Pre-Application for Housing
Housing Authority of Pikeville
Type of Assistance *
Section 8
PHA
Both
Head of Household Name *
Date of Birth *
Social Security Number *
Race *
White
Black/African American
Other
Sex *
Male
Female
Ethnicity *
Hispanic
Other
1st Other Household Member Name
1st Relationship to Head of Household
Other
Child
Spouse
1st Other Member Date of Birth
1st Other Member Social Security Number
1st Other Member Sex
Male
Female
2nd Other Household Member Name
2nd Relationship to Head of Household
Other
Child
Spouse
2nd Other Member Date of Birth
2nd Other Member Social Security Number
2nd Other Member Sex
Male
Female
3rd Other Household Member Name
3rd Relationship to Head of Household
Spouse
Child
Other
3rd Other Member Date of Birth
3rd Other Member Social Security Number
3rd Other Member Sex
Male
Female
4th Other Household Member Name
4th Relationship to Head of Household
Other
Child
Spouse
4th Other Member Date of Birth
4th Other Member Social Security Number
4th Other Member Sex
Male
Female
Current Physical Street Address *
City *
State *
Zip Code *
Current Telephone Number *
Mailing Address (blank if same as physical)
Mailing Address City
Mailing Address State
Mailing Address Zip Code
Estimated Total Family Income *
Income Rate *
Hourly
Weekly
Bi-Weekly
Monthly
Yearly
Other
Income Source *
Wages
SSI or Disability
Child Support
Social Security Retirement
Other
Are You Disabled? *
Yes
No
If Disabled, is Disability Physical? *
Yes
No
Does Not Apply
Does the family have an immediate and urgent need for housing? *
Yes
No
Please tell us why you feel you need assistance *
Have you lived in public housing before? *
Yes
No
If yes, where?
Have you ever received Section 8 assistance? *
Yes
No
If yes, where?
Please enter name, address, and phone number of current landlord *
Please enter name, address, and phone number of PREVIOUS landlord *
Additional Comments (optional)
Type the following:
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