Housing Authority Affordable Housing Assistance Programs Waiting List Pre-Application

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1 Housing Authority of the County of San Joaquin PO Box 447 Stockton, CA Housing Authority Affordable Housing Assistance Programs Waiting List Pre-Application Head Name: SSN: Date of Birth: Spouse/Co-head: SSN: Date of Birth: Mailing Address: City: State: ZIP: Home Phone #: Work Phone #: Message Phone #: Address: List all household members (if not enough space use a separate piece of paper that includes the information below) Name Age Sex Relationship to Head How many people are there in your household (including yourself)? What is your household s total monthly income? $ (Such as Wages, SSI/SSA, TANF, VA, Unemployment benefits or any other benefits and/or Cash contributions) Ethnicity Check One Race 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 Over [ ] Other

2 What is your primary language? [ ] English [ ] Spanish [ ] Hmong [ ] Tagalog [ ] Other (Please specify) Questions for Head of Household: Yes No 1. Do you live, work, or go to school in San Joaquin County? [ ] [ ] 2. Have you been displaced by government action through no fault of your own? [ ] [ ] 3. Are you or your spouse a U.S. Veteran? [ ] [ ] 4. Are you or anyone in your household disabled and is this disability expected to be long-term or for an indefinite duration? [ ] [ ] If yes to question 4 above, please check any and all of the following items that would help to best accommodate your disability: [ ] Hearing Access Required [ ] Mobility Accessed Required [ ] Visual Access Required CURRENT WAITING LIST PROGRAMS Please mark the box for each of the waiting lists you wish to be placed on Buthmann Homes Tracy, CA (Senior Complex (62 years or older) maximum family size 2) Franco Center Stockton, CA (Senior Complex (62 years or older) maximum family size 4) Conway Homes - Stockton, CA (maximum family size - 10) Sierra Vista Homes - Stockton, CA (maximum family size - 10) Thornton Development - Thornton, CA (maximum family size - 8) Tracy Development - Tracy, CA (maximum family size - 10) Project-Based Voucher (Disabled) Project-Based Voucher (Senior 62 years or older) I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE. I understand that submission of false information or misrepresentation may result in loss of eligibility to participate in any assisted housing programs. Head of Household Signature Date Spouse / Co-Head Signature Date WARNING! Title 18, Section 1001 of the United States Code, states that a person who knowingly and willingly makes false or fraudulent statements to any department or agency of the United States is guilty of a felony. For HA Use Only: Data Input Initials Date QC

3 Description of Programs Public Housing Housing Authority owned units that provide rental assistance to families, disabled, and elderly in San Joaquin County. The Housing Authority owns and operates the following four public Housing Developments: Conway Homes Located at 741 S Flint Avenue, Conway Homes is west of Interstate-5 near Eighth Street in Stockton, CA. Conway Homes consists of 436 individual single-story family homes and duplexes ranging from one to five bedrooms. Based on the occupancy standards set forth in the Housing Authority s Admissions and Continued Occupancy Policy, the maximum family size for this site it 10 family members. Each unit has its own driveway, front yard and fenced backyard with a storage shed and pets may be permitted with management s approval. Each home is equipped with gas stoves, new central heating and air systems, and laundry hook-ups. An on-site Community Police station is located within the community resulting in the lowest crime rate within the surrounding area. Sierra Vista Homes Located at 2436 South Belleview Street, Sierra Vista is east of Airport Way in Stockton, CA near the San Joaquin County Fairgrounds. Sierra Vista consists of 391 single-story and two-story duplexes, triplexes and four-plex family homes ranging from one to five bedrooms. Based on the occupancy standards set forth in the Housing Authority s Admissions and Continued Occupancy Policy, the maximum family size for this site is 10 family members. Each unit has its own fenced backyard and storage shed and off street parking is provided for all units. Pets may be permitted with management s approval and homes are equipped with gas stoves, new central heating and air systems, and laundry hook-ups. Sierra Vista Homes has an active resident council organization and community center and an on-site Community Police station is located within the community resulting in the lowest crime rate within the surrounding area. Tracy Development Tracy Development Office is located at 311 West Street. The Development is located off Fourth and West Street in Tracy. There are 195 single family dwelling units with a laundry hook-up ranging from one bedroom to five bedrooms. Based on the occupancy standards set forth in the Housing Authority s Admissions and Continued Occupancy Policy, the maximum family size for this site is 10 family members. There are schools and grocery stores located in the area. Buthmann Homes Buthmann Homes is a 20 unit senior (62 years or older) complex located at 2525 Buthmann Ave in Tracy, CA. Each unit is 1 bedroom. Based on the occupancy standards set forth in the Housing Authority s Admissions and Continued Occupancy Policy, the maximum family size for this site is 2 family members. Amenities include: central heating and air, carpeting, gas stove, security doors, laundry and recreation rooms. Highway Patrol is located across the street and restaurants and shopping are located in the area. Thornton Development Located east of Interstate-5 in Thornton, CA, the Thornton Development Office is located at North Manor Drive. This development consists of 81 single family dwelling units ranging from one to four bedrooms. Based on the occupancy standards set forth in the Housing Authority s Admissions and Continued Occupancy Policy, the maximum family size for this site is 8 family members. Each unit has laundry hook-up and elementary schools and grocery store located in the area. Franco Center Apartments The Franco Center Apartments, a modern multi-storied senior (62 years or older) complex, is located in beautiful historic downtown Stockton just east of the Stockton Police Facility. The Franco Center offers spacious Studio, One and Two bedroom apartments. Based on the occupancy standards set forth the maximum family size for this site it 4 family members..each unit is newly renovated and has large beautiful windows. Water, sewer and garbage are all included at no additional cost to the resident. A laundry facility is available for resident use on the fourth floor. Over

4 Project-Based Voucher Program The Project-Based Voucher Program offers rental assistance to designated privately owned unit through out San Joaquin County. Project-Based Voucher Program (Senior) Privately owned units designated for seniors throughout San Joaquin County participate in this program. Participation in the program is limited to seniors ages 62 and older and near elderly ages 55 and older. Project-Based Voucher Program (Disabled) Privately owned units designated for disabled individuals and families throughout San Joaquin County participate in this program. Participation in this program is limited to disabled individuals and families.

5 Housing Authority of the County of San Joaquin P. O. Box 711 Stockton, CA INSTRUCTIONS ON HOW TO COMPLETE THE ENCLOSED FORM HEAD OF HOUSEHOLD Head of Household is defined as the adult member of the household who is designated by the family as head, is wholly or partly responsible for paying the rent and has the legal capacity to enter into a lease under State/local law. Emancipated minors who qualify under State law will be recognized as head of household. MAILING ADDRESS Current address where mail is received. FAMILY COMPOSITION INFORMATION List all household members except Head of Household and Spouse/Co-head. Indicate the name, age, sex/gender and relationship to the head of household for each member. HOUSEHOLD INCOME INFORMATION List total monthly income for all members of the household including: any income from wages, SSI/SSA benefits, TANF, VA benefits, unemployment benefits or any other benefits and/or cash contributions. RACE AND ETHNICITY Indicate by checking the appropriate box for the ethnicity and race of the HEAD OF HOUSEHOLD ONLY. This information is necessary to comply with HUD regulations. Indicate the HEAD OF HOUSEHOLD S primary language. If the HEAD OF HOUSEHOLD S primary language is not listed please check "Other" and indicate the primary language. QUESTIONS FOR THE HEAD OF HOUSEHOLD 1. Do you live, work, or go to school in San Joaquin County? Answer YES, if you live, work or go to school in any city or unincorporated area in San Joaquin County (Escalon, Lathrop, Lodi, Manteca, Ripon, Stockton, Acampo, Woodbridge, Lockeford, Tracy, and Mountain House) 2. Are you or anyone in your household disabled and is this disability expected to be long-term or for an indefinite duration? Answer YES if your or a household member is disabled and believes this disability is permanent 3. Are you or your spouse a U.S. Veteran? Answer Yes, if you OR your spouse is a U.S. Veteran. 4. Have you been displaced by government action through no fault of your own? Answer YES if you have had to move due to governmental action, such as at the request of a city. Involuntarily displaced means you have been displaced (moved) from your residence and are not living in standard, permanent replacement housing. The request to move cannot be because of eviction or due to your actions. CURRENT WAIT LIST PROGRAMS Check one or more boxes that indicate which waiting lists you would like to be placed on. SIGN THE APPLICATION CERTIFYING THAT THE INFORMATION PROVIDED IS ACCURATE AND COMPLETE

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