ACRA - Durham
1017 Cook Rd
Durham, NC 27713

Application for Housing Assistance

Note: This is a preliminary application. For your security, please DO NOT submit copies of your Social Security Card or Photo ID through this website. We will request those documents securely at a later stage in the application process.

Website

Applicant Information Property Name:

First Name:

Last Name:

Current Address:

City, State, Zip:

Birth Date:

Home Phone:

Work/Cell Phone:

Email Address:

Gender (Optional):

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

Housing Questionnaire

2. Are you 62 or older as of January 31, 2010, and 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-time 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 type?

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:

Certification & Signature

Confidentiality Statement: All information provided in this application is strictly confidential and will be used solely for the purpose of determining eligibility for housing assistance.

Application Process: This is a preliminary application. After review, you will be contacted to schedule an interview where you will be required to provide formal identification (Picture ID) and Social Security Cards.

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information may result in the rejection of my application.

Electronic Signature (Type Full Name):

Date: