name":"Have-you-ever-been-on-probation","className":"col-lg-4","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"radio-group","label":"Are you still on probation?","inline":true,"name":"Are-you-still-on-probation","className":"col-lg-4","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"When were you on probation?","name":"When-were-you-on-probation","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Part C: Income Information","className":"d-block"},{"type":"header","subtype":"h4","label":"This part applies to all Family members, including minors.","className":"d-block"},{"type":"radio-group","label":"Does anyone in the household work full time, part-time, or seasonally - including wages, fees, tips bonuses, money for services?","inline":true,"name":"Does-anyone-in-the-household-work-full-time-part-time-or-seasonally---including-wages-fees-tips-bonuses-money-for-services","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name of 1st Family Member that works full time, part-time or seasonally","name":"Name-of-1st-Family-Member-that-works-full-time-part-time-or-seasonally","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer Name of 1st Family Member that works full time, part-time or seasonally","name":"Employer-Name-of-1st-Family-Member-that-works-full-time-part-time-or-seasonally","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Employer Telephone Number of 1st Family Member that works full time, part-time or seasonally","name":"Employer-Telephone-Number-of-1st-Family-Member-that-works-full-time-part-time-or-seasonally","className":"col-lg-4"},{"type":"text","label":"Employer Address of 1st Family Member that works full time, part-time or seasonally","name":"Employer-Address-of-1st-Family-Member-that-works-full-time-part-time-or-seasonally","className":"d-block","subtype":"text"},{"type":"text","label":"Name of 2nd Family Member that works full time, part-time or seasonally","name":"Name-of-2nd-Family-Member-that-works-full-time-part-time-or-seasonally","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Employer Name of 2nd Family Member that works full time, part-time or seasonally","name":"Employer-Name-of-2nd-Family-Member-that-works-full-time-part-time-or-seasonally","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Employer Telephone Number of 2nd Family Member that works full time, part-time or seasonally","name":"Employer-Telephone-Number-of-2nd-Family-Member-that-works-full-time-part-time-or-seasonally","className":"col-lg-4"},{"type":"text","label":"Employer Address of 2nd Family Member that works full time, part-time or seasonally","name":"Employer-address-of-2nd-Family-Member-that-works-full-time-part-time-or-seasonally","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Does any family member work for someone who pays in cash?","inline":true,"name":"Does-any-family-member-work-for-someone-who-pays-in-cash","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name of 1st Family Member Paid in Cash","name":"Name-of-1st-Family-Member-Paid-Cash","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer Name of 1st Family Member Paid in Cash","name":"Employer-Name-of-1st-Family-Member-paid-Cash","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer Address of 1st Family Member Paid in Cash","name":"Employer-Address-of-1st-Family-Member-paid-cash","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Employer Telephone Number of 1st Family Member paid in cash","name":"Employer-Telephone-Number-of-1st-Family-Member-paid-Cash","className":"col-md-6"},{"type":"text","label":"Name of 2nd Family Member Paid in Cash","name":"Name-of-2nd-Family-Member-Paid-Cash","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer Name of 2nd Family Member paid in cash","name":"Employer-Name-of-2nd-Family-Member-paid-cash","className":"col-md-6","subtype":"text"},{"type":"text","label":"Employer Address of 2nd Family Member paid in cash","name":"Employer-Address-of-2nd-Family-Member-paid-cash","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Employer Telephone Number of 2nd Family Member paid in cash","name":"Employer-Telephone-Number-of-2nd-Family-Member-paid-Cash","className":"col-md-6"},{"type":"radio-group","label":"Does any family member receive unemployment benefits, workers compensation, or severance pay?","inline":true,"name":"Does-any-family-member-receive-unemployment-benefits-workers-compensation-or-severance-pay","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Family Member Receiving Benefit</div>","name":"Family-Member-Receiving-Benefit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"T<span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">ype of Benefit Received</span>","name":"Type-of-Benefit-Received","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">A</span><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">mount of Benefit Received</span>","name":"Amount-of-Benefit-Received","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">E</span><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">mployer Name and A</span><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">ddress Benefits Received from</span>","name":"Employer-Name-and-Address-Benefits-Received-from","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Does Any Family Member Receive Child Support from the Child Support Recovery Unit?","inline":true,"name":"Does-Any-Family-Member-Receive-Child-Support-from-the-Child-Support-Recovery-Unit","className":"d-block","values":[{"label":" Yes","value":" yes, child support recovery unit"},{"label":"No","value":"No, Child support recovery unit"}]},{"type":"text","label":"Name of 1st Minor who Receives Child Support from the Child Support Recovery Unit","name":"Name-of-1st-Minor-who-Receives-Child-Support-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Absent Parent of the 1st Minor Receiving Child Support from the Child Support Recovery Unit","name":"Absent-Parent-of-the-1st-Minor-Receiving-Child-Support-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Child Support the 1st Minor Receives from the Child Support Recovery Unit","name":"Amount-of-Child-Support-the-1st-Minor-Receives-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 2nd Minor who Receives Child Support from the Child Support Recovery Unit","name":"Name-of-2nd-Minor-who-Receives-Child-Support-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Absent Parent of the 2nd Minor Receiving Child Support from the Child Support Recovery Unit","name":"Absent-Parent-of-the-2nd-Minor-Receiving-Child-Support-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Child Support the 2nd Minor Receives from the Child Support Recovery Unit","name":"Amount-of-Child-Support-the-2nd-Minor-Receives-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 3rd Minor who Receives Child Support from the Child Support Recovery Unit","name":"Name-of-3rd-Minor-who-Receives-Child-Support-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Absent Parent of the 3rd Minor Receiving Child Support from the Child Support Recovery Unit","name":"Absent-Parent-of-the-3rd-Minor-Receiving-Child-Support-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Child Support the 3rd Minor Receives from the Child Support Recovery Unit","name":"Amount-of-Child-Support-the-3rd-Minor-Receives-from-the-Child-Support-Recovery-Unit","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Does Any Family Member Receive Child Support Directly from the Absent Parent?","inline":true,"name":"Does-Any-Family-Member-Receive-Child-Support-Directly-from-the-Absent-Parent","className":"d-block","values":[{"label":" Yes","value":" yes, child support from absent parent"},{"label":"No","value":"No, child support from absent parent"}]},{"type":"text","label":"Name of 1st Minor who Receives Child Support Directly from the Absent Parent","name":"Name-of-1st-Minor-who-Receives-Child-Support-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<font color=\"#222222\" face=\"Poppins, sans-serif\"><span style=\"font-size: 16px;\">Name of Absent Parent of the 1st Minor Receiving Child Support Directly from the Absent Parent</span></font><br>","name":"Name-of-Absent-Parent-of-the-1st-Minor-Receiving-Child-Support-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Child Support the 1st Minor Receives Directly from the Absent Parent","name":"Amount-of-Child-Support-the-1st-Minor-Receives-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 2nd Minor who Receives Child Support Directly from the Absent Parent","name":"Name-of-2nd-Minor-who-Receives-Child-Support-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: Poppins, sans-serif; font-size: 16px;\">Name of Absent Parent of the 2nd Minor Receiving Child Support Directly from the Absent Parent</span>","name":"Name-of-Absent-Parent-of-the-2nd-Minor-Receiving-Child-Support-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Child Support the 2nd Minor Receives Directly from the Absent Parent","name":"Amount-of-Child-Support-the-2nd-Minor-Receives-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 3rd Minor who Receives Child Support Directly from the Absent Parent","name":"Name-of-3rd-Minor-who-Receives-Child-Support-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<span style=\"color: rgb(34, 34, 34); font-family: Poppins, sans-serif; font-size: 16px;\">Name of Absent Parent of the 3rd Minor Receiving Child Support Directly from the Absent Parent</span>","name":"Name-of-Absent-Parent-of-the-3rd-Minor-Receiving-Child-Support-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Child Support the 3rd Minor Receives Directly from the Absent Parent","name":"Amount-of-Child-Support-the-3rd-Minor-Receives-Directly-from-the-Absent-Parent","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Does Any Family Member Receive Alimony?","inline":true,"name":"Does-Any-Family-Member-Receive-Alimony","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of Family Member Receiving Alimony</div>","name":"Name-of-Family-Member-Receiving-Alimony","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">Amount of Alimony Received</span></div>","name":"Amount-of-Alimony","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">Former Spouse's Name of Person Receiving Alimony</span></div>","name":"Former-Spouses-Name-of-Person-Receiving-Alimony","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Does any member receive public assistance (KTAP and food stamps)?","inline":true,"name":"Does-any-member-receive-public-assistance-KTAP-and-food-stamps","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name of Family Member Receiving Public Assistance","name":"Name-of-Family-Member-Receiving-Public-Assistance","className":"col-md-6","subtype":"text"},{"type":"text","label":"Amount of Public Assistance Received","name":"Amount-of-Public-Assistance-Received","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Does any Family member receive Social Security or SSI benefits?","inline":true,"name":"Does-any-Family-member-receive-Social-Security-or-SSI-benefits","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"file","label":"If a Family Member Receives Social Security or SSI benefits please attach a copy of the award letter for each member listed below","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Attached-Award--Letter-for-Social-Security-or-SSI-benefits","subtype":"file","multiple":true,"className":"d-block"},{"type":"text","label":"Name of 1st Family Member Receiving Social Security or SSI benefits","name":"Name-of-1st-Family-Member-Receiving-Social-Security-or-SSI-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Social Security or SSI benefits the 1st Family Member is receiving","name":"Amount-of-Social-Security-or-SSI-benefits-the-1st-Family-Member-is-receiving","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Social Security number of 1st Family Member receiving Social Security benefits","placeholder":"xxx-xx-xxxx","name":"Social-Security-number-of-1st-Family-Member-receiving-Social-Security-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 2nd Family Member Receiving Social Security or SSI benefits","name":"Name-of-2nd-Family-Member-Receiving-Social-Security-or-SSI-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Social Security or SSI benefits the 2nd Family Member is receiving","name":"Amount-of-Social-Security-or-SSI-benefits-the-2nd-Family-Member-is-receiving","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Social Security number of 2nd Family Member receiving Social Security benefits","placeholder":"xxx-xx-xxxx","name":"Social-Security-number-of-2nd-Family-Member-receiving-Social-Security-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 3rd Family Member Receiving Social Security or SSI benefits","name":"Name-of-3rd-Family-Member-Receiving-Social-Security-or-SSI-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Social Security or SSI benefits the 3rd Family Member is receiving","name":"Amount-of-Social-Security-or-SSI-benefits-the-3rd-Family-Member-is-receiving","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Social Security number of 3rd Family Member receiving Social Security benefits","placeholder":"xxx-xx-xxxx","name":"Social-Security-number-of-3rd-Family-Member-receiving-Social-Security-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Name of 4th Family Member Receiving Social Security or SSI benefits","name":"Name-of-4th-Family-Member-Receiving-Social-Security-or-SSI-benefits","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of Social Security or SSI benefits the 4th Family Member is receiving","name":"Amount-of-Social-Security-or-SSI-benefits-the-4th-Family-Member-is-receiving","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Social Security number of 4th Family Member receiving Social Security benefits","placeholder":"xxx-xx-xxxx","name":"Social-Security-number-of-4th-Family-Member-receiving-Social-Security-benefits","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"If a family member receives Social Security of SSI benefits, do they also have a Part D Medicare drug plan?","inline":true,"name":"do-recipients-have-a-Part-D-Medicare-drug-plan","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>If they do receive a Part D Medicare drug Plan, who pays the premium and what a<span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">mount?</span></div>","name":"If-they-do-receive-a-Part-D-Medicare-drug-Plan-who-pays-the-premium-and-what-amount","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"<div>Does any family member receive income from a pension or annuity?</div>","inline":true,"name":"Does-any-family-member-receive-income-from-a-pension-or-annuity","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name of family member receiving pension or annuity","name":"Name-of-family-member-receiving-pension-or-annuity","className":"col-md-6","subtype":"text"},{"type":"text","label":"Amount of pension or annuity received","name":"Amount-of-pension-or-annuity-received","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"<div>Type of pension/annuity received</div>","name":"Type-of-pensionannuity-received","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Pension/annuity <span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">claim number</span></div>","name":"Pensionannuity-claim-number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address where pension/annuity received from","name":"Address-where-pension-annuity-received-from","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<div>Does any family member receive regular contributions from organizations or individuals not living in the unit?</div>","inline":true,"name":"Does-any-family-member-receive-regular-contributions-from-organizations-or-individuals-not-living-in-the-unit","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Contribution Amount</div>","name":"Contribution-Amount","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Name of family member who provides regular contributions</div>","name":"Name-of-family-member-who-provides-regular-contributions","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name and address of contributing organization or individual","name":"Name-and-address-of-contributing-organization-or-individual","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Did any family member file a federal income tax return last year?","inline":true,"name":"Did-any-family-member-file-a-federal-income-tax-return-last-year","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"file","label":"If a family member filed a federal income tax last year, please upload the tax return","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Federal-Income-Tax","subtype":"file","multiple":true,"className":"d-block"},{"type":"radio-group","label":"<div>Does any family member receive income from assets that include interest on checking or savings accounts, interest and dividends from certificates of deposit, stocks or bonds, or any income from rental property?</div>","inline":true,"name":"Does-any-family-member-receive-income-from-assets-that-include-interest-on-checking-or-savings-accounts-interest-and-dividends-from-certificates-of-deposit-stocks-or-bonds-or-any-income-from-rental-property","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of family member receiving income and type of asset</div>","name":"Name-of-family-member-receiving-income-and-type-of-asset","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Amount of income and interest received</div>","name":"Amount-of-income-and-interest-received","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"<div>Do any family members own a business or are self-employed?</div>","inline":true,"name":"Do-any-family-members-own-a-business-or-are-self-employed","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>If yes, provide the family member's name</div>","name":"If-yes-provide-the-family-members-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Business Owned","name":"Name-of-Business-Owned","className":"col-md-6","subtype":"text"},{"type":"text","label":"Business Address of Business owned","name":"Business-Address-of-Business-owned","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<div>Does any Family member receive any type of military pay/allotment (including the Coast Guard and Reserve Units)?</div>","inline":true,"name":"Does-any-Family-member-receive-any-type-of-military-pay-allotment-including-the-Coast-Guard-and-Reserve-Units","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of Family member who receives military pay/allotment?</div>","name":"Name-of-Family-member-who-receives-military-payallotment","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div>Amount Family Member receives from Military pay/allotment</div>","name":"Amount-Family-Member-receives-from-Military-payallotment","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div>Please list all sources of payment or allotment received by family member.</div>","name":"Source-of-payment-or-allotment","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"<div>Does any family member receive money to pay bills from someone outside your household?</div>","inline":true,"name":"Does-any-family-member-receive-money-to-pay-bills-from-someone-outside-your-household","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of the family member who receives money to pay bills from someone outside your household</div>","name":"Name-of-the-family-member-who-receives-money-to-pay-bills-from-someone-outside-your-household","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Amount of income received from someone outside your household to pay bills.</div>","name":"Amount-of-income-received-from-someone-outside-your-household","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Name and address of the party paying the bills</div>","name":"Name-and-address-of-the-party-paying-the-bills","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Part D: Assets","className":"d-block"},{"type":"radio-group","label":"<div>Does any family member own or have any interest in any property (real estate, mobile home, and/or land)?</div>","inline":true,"name":"Does-any-family-member-own-or-have-any-interest-in-any-property-real-estate-mobile-home-and-or-land","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of the family member who owns or has interest in property</div>","name":"Name-of-the-family-member-who-owns-or-has-interest-in-property","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Value of property owned</div>","name":"Value-of-property-owned","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Real Estate Address</div>","name":"Real-Estate-Address","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<div>Has any family member sold or given away any property (real estate, mobile home, and/or land) in the last two years?</div>","inline":true,"name":"Has-any-family-member-sold-or-given-away-any-property-real-estate-mobile-home-andor-land-in-the-last-two-years","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Describe property sold or given away</div>","name":"Describe-property-sold-or-given-away","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<div>Does any family member own any stocks or bonds?</div>","inline":true,"name":"Does-any-family-member-own-any-stocks-or-bonds","className":"d-block","values":[{"label":" Yes","value":"  yes"},{"label":"  No","value":"  no"}]},{"type":"text","label":"Describe stocks and bonds owned","name":"Describe-stocks-and-bonds-owned","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"header","subtype":"h4","label":"Where Do All Family Members Bank?","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Name of 1st family member with a bank account","name":"Name-of-1st-family-member-with-a-bank-account","className":"col-md-6","subtype":"text"},{"type":"text","label":"Type of Account of 1st Family Member","name":"Type-of-Account-of-1st-Family-Member","className":"col-md-6","subtype":"text"},{"type":"text","label":"Account Number of 1st Family Member Account","name":"Account-Number-of-1st-Family-Member-Account","className":"col-md-6","subtype":"text"},{"type":"text","label":"Bank Name and Address used by 1st Family Member","name":"Bank-Name-and-Address-used-by-1st-Family-Member","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of 2nd family member with a bank account<br>","name":"Name-of-2nd-family-member-with-a-bank-account","className":"col-md-6","subtype":"text"},{"type":"text","label":"Type of Account of 2nd Family Member<br>","name":"Type-of-Account-of-2nd-Family-Member","className":"col-md-6","subtype":"text"},{"type":"text","label":"Account Number of 2nd Family Member Account","name":"Account-Number-of-2nd-Family-Member-Account","className":"col-md-6","subtype":"text"},{"type":"text","label":"Bank Name and Address used by 2nd Family Member","name":"Bank-Name-and-Address-used-by-2nd-Family-Member","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"<div>Does anyone in the household have a debit card account independent of a bank?  (Example: Chime, Rocket, CashApp, PayPal, Green Dot, or Venmo)</div>","inline":true,"name":"Does-anyone-in-the-household-have-a-debit-card-account-independent-of-a-bank--Example-Chime-Rocket-CashApp-PayPal-Green-Dot-or-Venmo","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"file","label":"Please provide the last six statements of the independent debit card account","description":"Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"last-6-independent-back-statements","subtype":"file","multiple":true,"className":"d-block"},{"type":"radio-group","label":"<div>Does any family member have any savings certificates, money market funds, or trust funds?</div>","inline":true,"name":"Does-any-family-member-have-any-savings-certificates-money-market-funds-or-trust-funds","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No ","value":" no"}]},{"type":"text","label":"<div>Please describe the savings certificate, money market funds or trust fund</div>","name":"Describe-the-savings-certificate-money-market-funds-or-trust-fund","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Does any family member have any type of retirement account (company, IRA, Keogh)?","inline":true,"name":"Does-any-family-member-have-any-type-of-retirement-account-company-IRA-Keogh","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Please describe the type of retirement account","name":"Please-describe-the-type-of-retirement-account","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"<div>Does any family member have any inheritances, lottery winnings, or lump sum payments?</div>","inline":true,"name":"Does-any-family-member-have-any-inheritances-lottery-winnings-or-lump-sum-payments","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Please describe any inheritances, lottery winnings, or lump sum payments","name":"Please-describe-any-inheritances-lottery-winnings-or-lump-sum-payments","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"<div>Does any family member have any life insurance policies?</div>","inline":true,"name":"Does-any-family-member-have-any-life-insurance-policies","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of 1st Family Member with an insurance policy</div>","name":"Name-of-1st-Family-Member-with-an-insurance-policy","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Insurance Policy Number for 1st family member</div>","name":"Insurance-Policy-Number-for-1st-family-member","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Insurance Policy Amount and Value for 1st Family Member</div>","name":"Insurance-Policy-Amount-and-Value-for-1st-Family-Member","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Agency Name of 1st Family Member's Life Insurance</div>","name":"Agency-Name-of-1st-Family-Members-Life-Insurance","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Agency Address for 1st Family Members Life Insurance</div>","name":"Agency-Address-for-1st-Family-Members-Life-Insurance","className":"d-block","subtype":"text"},{"type":"text","label":"Name of 2nd Family Member with an insurance policy<br>","name":"Name-of-2nd-Family-Member-with-an-insurance-policy","className":"col-md-6","subtype":"text"},{"type":"text","label":"Insurance Policy Number for 2nd family member<br>","name":"Insurance-Policy-Number-for-2nd-family-member","className":"col-md-6","subtype":"text"},{"type":"text","label":"Insurance Policy Amount and Value for 2nd Family Member<br>","name":"Insurance-Policy-Amount-and-Value-for-2nd-Family-Member","className":"col-md-6","subtype":"text"},{"type":"text","label":"Agency Name of 2nd Family Member's Life Insurance<br>","name":"Agency-Name-of-2nd-Family-Members-Life-Insurance","className":"col-md-6","subtype":"text"},{"type":"text","label":"Agency Address for 2nd Family Member's Life Insurance<br>","name":"Agency-Address-for-2nd-Family-Members-Life-Insurance","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Part E: Expenses","className":"d-block"},{"type":"radio-group","label":"<div>Does any family member have expenses for childcare of a child aged 12 years or younger?</div>","inline":true,"name":"Does-any-family-member-have-expenses-for-childcare-of-a-child-aged-12-years-or-younger","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of 1st Minor Child age 12 years or younger</div>","name":"Name-of-1st-Minor-Child-age-12-years-or-younger","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div>1st Minor Childcare Provider's Name</div>","name":"1st-Minor-Childcare-Providers-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div>1st Minor Childcare Provider's Telephone Number</div>","name":"1st-Minor-Childcare-Providers-Telephone-Number","className":"col-lg-4","subtype":"text"},{"type":"text","label":"<div>1st Minor Childcare Provider's Address</div>","name":"1st-Minor-Childcare-Providers-Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">1st minor Child's </span>Monthly Childcare Cost to You</div>","name":"First-Minor-Monthly-Childcare-Cost-to-You","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of 2nd Minor Child age 12 years or younger","name":"Name-of-2nd-Minor-Child-age-12-years-or-younger","className":"col-lg-4","subtype":"text"},{"type":"text","label":"2nd Minor Childcare Provider's Name","name":"2nd-Minor-Childcare-Providers-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"2nd Minor Childcare Provider's Telephone Number","name":"2nd-Minor-Childcare-Providers-Telephone-Number","className":"col-lg-4","subtype":"text"},{"type":"text","label":"2nd Minor Childcare Provider's Address","name":"2nd-Minor-Childcare-Providers-Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"<span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">2nd Minor Child's </span>Monthly Childcare Cost to You","name":"2nd-Minor-Childs-Monthly-Childcare-Cost-to-You","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"<div>Is any portion of your childcare expenses reimbursed from an outside agency or person?</div>","inline":true,"name":"Is-any-portion-of-your-childcare-expenses-reimbursed-from-an-outside-agency-or-person","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of agency of person who reimburses childcare expenses</div>","name":"Name-of-agency-of-person-who-reimburses-childcare-expenses","className":"d-block","subtype":"text"},{"type":"text","label":"Address of agency of person who reimburses childcare expenses<br>","name":"Address-of-agency-of-person-who-reimburses-childcare-expenses","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<div>Do you pay a care attendant or for any equipment for any member(s) with disabilities that is necessary to permit that person or someone else in the family to work?</div>","inline":true,"name":"Do-you-pay-a-care-attendant-or-for-any-equipment-for-any-members-with-disabilities-that-is-necessary-to-permit-that-person-or-someone-else-in-the-family-to-work","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Care Attendant's Name</div>","name":"Care-Attendants-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Care Attendant's Telephone Number</div>","name":"Care-Attendants-Telephone-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Care Attendant's Address</div>","name":"Care-Attendants-Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"<div>Monthly cost to you for the care attendant and/or the equipment?</div>","name":"monthly-cost-to-you-for-the-care-attendant-andor-the-equipment","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"<div><b>Part E for Elderly or Disabled Families Only - Complete the following questions in this part of Part E only if the head of the family or spouse is 62 years of age or older, or if the head of Household or spouse is a person with a disability.</b></div>","className":"d-block"},{"type":"radio-group","label":"<div>Do you have Medicare?</div>","inline":true,"name":"Do-you-have-Medicare","className":"col-md-6","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"If you have Medicare, what is your monthly premium?","name":"If-you-have-Medicare-what-is-your-monthly-premium","className":"col-md-6","subtype":"text"},{"type":"radio-group","label":"Do you pay for any other kind of medical insurance?","inline":true,"name":"Do-you-pay-for-any-other-kind-of-medical-insurance","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"Name Medical Insurance Company:","name":"Name-Medical-Insurance-Company","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of Medical Insurance Agent","name":"Name-of-Medical-Insurance-Agent","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address of Medical Insurance Company:","name":"Address-of-Medical-Insurance-Company","className":"d-block","subtype":"text"},{"type":"text","label":"<div>Medical Insurance Agent’s Telephone Number:</div>","name":"Medical-Insurance-Agents-Telephone-Number","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Medical Insurance Monthly Premium Amount","name":"Medical-Insurance-Monthly-Premium-Amount","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Medical Insurance Policy Number:","name":"Medical-Insurance-Policy-Number","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Do you have any outstanding medical bills that you are paying?","inline":true,"name":"Do-you-have-any-outstanding-medical-bills-that-you-are-paying","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"<div>Name of First Provider with outstanding medical bills</div>","name":"Name-of-First-Provider-with-outstanding-medical-bills","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"<div>Telephone Number of First Provider with outstanding medical bills</div>","name":"Telephone-Number-of-First-Provider-with-outstanding-medical-bills","className":"col-md-6"},{"type":"text","label":"<div>Address of First Provider with outstanding medical bills</div>","name":"Address-of-First-Provider-with-outstanding-medical-bills","className":"d-block","subtype":"text"},{"type":"text","label":"Name of Second Provider with outstanding medical bills","name":"Name-of-Second-Provider-with-outstanding-medical-bills","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of Second Provider with outstanding medical bills","name":"Telephone-Number-of-Second-Provider-with-outstanding-medical-bills","className":"col-md-6"},{"type":"text","label":"Address of Second Provider with outstanding medical bills","name":"Address-of-Second-Provider-with-outstanding-medical-bills","className":"d-block","subtype":"text"},{"type":"radio-group","label":"<div>Do you expect to incur medical expenses in the next 12 months that will not be covered by insurance?</div>","inline":true,"name":"Do-you-expect-to-incur-medical-expenses-in-the-next-12-months-that-will-not-be-covered-by-insurance","className":"d-block","values":[{"label":" Yes","value":" yes"},{"label":" No","value":" no"}]},{"type":"text","label":"List anticipated medical expenses not covered by insurance:","name":"List-anticipated-medical-expenses-not-covered-by-insurance","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h3","label":"Part F: References<br>","className":"d-block"},{"type":"header","subtype":"h4","label":"Note: Personal references are not required for Housing Choice Voucher Program (HCVP) (HUD) applicants.","className":"d-block"},{"type":"text","label":"Name of your current landlord or person with whom you may be living:","name":"Name-of-your-current-landlord-or-person-with-whom-you-may-be-living","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number of your current landlord or person with whom you may be living:","name":"Telephone-Number-of-your-current-landlord-or-person-with-whom-you-may-be-living","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address of your current landlord or person with whom you may be living:","name":"Address-of-your-current-landlord-or-person-with-whom-you-may-be-living","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"header","subtype":"h4","label":"Please list below four (4) personal references with names, addresses, and phone numbers where they can be reached between the hours of 8:30 AM and 4:30 PM on weekdays.<br>These references must not be related to you or your children in any way.<br>They must be reliable adults who live in this eastern Kentucky area if possible.<br>","className":"d-block"},{"type":"header","subtype":"h4","label":"Personal References:","className":"d-block"},{"type":"text","label":"Name of 1st Personal Reference","name":"Name-of-1st-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","label":"Street Address of 1st Personal Reference","name":"Street-Address-of-1st-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of 1st Personal Reference","name":"Telephone-Number-of-1st-Personal-Reference","className":"col-md-6"},{"type":"text","label":"1st Reference - Number of Years Known:","name":"1st-Reference---Number-of-Years-Known","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of 2nd Personal Reference","name":"Name-of-2nd-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","label":"Street Address of 2nd Personal Reference","name":"Street-Address-of-2nd-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of 2nd Personal Reference","name":"Telephone-Number-of-2nd-Personal-Reference","className":"col-md-6"},{"type":"text","label":"2nd Reference - Number of Years Known","name":"2nd-Reference---Number-of-Years-Known","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of 3rd Personal Reference","name":"Name-of-3rd-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","label":"Street Address of 3rd Personal Reference","name":"Street-Address-of-3rd-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number of 3rd Personal Reference","name":"Telephone-Number-of-3rd-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","label":"3rd Reference - Number of Years Known","name":"3rd-Reference---Number-of-Years-Known","className":"col-md-6","subtype":"text"},{"type":"text","label":"Name of 4th Personal Reference<br>","name":"Name-of-4th-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","label":"Street Address of 4th Personal Reference","name":"Street-Address-of-4th-Personal-Reference","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of 4th Personal Reference","name":"Telephone-Number-of-4th-Personal-Reference","className":"col-md-6"},{"type":"text","label":"4th Reference - Number of Years Known","name":"4th-Reference---Number-of-Years-Known","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"header","subtype":"h2","label":"Landlords (Present & Past)<br>Please List Your Last Five Place(s) Of Residency For The Past (5) Years:<br>","className":"d-block"},{"type":"text","label":"Address of Current Place of Residence","name":"Address-of-Current-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Telephone Number of Current Landlord or Manager","name":"Telephone-Number-of-Current-Landlord-or-Manager","className":"col-md-6"},{"type":"text","label":"Address of 2nd Most Recent Place of Residence","name":"Address-of-2nd-most-recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number of Landlord or Manager of 2nd Most Recent Place of Residence","name":"Telephone-Number-of-Landlord-or-Manager-of-2nd-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address of 3rd Most Recent Place of Residence","name":"Address-of-3rd-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number of Landlord or Manager of 3rd Most Recent Place of Residence","name":"Telephone-Number-of-Landlord-or-Manager-of-3rd-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address of 4th Most Recent Place of Residence","name":"Address-of-4th-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number of Landlord or Manager of 4th Most Recent Place of Residence","name":"Telephone-Number-of-Landlord-or-Manager-of-4th-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Address of 5th Most Recent Place of Residence","name":"Address-of-5th-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"text","label":"Telephone Number of Landlord or Manager of 5th Most Recent Place of Residence","name":"Telephone-Number-of-Landlord-or-Manager-of-5th-Most-Recent-Place-of-Residence","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Applicant/Participant Certification","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div>I certify that the information given to the Floyd County Housing Authority on family composition and characteristics, drug and criminal activity, income, assets, and expenses, is accurate and complete. I understand that false statements or information are punishable under federal law and grounds for denial or termination of housing assistance. I understand that I am required to report in writing all changes in family composition, income, assets, and expenses of any family member(s) to the Floyd County Housing Authority as soon as the change occurs. I understand that all changes in family composition due to birth, adoption, or court-awarded custody must be reported in writing to the Floyd County Housing Authority as soon as the change occurs. Further, no one is permitted to move into my unit without prior written approval of the Floyd County Housing Authority, my landlord. I understand that it is my responsibility to provide documents at the request of the PHA. I understand that any attempt to obtain public housing, any rent subsidy or rent reduction by false information, impersonation, failure to disclose, or other fraud, and any assistance to such an attempt is a crime.</div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div>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.</div>","className":"d-block"},{"type":"text","required":true,"label":"Signature of Head of Household:","placeholder":"By typing your name, you are signing this document.","name":"Signature-of-Head-of-Household","className":"d-block","subtype":"text"},{"type":"text","label":"Signature of Spouse/Co-Head of Household","placeholder":"By typing your name, you are signing this document.","name":"Signature-of-Spouse-Co-Head-of-Household","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"}]