City of Tucson Community Services Department -- Public Housing Program

City Of Tucson Public Housing Program Application Form

Community Services Department
City of Tucson
(520) 791-4616

Your Name :
First MI Last

Mailing Address :
Street Apt #
City State Zip

Phone : home or message number

Social Security No. : - -
Pursuant to the code of Federal regulations: Social Security numbers of household members are mandatory.

Family Composition:

Name	Age	Date of Birth	Relationship to you	Sex
		/ /	Head of Household	Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female
		/ /		Male Female

Yearly gross income of the household: $

Number of people in the household:

Is the head of household or the spouse elderly (62 years or more)?: Yes No

Is the head of household or the spouse disabled?: Yes No

Race and ethnicity description for the head of household.
Race :
White Black Indian American/Alaska Native Asian/Pacific Islander
Ethnicity :
Hispanic Non-Hispanic

All information given on this form is confidential and will not be released to anyone without your written consent.
Final eligibility will be determined before housing assistance is available for you.
All adult family members will be screened for tenancy considering information provided through landlord references, credit reports and criminal background investigations.

I certify that I have provided accurate and complete information regarding family composition, to the best of my knowledge and belief. I understand that providing false statements and/or information is punishable under federal law and is grounds for denial of program assistance or termination of tenancy.

I agree with the above certification. I do not agree with the above certification.

If you should require an accommodation or alternative arrangements due to a disability, please call (520) 791-4616.

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