Application for Occupancy
491 E Center Street, Juneau, WI 53039
Phone: 920-386-2866 * TTY: 1-800-947-3529 * Fax: 920-386-2725
Website: www.dodgehousing.org * Email: info@dodgehousing.org
PLACE A √ NEXT TO EACH LOCATION YOU ARE APPLYING FOR
Apartments for seniors (62+) or persons living with a disability regardless of age**
One bedroom units, no more than 2 occupants.
Beaver Dam ___ Juneau ___ Lowell ___ Hustisford ___ Iron Ridge ___
Theresa ___ Reeseville ___ Old Ashippun ___ Waupun (Harris Court) ___
Apartments for ANY low income persons
Burnett ___ One bedroom units, no more than 2 occupants
Horicon Oak Grove Phase 1 ___ One, two and three bedroom units
Horicon Oak Grove Phase 2 ___ Three bedroom duplex units
**A person receiving SS, SSI, SSD or other disability benefit is eligible. If a person is not receiving SS, SSI, SSD
or other disability benefit, an applicant may be eligible if a medical professional can verify the applicant
meets the definition of disability.
If you feel you qualify as a senior (62+) or person living with a disability regardless of age: CHECK HERE
APPLICANT INFORMATION
Last Name First Name MI Date of Birth Sex
______________________________ ____________________ ___ ___________ M/F
Present Address
_______________________________________________________________________________
(PO Box/Mailing Address) (City ) (State) (Zip Code)
Home Phone ( ) _______________________ Cell Phone ( ) _______________________
Full-Time Student YES/NO Social Security Number __________________
Ethnicity (check one)* ** Race (Check all that apply)***
Hispanic/Latino____ White___ American Indian/Alaska Native___
Not Hispanic/Latino___ Black/African American ___ Asian___
Native Hawaiian/Other Pacific Islander___
***There is no penalty for not disclosing this information. It is gathered for statistical purposes only.
OFFICE USE ONLY: Application received by: _______________________________________ Date: _____________________ Time: ________________
ADDITIONAL HOUSEHOLD MEMBER INFORMATION
Indicate the current status of all other adults and children that will live in the housing apartment. Add new
members in the space provided below, including the full Social Security number for each.
*Enter one of the following for Relation for each person listed:
*C=Co-Head *S=Spouse *A=Other Adult *Y=Youth Under 18 *L=Live-In Aide
Last Name First Name MI Date of Birth Sex
_______________________________ _____________________ ___ ____________ M/F
Social Security Number _______________ Relation to Applicant ______* Full-Time Student Yes/No
Ethnicity (check one)*** Race (Check all that apply)***
Hispanic/Latino____ White___ American Indian/Alaska Native___
Not Hispanic/Latino___ Black/African American ___ Asian___
Native Hawaiian/Other Pacific Islander___
***There is no penalty for not disclosing this information. It is gathered for statistical purposes only.
Last Name First Name MI Date of Birth Sex
_______________________________ _____________________ ___ ____________ M/F
Social Security Number _________________ Relation to Applicant ______* Full-Time Student Yes/No
Ethnicity (check one)*** Race (Check all that apply)***
Hispanic/Latino____ White___ American Indian/Alaska Native___
Not Hispanic/Latino___ Black/African American ___ Asian___
Native Hawaiian/Other Pacific Islander___
***There is no penalty for not disclosing this information. It is gathered for statistical purposes only.
Last Name First Name MI Date of Birth Sex
_______________________________ _____________________ ___ ____________ M/F
Social Security Number ________________ Relation to Applicant ______* Full-Time Student Yes/No
Ethnicity (check one) Race (Check all that apply)
Hispanic/Latino____ White___ American Indian/Alaska Native___
Not Hispanic/Latino___ Black/African American ___ Asian___
Native Hawaiian/Other Pacific Islander___
***There is no penalty for not disclosing this information. It is gathered for statistical purposes only.
INCLUDE EXTRA SHEET FOR ADDITIONAL HOUSEHOLD MEMBERS IF NEEDED.
1. What is your preferred moving date? ______________________________
2. Does your family lack a regular nighttime residence, live in a shelter, or other Yes/No
non residential place?
3. Do you currently live or have you previously lived in, public housing, housing assisted Yes/No
by the Section 8 program, or any other type of federally subsidized housing?
4. Have you or any member of your household been evicted from Public housing, Yes/No
Indian housing, Section 23 housing, or housing assisted by the Section 8 program,
for drug-related criminal activity during the past three years?
5. Do you or any member of your household have a history of controlled substance Yes/No
or alcohol abuse that has not been abated through rehabilitation?
6. Have you or any member of your household been convicted of drug-related criminal Yes/No
activity for manufacture or production of methamphetamine on the premises of
federally assisted housing?
7. Are you or any member of your household subject to a lifetime sex offender Yes/No
registration under a State sex offender registration program?
8. Do you have any specific housing requirements, such as special handicapped Yes/No
accessible unit?
9. Do you hold a letter of Priority Entitlement? Yes/No
10. Do you certify that this unit will be your permanent residence and that you will Yes/No
not/do not maintain a separate residence unit in a different location?
11. Will you require an on-premise vehicle parking spot? Yes/No
12. Has any member of the household used another name (for example, maiden name)
or social security number? If yes, list names: ____________________________ Yes/No
13. Some of our apartments are designated as smoke free units. Is this a concern for you? Yes/No
14. Are you a veteran or the spouse of a veteran? Yes/No
Please list below all former addresses within the past 7 years, starting
with the present:
Property Address Own/Rent Name, Address & Phone # of Owner/Manager Dates (Month & Year)
1)_____________________ ________ _____________________________________________ ______/_____ to
_____________________ _____________________________________________ ______/_____
2)_____________________ ________ _____________________________________________ ______/_____ to
_____________________ _____________________________________________ ______/_____
3)_____________________ ________ _____________________________________________ ______/_____ to
_____________________ _____________________________________________ ______/_____
INCLUDE EXTRA SHEET FOR ADDITIONAL INFORMATION IF NEEDED.
ASSET INFORMATION
Has any member of the household given away or disposed of assets valued at
more than $1,000 for less than fair market value during the past two years? Yes/No
List all assets for all household members. Assets are any one of the following types:
Checking Account Savings Account Money Market Account Stocks
Certificates of Deposit Mutual Funds 401(k) or 403(b) Bonds IRA Accounts
Life Insurance Policies Bonds Trust Funds Annuity Accounts
Real Property (land)
______________ _____________ ____________ _______________________________
Name on Account Type of Asset Current Balance Name and Address of Financial Institution
______________ _____________ ____________ _______________________________
Name on Account Type of Asset Current Balance Name and Address of Financial Institution
______________ _____________ ____________ _______________________________
Name on Account Type of Asset Current Balance Name and Address of Financial Institution
______________ _____________ ____________ _______________________________
Name on Account Type of Asset Current Balance Name and Address of Financial Institution
INCOME INFORMATION
Did you file a Federal Income Tax Return last year? Yes/No
Does anyone living outside your household pay for or provide money for any Yes/No
of your household bills or living expenses?
List all income for all household members. Income is any one of the following types:
Wages/Salaries Child Support Alimony Payments Social Security Benefits
Self Employment Disability Benefits SSI Workers Compensation
TANF Pension Unemployment Benefits VA or Military Pay
Pension Annuity Payments Retirement Payments Rental Income for property
Periodic Gifts Food Stamps Financial assistance for school
______________ _____________ ________________ _____________________________
Applicant Name Type of Income Gross Income Amount *** Name and Address of Income Source
______________ _____________ ________________ _____________________________
Applicant Name Type of Income Gross Income Amount *** Name and Address of Income Source
______________ _____________ _________________ _____________________________
Applicant Name Type of Income Gross Income Amount *** Name and Address of Income Source
______________ _____________ _________________ _____________________________
Applicant Name Type of Income Gross Income Amount *** Name and Address of Income Source
*** Indicate if income listed is hourly, weekly, monthly or annually.
INCLUDE EXTRA SHEET FOR ADDITIONAL INFORMATION IF NEEDED.
HOUSEHOLD EXPENSES
Does any member of your household have UNREIMBURSED expenses for care Yes/No
of a child age 12 or younger so that an adult member can work or attend classes?
Does any member of your household have UNREIMBURSED expenses for care Yes/No
of a person with disabilities so that an adult member can work?
Out of pocket medical expenses (To be completed for households with persons who are
disabled or age 62+ only) Include doctor, dentist, eye care, supplemental health insurance,
hearing aid payments, monthly payments required on accumulated major medical bills, even over
the counter medication your doctor recommends.
______________ _____________ ____________ _______________________________
Applicant Name Type of Expense Amount *** Name and Address of Medical Provider
______________ _____________ ____________ _______________________________
Applicant Name Type of Expense Amount *** Name and Address of Medical Provider
______________ _____________ ____________ _______________________________
Applicant Name Type of Expense Amount *** Name and Address of Medical Provider
______________ _____________ ____________ _______________________________
Applicant Name Type of Expense Amount *** Name and Address of Medical Provider
*** Indicate if amount listed is monthly or annually.
ALL ADULT HOUSEHOLD MEMBERS MUST SIGN THIS FORM
CERTIFYING ACCURACY OF INFORMATION PROVIDED
I certify that the information on this form is true and complete to the best of my knowledge and
belief. I understand that false or incomplete information is grounds for termination of housing
assistance and/or termination of tenancy. I understand that I can be fined up to $10,000, or
imprisoned up to five years if I furnish false or incomplete information.
__________________________________________________________ _________________________________________________________
Applicant Signature Date Applicant Signature Date
The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting
through the USDA/Rural Development, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin,
religion, sex, familial status, age, and disability are complied with. You are not required to furnish this information, but are encouraged to do so. This information
will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note
the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.
"The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disa-
bility, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or
because all or a part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with
disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET
Center at (202) 720-2600 (voice and TDD).To file a complaint of discrimination write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue,
S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider, employer, and lender.”
This institution is an equal opportunity provider and employer.
INCLUDE EXTRA SHEET FOR ADDITIONAL INFORMATION IF NEEDED.
CRIMINAL HISTORY DISCLOSURE
All adult applicants are required to disclose criminal history. If you have any
criminal charges, misdemeanor or felony, you must disclose that information
regardless of the date of occurrence. Court records and/or background check will
be accessed for all applicants to verify this information. Indicate any criminal
charges and sign below.
Applicant Name: _______________________________Criminal History: _______________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
List all states in which you have ever lived.
________________________________________________________________________________
________________________________________________________________________________
Are you subject to a sex offender registration requirement in any state? Y/N
If yes, which state: ___________________________________ This information will be verified using the
Dru Sjodin National Sex Offender database.
By signing this form I acknowledge that I have reported all criminal history. I understand that
not disclosing criminal history information makes my application invalid and may be grounds
for denial or termination of housing.
Signature: __________________________________ Date: ___________________________
Applicant Name: _______________________________Criminal History: _______________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
List all states in which you have ever lived.
________________________________________________________________________________
Are you subject to a sex offender registration requirement in any state? Y/N
If yes, which state: ___________________________________ This information will be verified using the
Dru Sjodin National Sex Offender database.
By signing this form I acknowledge that I have reported all criminal history. I understand that
not disclosing criminal history information makes my application invalid and may be grounds
for denial or termination of housing.
Signature: __________________________________ Date: ___________________________
INCLUDE EXTRA SHEET FOR ADDITIONAL INFORMATION IF NEEDED.
Complete for each household member. Include extra sheets for
additional household members if needed.
DECLARATION OF CITIZENSHIP STATUS (SECTION 214)
NOTICE TO APPLICANTS AND TENANTS: In order to be eligible to receive the housing assistance you seek, you, as an applicant or
current recipient of housing assistance, must be lawfully within the U.S. Please read the Declaration statements carefully, check that which applies
to you, and sign and return the document to the Housing Authority Office. Please feel free to consult with an immigration lawyer or other
immigration expert of your choosing.
I, ______________________________________, certify, under penalty of perjury 1/, 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, a naturalized citizen or a national of the United States; or
( ) I have eligible immigration status and I am 62 years of age or older. Attach evidence of
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 a
signed verification consent form.
( ) Immigrant status under §101(a)(15) or 101(a)(20) of the Immigration and
Nationality Act (INA) 3/; or
( ) Permanent residence under §249 of INA 4/; or
( ) Refugee, asylum, or conditional entry status under §§207, 208, or 203 of the INA 5/; or
( ) Parole status under §§212(d)(5) of the INA 6/; or
( ) Threat to life or freedom under §243(h) of the INA 7/; or
( ) Amnesty under §245 of the INA 8/.
____________________________________________________ ______________________
(Signature of Family Member) (Date)
( ) Check box if signature is of adult residing in the unit who is responsible for child named on
statement above.
(see reverse side for notes and instructions)
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 matter within the
jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, 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 cat-
egories:
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 a Section 214 covered program on June
19, 1995. If you are eligible and elect to select this category, you must include a document providing evi-
dence of proof of age. No further documentation of eligible immigration status is required.
3/ Immigrant status under §§101(a)(15) or 101(a)(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]; pursu-
ant 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 on account of race, religion, or political opinion or be-
cause 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 noncitizen 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].
Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration
status (other than for non-citizens age 62 or older and receiving assistance on June 19, 1995), HA must enter
INS/SAVE Verification Number and date that it was obtained. A 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.
