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- HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC)
Mailing Address: Post Office Box 2109 Physical Address: 5210 Kuhn Street
Port Townsend, WA 98368
Phone (360) 379-2565 Fax (360) 379-2561
HAJC APPLICATION PROCEDURES
1) Applications will be accepted via mail or over the counter ONLY. Submit original
application along with:
Declaration of citizenship form, enclosed, for each adult in the household.
A copy of each person’s social security card, (over the age of six) must
also accompany each application.
Applications must be signed by each person over the age of 18.
2) Application is processed and you are placed on the waiting list.
3) A letter will be sent to applicant to inform them that placement on the waiting list has
occurred.
4) Placement on the waiting list may be reviewed on our website at
www.jeffersonhousing.org. Allow 4 weeks for this information to appear on the webpage.
5) When applicant’s name comes up on the waiting list, applicant will be notified by MAIL.
6) APPLICANT IS RESPONSIBLE TO NOTIFY HAJC IN WRITING OF ANY
CHANGES OF ADDRESS, within 10 days.
7) If notification is returned from the post office due to insufficient address, applicant will be
removed from the waiting list. No further notification will be sent.
8) If notification is returned from the post office due to “Moved, left no forwarding address”
status, applicant will be removed from the waiting list. No further notification will be sent.
9) Section 8 waiting list only: Once every 6 months to 1 year, the Section 8 waiting list is
updated. If applicant does not respond to the request for updated information (Purge) within the
given time frame, applicant will be removed from the waiting list.
- HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC)
5210 Kuhn Street Port Townsend, Washington 98368
Phone (360) 379-2565 FAX (360) 379-2561
Eligibility Pre-Application Form
Housing Choice Voucher Program: Jefferson County
Applicant Information
Last Name First Name Middle
Mailing Address City State Zip
Street Address City State Zip
Home Tel. ( ) Mess. Tel. ( ) Work Tel. ( )
Household Members: Start with head of household, then list spouse/co-head, then minors, then any other adults.
Legal Name Sex Relationship Social Security Date of Birth Place of Birth
Last, First, Middle Initial M/F to Head Number Month/date/year City/State
1 Head
2
3
4
5
6
7
Optional Information for Statistical Purposes Only (Please check all that apply):
Head of Household: African American/Black Caucasian/White Asian Pacific Islander
Native American/Alaskan Native Multi-Racial Hispanic
Spouse/Other Adult: African American/Black Caucasian/White Asian Pacific Islander
Native American/Alaskan Native Multi-Racial Hispanic
Children: African American/Black Caucasian/White Asian Pacific Islander
(mark all that apply) Native American/Alaskan Native Multi-Racial Hispanic
Are you a Veteran? Yes No
Are you Homeless? Yes No
- 1. Have you or anyone in your household ever used any other name(s)? Yes No
If yes, what name(s) and who used it? ____________________________________________
2. Have you or anyone in your household ever used a social security number other than those
listed? Yes No
If yes, what number(s) and who used it? ___________________________________________
The following are types of income that must be reported:
Wages, Tips, Salary
TANF
VA Benefits
Social Security, SSI, SSDI
Unemployment
Pension or retirement
Worker’s Compensation
Child Support
Per Capita payments
Interest income from bank accounts, investments etc.
Income from real estate
Contributions from family members (this includes regular payments of bills, purchase of products such as
diapers, food etc.)
INCOME INFORMATION: Please list the source and amount of all current income received by all
household members, including your children and yourself.
Monthly
Household Member Income Source Hourly Wage # of Hours per week
Amount
Name
$
$
$
$
$
$
$
$
ATTENTION APPLICANT: You are responsible for maintaining current and accurate
application information. You are required to notify the Housing Authority of Jefferson
County in writing of any change in address; income and/or household composition (please
use “Change of Circumstance” form available in the lobby). If we cannot contact you at
the address listed on this application or an updated address, your name will be
removed from the waiting list, and you will have to re-apply.
- Are you or any other members of your household disabled? Yes _____ No _____
If yes, which member(s) are disabled?
__________________________________ __________________________________
__________________________________ __________________________________
Do you or any member of your family require any of the following accommodations or unit
modifications?
• Wheelchair accessible unit
• Sensory impaired accessible unit
• Ground floor unit (no stairs)
• Other physical adaptations (grab bars etc.)
• Service/Companion Animal
• Copy mail to Case Manager
• Large type documents
• Live-in aide/caregiver
• Payee (please list name) ___________________________
• Other _______________________________________________________
The Housing Authority of Jefferson County complies with the Fair Housing Act and provides
reasonable accommodations and modifications to persons with disabilities.
Special Assistance
1) Do you need this document translated into a language other than English?
If yes, which language? _______________________
a) Kailangan nyo po ba ang ibang pananalita o linguwahe para isalin itong dokumentong ito maliban sa
Ingles? Kung oo, ano po bang pananalita o linguwahe? ______________________________
b) ¿Necesita usted que este documento sea traducido a otro idioma diferente que en ingles?
¿Si es asi, que idioma? ________________________________
c) Bạn có cần tài liệu này ðuợc dịch qua ngôn ngữ nào khác ngoài tiếng Anh không?
Nếu có, ngôn ngữ nào? _______________________
2) Do you need help communicating with the Housing Authority of Jefferson County in a language other than
English? If yes, which language? _____________________
a) Kailangan nyo po ba ang tulong para makausap ang Housing Authority of Jefferson County sa ibang
pananalita o linguwahe maliban sa Ingles? Kung oo, ano po bang pananalita o inguwahe?
______________________
b) ¿Necesita usted comunicarse con la autoridad de vivienda de Jefferson County en otra idioma que no sea
el ingles? ¿Si es asi, que idioma? ________________________________
c) Bạn có cần thông dịch khi giao tiếp với Housing Authority of Jefferson County không?
Nếu có, ngôn ngữ nào? _______________
3) Do you need sign language assistance for your appointments with the Housing Authority of Jefferson County?
Yes ________ No ________
- If you want the Housing Authority of Jefferson County to speak with your case manager,
friend or relative about your housing status, you must first complete and sign the
following release. Remember to write in the name of the person that you are allowing us
to speak with and sign the bottom of the release.
RELEASE OF INFORMATION
I, ______________________, give the Housing Authority of Jefferson County permission to
CLIENT NAME (print)
speak with _______________________________________________ regarding my housing application.
(Name of Person or Organization)
I voluntarily allow the above named parties to obtain and/or release information regarding my
housing application. I understand that this information will not be forwarded to anyone other
than the parties listed above, without my written permission. I understand that I can revoke this
release at any time. This consent form expires 15 months after signing.
_________________________________ _______________ _____________________
Applicant’s Signature Date of Birth Social Security Number
It is the responsibility of all clients to provide accurate and complete information to HAJC. If you
do not provide all required information or if you submit false information to HAJC you may be
charged with federal fraud. (Title 18, Section 1001 of the U.S. Code)
I CERTIFY THAT ALL INFORMATION I HAVE PROVIDED IS COMPLETE AND ACCURATE.
I understand that any misrepresentation of information or failure to disclose information
requested on this application may disqualify me from consideration for admission or participation,
and may be grounds for eviction or termination of assistance.
I understand that this is not a contract and does not bind either party. The information contained
in this application is true, and complete to the best of my knowledge. I have no objection to
inquiries being made for the purpose of verifying the statements made herein.
_____________________________________ ______________ ______________________________________ ____________
Head Of Household Signature Date Co-Applicant Signature Date
- HOUSING AUTHORITY OF JEFFERSON COUNTY
Mailing Address: Post Office Box 2109 Physical Address: 5210 Kuhn Street
Port Townsend, WA 98368
Phone (360) 379-2565 Fax (360) 379-2561
Declaration of Section 214 Status
Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each
applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read the Declaration
statement carefully and sign and return it to the Bremerton Housing Authority Office. Please feel free to
consult with an immigration lawyer or other immigration expert of your choice.
I, ____________________________________________ certify, under penalty of purjury1, that, to
the best of my knowledge, I am lawfully within the United States because (please check the
appropriate box):
[ ] I am a citizen by birth, naturalized citizen or national of the United States; or
[ ] I have eligible immigration status and I am 62 years of age or older. (Attach proof of age)2;
or
[ ] I have eligible immigration status as checked below (see reverse side of this form for
explanations). Attach INS document(s) evidencing eligible immigration status and signed
verification consent form.
[ ] Immigrant status under ¶¶1001(a)(15) or 101(a)(20) of the INA3; or
[ ] Permanent residence under ¶249 of INA4; or
¶¶
[ ] Refugee, asylum, or conditional entry status under 207, 208 or 203 of the INA5; or
[ ] Parole status under ¶¶212(d)(f) of the INA6 ; or
[ ] Threat to life or freedom under ¶243(h) of the INA7 ; or
[ ] Amnesty under ¶245 of the INA8.
________________________________________ _____________________________
(Signature of Family Member) (Date)
*Parent/Guardian must sign for family members under age 18. DO NOT sign child’s name.*
[ ] Check box if signature of adult residing in the unit who is responsible for child named on
statement above.
[See reverse side for footnotes and instructions]
Equal Housing Opportunity Barrier Free
rev 03/07/01
f:\housing\forms\declr14.doc
- Instructions to Housing Authority: Following verification of status claimed by person declaring eligible
immigration status (other than for noncitizens age 62 or older and receiving assistance on June 19, 1995), the HA
must enter INS/SAVE Verification Number and date that it was obtained. An HA signature is not required.
Instructions to Family Member for Completing Form: On opposite page, print or type first name, middle
initial(s) and last name. Place an “X” or “√” in the appropriate boxes. Sign and date at bottom of page. Place
an “X” or “√” in the box below the signature if the signature is by the adult residing in the unit who is
responsible for child.
1
Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a
document or writing containing any false, fictitious, or fraudulent statement or entry, in any manner within the
jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned
for not more than five years, or both.
The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following
categories:
2
Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or
who will be 62 years of age or older and receiving assistance under Section 214 covered program on June 19,
1995. If you are eligible and elect to select this category, you must include a document providing evidence of
proof of age. No further documentation of eligible immigration status is required.
3
Immigrant status under ¶¶101(a)(15) or 101(a)(20) of INA. A noncitizen lawfully admitted for permanent
residence, as defined by ¶101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by
¶
101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category
includes a noncitizen admitted under ¶¶210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural
worker status], who has been granted lawful temporary resident status.
4
Permanent residence under ¶249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or such
later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not
ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an
exercise of discretion by the Attorney General under ¶249 of the INA (8 U.S.C. 1259) [amnesty granted under INA
249].
5
Refugee, asylum, or conditional entry status under ¶¶207, 208 or 203 of INA. A noncitizen who is lawfully
present in the U.S. pursuant to an admission under ¶207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to
the granting of asylum (which has not been terminated” under ¶208 of the INA (8 U.S.C. 1158) [asylum status]; or
as a result of being granted conditional entry under ¶203(a)(7) of the INA (U.S.C. 1153 (a)(7)) before April 1,
1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of
being uprooted by catastrophic national calamity [conditional entry status].
6
Parole status under ¶212(d)(5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise
of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under
¶
212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].
7
Threat to life or freedom under ¶243(h) of INA. A non citizen who is lawfully present in the U.S. as a result of
the Attorney General’s withholding deportation under ¶243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or
freedom].
8
Amnesty under ¶245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under
¶
245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A]
Equal Housing Opportunity Barrier Free
rev 1/7/00
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