Park Place 215 Grand Avenue Merrill WI 54452 PH 715-722-1081 Fax 715-539-0846
Jenny Towers 711 E First Street Merrill WI 54452 PH 715-722-1081 Fax 715-536-7378
Stonebridge 307 W Main Street Merrill WI 54452 PH 715-722-1081 Fax 715-722-1083 TTY# 800-947-3529 Website: www.merrillha.com
APPLICANT NAME: ____________________________________________________
Your application will be verified for eligibility and your name placed on a waiting list based on date and time of completed application. The Merrill Area Housing Authority has a preference for individuals or families that live in the City of Merrill and Lincoln County. You will be contacted
when your name reaches the top of the list. I am interested in having my name placed on a waiting list(s) for an apartment at the following complex(es):
SECTION 8 NEW CONSTRUCTION
ELDERLY/DISABLED (62 and Older or Disabled)
JENNY TOWERS (ELDERLY & DISABLED): ( ) 1 Bedroom
SECTION 8 NEW CONSTRUCTION MULTI-PERSON HOUSING
DUPLEXES (WOODBINE AVENUE) ( ) 2 Bedroom
HOMES (ST PAUL, MAIN & CALIFORNIA): ( ) 3 Bedroom
SECTION 8 MULTIFAMILY PBRA
INDIVIDUALS/DISABLED (Age 18 & older)
PARK PLACE (215 Grand Ave): ( ) 1 Bedroom
STONEBRIDGE (307 W Main St): ( ) 1 Bedroom ( ) 2 Bedroom
WESTGATE (WATER STREET): ( ) 2 Bedroom ( ) 3 Bedroom ( ) 4 Bedroom
VERIFICATION OF SOCIAL SECURITY CARDS FOR ALL MEMBERS OF THE HOUSEHOLD, And DRIVERS LICENSE OR STATE ID’S FOR ALL ADULT MEMBERS OF THE HOUSEHOLD, ARE REQUIRED AT THE TIME YOUR APPLICATION IS PROCESSED
Revised January 25, 2019
MERRILL AREA HOUSING AUTHORITY APPLICATION FOR OCCUPANCY
Head of Household (Member #1): _______________________________________
SS#: _________________________________
Maiden Name or Other Names Used, etc.: ________________________________
Date of Birth: ________________________
Age: ________ Sex: ☐Male ☐Female Veteran: ☐Yes ☐No
Race: ☐White ☐Black/African ☐Indian-American/Alaskan ☐Asian ☐Hispanic ☐Decline
Occupation: _________________________
Student: ☐Full time ☐Part time ☐Neither Dates Enrolled: _______________
List all states you have resided in: ___________________________________________
Co-Head of Household (Member #2):
SS#: Maiden Name or Other Names Used, etc.: ______________________________
Date of Birth: _________________________
Age: ________ Sex: ☐Male ☐Female Veteran: ☐Yes ☐No
Race: ☐White ☐Black/African ☐Indian-American/Alaskan ☐Asian ☐Hispanic ☐Decline
Occupation: _________________________
Student: ☐Full time ☐Part time ☐Neither Dates Enrolled: _________________ List all states you have resided in: __________________________________________
Current Address: ___________________________________________________________
Mailing Address: ____________________________________________________________
Telephone Number: _________________ Work Number: ___________________ Cell Phone: ______________________ Best time to call: ______________________ Emergency contact (Name & Phone Number): ______________________________
Do you currently have any pets: ☐ Yes ☐ No Type: ☐ Cat ☐ Dog Weight?
HOUSEHOLD INFORMATION
Please provide the following information for all people that will be living with you in your apartment: All adults (including yourself), children under the age of 18, list how they are related to the head of household for each person, and mark race of each household member.
(W) White (B) Black/African (I) Indian/Alaskan (H) Hispanic (A) Asian
(O) Other
Name SS# DOB Sex (M/F) Veteran Yes/No Race Relationship _________ ___________ ________ _________ ________ _____ _____________ _________ ___________ ________ _________ ________ _____ _____________ _________ ___________ ________ _________ ________ _____ _____________ Is there any member of the household that is considered a disabled Individual? ☐Yes ☐No
If so, who?: _________________________________________________________________
DISABLED/HANDICAP INFORMATION
Would any member of your household benefit from a wheelchair adapted/barrier free unit? ☐Yes
Tenants or Co-Tenants which meet the definition of disabled or handicapped qualify for a $400 deduction to their annual income when determining rent contribution and certain other deductions.
See information listed below which defines disabled or handicap.
Do you feel you qualify and would like to request this adjustment to your income? ☐Yes ☐No If yes, please provide documentation from your physician confirming your qualification for this status. Failure to provide this information may result in the denial of these deductions.
INCOME INFORMATION
List all sources of gross income earned by all individuals living in your household to include: Income from wages, self-employment, Social Security, disability payments (SSI), retirement or pensions, veteran’s benefits, W2, alimony, child support, workman’s compensation, unemployment benefits, cash paid jobs, etc.
Household Member: ______________________________________________________ Source of Gross Income: ______________________________________________ Weekly Hours Worked: _______ Hourly Wage: $______________ Monthly Gross Income: $________________
Household Member: ______________________________________________________ Source of Gross Income: _____________________________________________ Weekly Hours Worked: _______ Hourly Wage: $______________ Monthly Gross Income: $________________
Household Member: _______________________________________________________ Source of Gross Income: ____________________________________________ Weekly Hours Worked: _______ Hourly Wage: $______________ Monthly Gross Income: $________________
CHILD SUPPORT
Was child support ordered to be paid? ☐Yes ☐No
If receiving child support, please list name of person pay the support: Be sure to list address where the child support is paid from. If receiving support directly from the payer, indicate their name and address. If receiving support through the court, indicate County Agency name and address.
Name: _____________________________________________________________________ Agency Name: _____________________________________________________________ File Number: ______________________________
Address: ___________________________________________________________________
Name: _____________________________________________________________________ Agency Name: _____________________________________________________________ File Number: ______________________________
Address: ___________________________________________________________________
CLAIMING ZERO INCOME
Are you receiving help on a regular basis from someone not living in your household to help you pay rent, purchase household/personal items, or pay other bills? If so, complete the following:
Name: ___________________________________ Phone Number: # _______________
Address: ____________________________________________________________________
ASSET INFORMATION
(List all information for all individuals residing in household)
Cash on Hand: List Amount on Hand at Present Time: $____________________ (Include cash in safety deposit boxes, home safes, etc…)
Checking Accounts
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Savings Accounts Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
CD’s or IRA’s Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Bank Name: _________________________________________ $____________________
Bank Address: _______________________________________ Current Balance
Stocks/Bonds
Type: _____________ # Owned: _____ Dividend Rate: ____ % Value: $_________
Type: _____________ # Owned: _____ Dividend Rate: ____ % Value: $_________
Annuities/Trusts: Type: _____________ # Owned: _____ Dividend Rate: ____ % Value: $_________
Type: _____________ # Owned: _____ Dividend Rate: ____ % Value: $_________
REAL ESTATE – Owned at present time or sold within the last 2 years
Type of Property: __________________________ Market Value $________________
If sold within last 2-year period, list amount sold for $__________________
Is property owned jointly? ☐Yes ☐No If yes, list name of person: __________ Type of Property: __________________________ Market Value $________________ If sold within last 2-year period, list amount sold for $______________________
Is property owned jointly? ☐Yes ☐No If yes, list name of person: __________________________________________________
Land Contract Sale
Original land contract amount: $______ Balance due at present time: $_____ Terms of Land Contract: $ ______ Monthly $_____ Annual Interest Rate: ____%
All Other Assets Owned (Funeral Trusts with Revocable Interest, Whole Life Ins Policies, etc…)
Type: _________ Name of Bank: ________ Value: $_______ Interest Rate _____% Type: _________ Name of Bank: ________ Value: $_______ Interest Rate _____%
MEDICAL EXPENSES (To be completed for Elderly/Disabled households only)
If you or any member of your household is 62 years of age or older; disabled; and if any household member pays for medications, medical/dental treatments, supplemental insurance premiums, or
prescriptions which are not reimbursed, list information below:
Medical Expense Provider Name
Medicare Premium: $____________ _______________________________ Prescriptions: $__________________ _______________________________
Medical Bill Pymts: $_____________ _______________________________ Supplemental Ins: $_____________ _______________________________
Dental Insurance: $______________ _______________________________
Vision Insurance: $______________ ________________________________
Eyeglasses: $____________________ ________________________________
Hearing aid: $___________________ ________________________________
CURRENT HOUSING EXPENSES
______Rent $_________ Monthly for rent $________ Monthly Utilities
______Own $_________ Monthly Mortgage $________ Monthly Utilities
Present Landlord: ____________________________________________
Landlord Address: __________________________________________________________ Phone #: _______________ # of Bedrooms _______ # of People __________ Are you responsible to pay utilities: ☐Yes ☐No Which utilities? __________
Are you currently delinquent with rent or utilities payment: ☐Yes ☐No If eviction in process were utilities being disconnected? ☐Yes ☐No Have you been evicted in the last 3 years? ☐Yes ☐No
CHILDCARE EXPENSES
List amount paid by family for the care of minor children under 13 years of age when such care is necessary to enable a family member to further education or to be gainfully employed.
$__________ Monthly Childcare Provider’s Name: ______________________
Address: ______________________________________ Phone: ____________________
REFERENCES
Previous Landlord Name: __________________________________________________
Landlord Address: _________________________________________________________
Landlord Phone: ______________________
Rental Unit Address: _______________________________________________________
Occupancy Dates: ______________________
Previous Landlord Name: __________________________________________________
Landlord Address: _________________________________________________________
Landlord Phone: ______________________
Rental Unit Address: _______________________________________________________
Occupancy Dates: ______________________
Has any member of the household rented from the Merrill Area Housing Authority in the past?
☐Yes or ☐ No If yes, occupancy dates:
Has any member of the household received any rental assistance in the past” (Section 8 Voucher, NEWCAP, Rural Housing, rental assisted housing with any other housing authority)
CRIMINAL HISTORY
Have you or any member of your household been charged with any felonies? ☐Yes ☐No If yes, list
individual name:
List dates, charges, city and state it occurred:
_
Have you or any member of your household been charged with drug related activity? ☐Yes ☐No If
yes, list individual name:
List dates, charges, city and state it occurred:
_
Have you or any member of your household required to register as a sex offender? ☐Yes ☐No If
yes, list individual name:
Do you currently have any current or outstanding landlord property damages? ☐Yes ☐No
Do you currently have any unpaid rent? ☐Yes ☐No
Do you currently have any unmet utility bills? ☐Yes ☐No
“The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and
activities on the basis of race, color, national origin, sex, religion, age, disability, political
beliefs, sexual orientation or marital or family status. (Not all prohibited bases apply to all
programs) Persons with disabilities who require alternative means for communication of program
information (Braille, large print, audio tape, etc.) should contact USDA’s TARGET center at (202)
720-2600 (voice and TDD). To file a complaint of discrimination, write: USDA, Director, Office of
Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC
20250-9410 or call (202) 720-5964 (voice and TDD). USDA is
equal opportunity provider and employer.”
APPLICANT CERTIFICATION: I understand that the above information is being collected
to determine my eligibility and that the information provided will be verified and may be released
to appropriate Federal, State or local agencies. I/we certify that the answers and information
given on this application are true and complete to the best of my/our knowledge and belief and I/we
authorize inquires to be made of pertinent third parties to verify our income and deductions. I/we
understand that false statements or information are punishable by fine or imprisonment under
Federal and State Law.
In addition to verifying income, assets and other information, a criminal background check is
conducted before any applicant is approved.
I also certify that the unit applied for will be my household’s permanent residence and I do
not/will not maintain a separate subsidized rental unit in a different location.
Applicant’s Signature Social Security # Date
Co-Applicant’s Signature Social Security # 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 Rural Housing Service 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.
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OFFICE USE ONLY
Race: (Mark one or more)
1. American Indian/Alaska Native
2. Hispanic
3. Asian
4. Black/African American
5. Native Hawaiian or Other Pacific Islander
6. White
Gender: ☐Male ☐Female