Tài liệu HAJC APPLICATION PROCEDURES pdf

HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC)
Mailing Address: Post Office Box 2109  Physical Address: 5210 Kuhn Street
Port Townsend, WA 98368
Phone (360) 379-2565  Fax (360) 379-2561

HAJC APPLICATION PROCEDURES

1) Applications will be accepted via mail or over the counter ONLY. Submit original
application along with:

 Declaration of citizenship form, enclosed, for each adult in the household.

A copy of each person’s social security card, (over the age of six) must
also accompany each application.

Applications must be signed by each person over the age of 18.

2) Application is processed and you are placed on the waiting list.

3) A letter will be sent to applicant to inform them that placement on the waiting list has
occurred.

4) Placement on the waiting list may be reviewed on our website at
www.jeffersonhousing.org
. Allow 4 weeks for this information to appear on the webpage.

5) When applicant’s name comes up on the waiting list, applicant will be notified by MAIL.

6) APPLICANT IS RESPONSIBLE TO NOTIFY HAJC IN WRITING OF ANY
CHANGES OF ADDRESS, within 10 days.

7) If notification is returned from the post office due to insufficient address, applicant will be
removed from the waiting list. No further notification will be sent.

8) If notification is returned from the post office due to “Moved, left no forwarding address”
status, applicant will be removed from the waiting list. No further notification will be sent.

9) Section 8 waiting list only: Once every 6 months to 1 year, the Section 8 waiting list is
updated. If applicant does not respond to the request for updated information (Purge) within the
given time frame, applicant will be removed from the waiting list.

HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC)
5210 Kuhn Street  Port Townsend, Washington 98368
Phone (360) 379-2565  FAX (360) 379-2561

Eligibility Pre-Application Form



Housing Choice Voucher Program: Jefferson County


Applicant Information
Last Name First Name Middle
Mailing Address City State Zip
Street Address City State Zip
Home Tel. ( ) Mess. Tel. ( ) Work Tel.
( )

Household Members: Start with head of household, then list spouse/co-head, then minors, then any other adults.

Legal Name
Last, First, Middle Initial

Sex
M/F
Relationship
to Head
Social Security
Number
Date of Birth
Month/date/year
Place of Birth
City/State
1
Head

2
3
4
5
6
7


Optional Information for Statistical Purposes Only (Please check all that apply):

Head of Household:  African American/Black  Caucasian/White  Asian  Pacific Islander
 Native American/Alaskan Native  Multi-Racial  Hispanic

Spouse/Other Adult:  African American/Black  Caucasian/White  Asian  Pacific Islander
 Native American/Alaskan Native  Multi-Racial  Hispanic

Children:  African American/Black  Caucasian/White  Asian  Pacific Islander
(mark all that apply)  Native American/Alaskan Native  Multi-Racial  Hispanic

Are you a Veteran?  Yes  No
Are you Homeless?  Yes  No


1. Have you or anyone in your household ever used any other name(s)?

Yes

No
If yes, what name(s) and who used it? ____________________________________________

2. Have you or anyone in your household ever used a social security number other than those
listed?

Yes

No
If yes, what number(s) and who used it? ___________________________________________

The following are types of income that must be reported:

¾ Wages, Tips, Salary
¾ TANF
¾ VA Benefits
¾ Social Security, SSI, SSDI
¾ Unemployment
¾ Pension or retirement
¾ Worker’s Compensation
¾ Child Support
¾ Per Capita payments
¾ Interest income from bank accounts, investments etc.
¾ Income from real estate
¾ Contributions from family members (this includes regular payments of bills, purchase of products such as
diapers, food etc.)


INCOME INFORMATION: Please list the source and amount of all current income received by all
household members, including your children and yourself.


Household Member
Name
Income Source
Monthly
Amount
Hourly Wage # of Hours per week
$
$
$
$
$

$
$
$

ATTENTION APPLICANT: You are responsible for maintaining current and accurate
application information. You are required to notify the Housing Authority of Jefferson
County in writing of any change in address; income and/or household composition (please
use “Change of Circumstance” form available in the lobby). If we cannot contact you at
the address listed on this application or an updated address, your name will be
removed from the waiting list, and you will have to re-apply.

Are you or any other members of your household disabled? Yes _____ No _____
If yes, which member(s) are disabled?
__________________________________ __________________________________
__________________________________ __________________________________

Do you or any member of your family require any of the following accommodations or unit
modifications?

• Wheelchair accessible unit
• Sensory impaired accessible unit
• Ground floor unit (no stairs)
• Other physical adaptations (grab bars etc.)
• Service/Companion Animal
• Copy mail to Case Manager
• Large type documents
• Live-in aide/caregiver
• Payee (please list name) ___________________________
• Other _______________________________________________________

The Housing Authority of Jefferson County complies with the Fair Housing Act and provides
reasonable accommodations and modifications to persons with disabilities.


Special Assistance

1) Do you need this document translated into a language other than English?
If yes, which language? _______________________

a) Kailangan nyo po ba ang ibang pananalita o linguwahe para isalin itong dokumentong ito maliban sa
Ingles? Kung oo, ano po bang pananalita o linguwahe? ______________________________

b) ¿Necesita usted que este documento sea traducido a otro idioma diferente que en ingles?
¿Si es asi, que idioma? ________________________________
c)
Bạn có cần tài liệu này ðuợc dịch qua ngôn ngữ nào khác ngoài tiếng Anh không?
Nếu có, ngôn ngữ nào? _______________________


2) Do you need help communicating with the Housing Authority of Jefferson County in a language other than
English? If yes, which language? _____________________

a) Kailangan nyo po ba ang tulong para makausap ang Housing Authority of Jefferson County sa ibang
pananalita o linguwahe maliban sa Ingles? Kung oo, ano po bang pananalita o inguwahe?
______________________

b) ¿
Necesita usted comunicarse con la autoridad de vivienda de Jefferson County en otra idioma que no sea
el ingles? ¿Si es asi, que idioma? ________________________________

c) Bạn có cần thông dịch khi giao tiếp với Housing Authority of Jefferson County không?
Nếu có, ngôn ngữ nào? _______________

3) Do you need sign language assistance for your appointments with the Housing Authority of Jefferson County?
Yes ________ No ________

If you want the Housing Authority of Jefferson County to speak with your case manager,
friend or relative about your housing status, you must first complete and sign the
following release. Remember to write in the name of the person that you are allowing us
to speak with and sign the bottom of the release.

RELEASE OF INFORMATION


I, ______________________, give the Housing Authority of Jefferson County permission to

CLIENT NAME (print)

speak with
_______________________________________________
regarding my housing application.
(Name of Person or Organization)

I voluntarily allow the above named parties to obtain and/or release information regarding my
housing application. I understand that this information will not be forwarded to anyone other
than the parties listed above, without my written permission. I understand that I can revoke this
release at any time. This consent form expires 15 months after signing.


_________________________________ _______________ _____________________
Applicant’s Signature Date of Birth Social Security Number

It is the responsibility of all clients to provide accurate and complete information to HAJC. If you
do not provide all required information or if you submit false information to HAJC you may be

charged with federal fraud. (Title 18, Section 1001 of the U.S. Code)

I CERTIFY THAT ALL INFORMATION I HAVE PROVIDED IS COMPLETE AND ACCURATE.

I understand that any misrepresentation of information or failure to disclose information
requested on this application may disqualify me from consideration for admission or participation,
and may be grounds for eviction or termination of assistance.

I understand that this is not a contract and does not bind either party. The information contained
in this application is true, and complete to the best of my knowledge. I have no objection to
inquiries being made for the purpose of verifying the statements made herein.



_____________________________________ ______________ ______________________________________ ____________
Head Of Household Signature Date Co-Applicant Signature Date