GRIMES, IA 50111
(515) 986-1882 phone / (515) 986-1883
fax
PLEASE PRINT APPLICATION TO MAIL OR FAX. Only
complete applications will be accepted.
If
you need special accommodations completing this application please contact
CIRHA AT (515) 986-1882.
NAME
PHYSICAL ADDRESS
CITY STATE ZIP
MAILING ADDRESS
CITY STATE ZIP
HOME PHONE
WORK PHONE
YOU ARE RESPONSIBLE FOR REPORTING ADDRESS CHANGES TO THE
CIRHA OFFICE.
YOUR
PREVIOUS TWO (2) ADDRESSES AND DATES YOU LIVED THERE:
________ to ________
Address ____________________________________________
________ to ________
Address ____________________________________________
FAMILY MEMBERS: List all persons including yourself who will
reside in the rental unit while you are on this program
RELATIONSHIP BIRTH SOCIAL
FULL NAME TO HEAD DATE
SECURITY # SEX
1.)
__________________________ Head
of Household ______________
_________________ M
F
2.)
__________________________
______________
______________ _________________ M
F
3.)
__________________________
______________
______________
_________________ M F
4.)
__________________________
______________
______________ _________________ M
F
5.)
__________________________
______________
______________ _________________ M
F
Are you expecting a baby ?: Yes
No Due Date:
________________________
SOURCES
OF INCOME:
List FIP, TANF, welfare, employment, Social Security, SSI,
pensions, disability compensation, unemployment compensation, alimony, child
support, Armed Forces Reserves, etc…
HOUSEHOLD MEMBER SOURCES OF INCOME GROSS EARNINGS
$ PER
$ PER
$ PER
POLICE
RECORD CHECK:
Central Iowa
Regional Housing Authority will conduct a review of each applicant’s criminal
record.
Has
any household member ever been charged with any type of sexual offense? Yes No
If yes, whom
_________________________________
Dates ________________________
State and
Has
any household member been charged with a drug related crime? Yes No
If yes, whom
_________________________________
Dates ________________________
State and
Has
any household member been charged with a crime causing injury to another
person? Yes No
If yes, whom __________________________________ Dates
________________________
State and
PROGRAM
INFORMATION:
Have you
previously participated in a rental assistance program? Yes No
If yes, with what Housing Authority?
________________________________________________
(You may choose to be on both lists.)
|
SECTION 8 VOUCHER YES (circle one) NO Choose Section 8 if: 1)
You wish to receive rental assistance in a unit you
would find yourself (this might include the unit where you currently live if
it meets Section 8 criteria). 2)
You wish to live in the counties of Boone, Dallas,
Jasper, Madison, Marion or Story in any towns except Ames, Knoxville, or
Pella. REQUIRED! Attach a copy of one of the following items so CIRHA may determine proper preference for the Section 8 waiting
list: 1) Your current lease 2) Utility bill 3) Valid driver’s license or
state issued ID of Head of Household. 4) A piece of mail addressed to
the Head of Household from a state or
federal agency. Also indicate if either of the following applies to
you in determining proper preference: 1)
Do you claim the preference of elderly (age 62 and
older), disabled or handicapped Head of Household? YES NO 2)
Do you claim the preference of near elderly (age 50 to
61) Head of Household: YES NO Section
8 applicants may expect a 6 month to 5 year wait depending on preference. |
PUBLIC HOUSING Owned by
CIRHA YES (circle one) NO Choose Public Housing if: 1)
You would prefer to have CIRHA offer you an existing
unit rather than having to find one yourself. 2)
You are willing to move to a unit owned by CIRHA in one
of the towns listed below. (NOTE: Do not choose Public Housing if you do not
wish to live in one of the towns listed below.) REQUIRED! Circle YES or NO for the counties below: (The towns of Boone and
Madrid) (The towns of Perry and
Redfield) (The towns of Colfax and
Newton) (The town of Melcher/Dallas) Do not write in additional towns or counties. The towns listed are where CIRHA owns
Public Housing. (For other towns and
counties choose the Section 8 program on left side of page.) Public Housing applicants may
expect approximate 3 month wait depending on vacancies. |
After CIRHA receives your
application you will receive a confirmation letter listing each of the waiting
lists you have selected.
Once your name reaches the
top of a waiting list you will be contacted by mail to schedule an enrollment
interview.
YOU MUST
INFORM CIRHA IN WRITING IF YOUR ADDRESS CHANGES !!!
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APPLICANT
CERTIFICATION:
ALL APPLICATION INFORMATION
IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
APPLICANT SIGNATURE: DATE:
CO-APPLICANT SIGNATURE: DATE:
WARNING: Section 1001 of Title
18 of the U.S. code makes it a criminal offense to make willful false
statements of misrepresentation to any Department or agency of the U.S. as to
any matter within its jurisdiction.
Racial group identification
(Used for statistical purposes only).
White _____ Hispanic _____ Native American _____
Other _____
African American _____ Asian
_____ Prefer not to answer
_____