The fields shaded in gray are required fields and must be filled in before clicking submit. If you click submit and the application is not submited, please scroll through to see if any gray fields are left blank or a field is in red which indicates an error.

If you do not see a page indicating your pre-application was accepted after clicking "Submit" please review the page for errors or submit a new pre-application.

Housing Authority Affordable Assistance Program

Waiting List Pre-Application

Head First Name	Head Last Name	SSN (Numbers Only Ex: 000121234)	Date of Birth (MM/DD/YY)

Spouse/Co-Head First Name	Spouse/Co-Head Last Name	SSN (Numbers Only Ex: 000121234)	Date of Birth (MM/DD/YY)

Home Address When entering the address do not use commas just spaces	City	State	Zip

Home Phone Include Area Code	Work Phone Include Area Code	Message Phone Include Area Code

Mailing Address (if different from Home Address)

Mailing Address	City	State	Zip

Household Information

List all household members. The Head of Household will be the first person entered then second person would be the spouse or co-head if applicable. Note: Age must be numbers and no letters. For example 8m would be 0.
Name	Age	Sex	Relationship to Head
		Female Male
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult
		Female Male	Spouse Co-Head Foster Youth <18 Live In Aid Adult

Household Income and Demographics

What is your households total monthly income?	$
(Such as wages, SSI/SSA, TANF, VA, Unemployment Benefits or any other benefits and/or Cash Contributions)

Ethnicity	Race
Check One	Check all that apply
Hispanic or Latino	American Indian/Alaska Native
Not Hispanic or Latino	Asian
	Black/African American
	Native Hawaiian/Other Pacific Islander
	White
	Other

What is your primary language?

English Spanish Hmong Tagalog

Other (Please Specify)

Questions for Head of Household
1. Do you live, work or go to school in San Joaquin County?	Yes	No
2. Are you or anyone in your household disabled and is this disability expected to be long-term or for an indefinite duration?	Yes	No
3. Are you or your spouse a US Veteran?	Yes	No
4. Have you been displaced by a government action through no fault of your own?	Yes	No

 

Current Waiting List Programs - Public Housing and HCVP

Please mark the box for each of the waiting lists you wish to be placed on.

Buthmann Homes - Tracy (Senior) Franco Center (Senior) Conway Homes Sierra Vista Homes Thornton Development Tracy Development Project-Based Voucher (Disabled) Project-Based Voucher (Senior) You must select at least one waiting list to be added to

Supplement to Application for Federally Assisted Housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other revelant information of a family member, friend, or social, health, advocacy, or other organizaztion. This contact information is for the purpose of identifying a person or organization that my be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change this information that you provide on the form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information.

Name of Additional Contact Person or Organization	Telephone Number Include Area Code	Cell Phone Number Include Area Code

Address	Email Address	Relationship to Applicant

Reason for Contact: (Check all that apply)
Emergency	Assistance with Recertification Process
Unable to contact you	Change in Lease Terms
Termination of Rental Assistance	Change in House Rules
Eviction from Unit	Other
Late Payment of Rent

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant's application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimation Act of 1975.

Check this box if you choose not to provide the contact information

By clicking submit, I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE. I understand that submisssion of false information or misrepresentation may result in the loss of eligibility to participate in any assisted housing programs.

WARNING! Title 18, Section 1001 of the United States Code, states that a person who knowingly and willing makes false or fraudulent statements to any department or agency of the United States is guilty of a felony.