ACRA - Durham
1017 Cook Rd
Durham, NC 27713
APPLICATION FOR HOUSING ASSISTANCE
Applicant Information
Property Name:
New Blevins
Fitts-Powell
Other
Applicant Name:
Current Address:
City, State, Zip:
Birth Date:
Home Phone:
Work Phone:
Gender (Optional):
Select...
Male
Female
Other
Place of Birth (City & State):
1. Household Composition
Please list each person who would occupy the premise with you:
Last Name
First Name
D.O.B.
Gender
Relationship
Income Source
Action
+ Add Household Member
Housing Questionnaire
2. Are you 62 or older as of January 31, 2010, and who do not have a SSN number?
Yes
No
If yes, were you receiving HUD rental assistance at another location on January 31, 2010?
Yes
No
3. Are you or any other occupant of the household, a part or full-time student?
Yes
No
If yes, are you enrolled as a student at an institute of higher learning?
Yes
No
4. Do you anticipate any change in your household composition (i.e. Pregnancy)?
Yes
No
If yes, please give an anticipated date of change:
5. Are you a part of any Military branch?
Yes
No
If yes, which status applies?
Active
Reserved
Veteran
6. Do you plan to bring a pet?
Yes
No
Is it a service animal?
Yes
No
7. Are you a qualified individual with a disability?
Yes
No
8. How many bedrooms are you requesting?
One
Two
Three
9. Would you require an accessible unit?
Yes
No
If yes, which would you need?
Mobility
Visual
Audio
10. Have you ever been evicted from a federal subsidized housing unit?
Yes
No
If yes, please provide details:
Name of Property:
Phone Number:
Name of Manager:
Date of eviction:
