HUD Section 8 Housing Application

Seneca Housing Inc. (SHI) Housing Choice Voucher (HCV) Form

This form must be completed by the Head of Household. Use legal name for each household member.

If selected for the waiting list, you will be required to provide proof of residency if your address is in the location of the waiting list for which you are applying.

I. HOUSEHOLD: List all people that will live in your home.

Please note that information about disability status and age may be used to determine selection from waiting list.
Enter information about all family members who will live in the home including any unborn children.
Relation: head of house, domestic partner, co-head, son, daughter, foster child/adult, live-in-aide, other adult
Race: Black/African American, American Indian/Alaskan Native, Asian, Native Hawaiian/Other Pacific Islander, White

1. Head of Household

Add Household Member

II. ADDITIONAL HOUSEHOLD INFORMATION

III. FAMILY'S ANNUAL INCOME

Complete all income sources for the family including, but not limited to: wages, Welfare/TANF, outside contributions, self-employment income, child support, unemployment, Social Security, and SSI.

IV. FAMILY'S ASSETS

Complete the following for all assets owned by a household member including, but not limited to: checking accounts, savings accounts, property held as an investment, bonds, IRA, life insurance policy, money market account, 401k, and trust funds.

V. CERTIFICATION STATEMENT

I/we certify that all the information provided is accurate and complete to the best of my/our knowledge. I/we have reviewed this form and certify that the information shown is true and correct.

I/we certify that knowingly supplying false, incomplete or inaccurate information is punishable under federal or state criminal law. I/we certify that knowingly supplying false, incomplete or inaccurate information is grounds for termination of housing assistance, termination of tenancy, or denial of assistance

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Our mission is to improve Seneca County in order to bolster stability and preservation of our neighborhoods and community.

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