Pre-Application for Public Housing

Terrace Gardens Apartments · 85 West Church Street, Newark, OH 43055
(740) 349-9260 · FAX (740) 345-7781

Both sides of this application must be filled out completely in order to be able to process your application. If you have any questions please ask for assistance. Assistance will be provided. Completed applications will be entered on the waiting list in the order received. The waiting list will then be sorted according to applicant admission preferences.

Head of household

Name of Head

City and State of Birth

Date of Birth

Social Security Number

Sex

Current mailing address

Phone number

For statistical purposes only

This information is required for statistical purposes so that the Department of HUD may determine the degree to which its programs are utilized by minority families.

Race of Head

African American/Black Asian or Pacific Islander Caucasian/White Native American / Alaskan Native

Ethnicity of Head

Hispanic/Latino Non-Hispanic/Non-Latino

Household questions

If yes, under what name?

Co-head of household

Name of Co-Head

City and State of Birth

Date of Birth

Social Security Number

Sex

Family income information

Please list the source and amount of all current income received by all family members including yourself. Include all earnings and benefits received from OWF/TANF, VA, Social Security, SSI, SSDI, Unemployment, Worker's Compensation, Pension, etc.

Family income: member name, income source, amount and frequency
Family member name	Income source	Amount $	Frequency
Row 1 family member name	Row 1 income source	Row 1 amount	WeekMonthYear
Row 2 family member name	Row 2 income source	Row 2 amount	WeekMonthYear
Row 3 family member name	Row 3 income source	Row 3 amount	WeekMonthYear
Row 4 family member name	Row 4 income source	Row 4 amount	WeekMonthYear
Row 5 family member name	Row 5 income source	Row 5 amount	WeekMonthYear

Landlord information

Current landlord

Current landlord's name

Phone number

Address

Move-in date

Former landlord

Former landlord's name

Phone number

Address

Move-in date

Move-out date

Terrace Gardens Apartments will be contacting former landlords for the period three years from the date of application.

Certification

I/we certify that the statements on this application are true to the best of my/our knowledge and belief and understand that you will be verified. I/we authorize the release of information to Terrace Gardens Apartments by my/our employer(s), the Department of Job and Family Services, the Social Security Administration, and/or other business or government agencies. I/we understand that any false statement made on this application will cause me/us to be disqualified for admission. Also, by signing this form I/we give permission to Terrace Gardens Apartments to conduct a criminal background, credit, and rental history check.

Applicant signature

Date

Co-applicant signature

Date