Waiting list registration for housing assistance In order to be placed on the waiting list, you must complete all the information on this form.  The form will be transmitted to our office. You should receive a confirmation letter within two weeks from our office. Please print out and keep the confirmation page after you submit this form. Information about the person applying for assistance: Last name First name Middle initial Mailing address City State Zip Telephone Please check all the programs for which you are applying (you may check as many as you like): Section 8 Voucher Program Moderate Rehabilitation units * Public Housing and HACSA-owned units--please check only those communities where you would accept housing: Family units only Eugene/Springfield Florence Veneta Elderly (62+ years) or disabled Eugene/Springfield Florence Veneta/Junction City/Cottage Grove/Creswell Family/Elderly/Disabled Village Oaks (Located in SW Eugene. Minimum rent according to bedroom size: 1 bedroom = $283/mo; 2 bedroom = $336/mo; 3 bedroom = $381/mo.) Please list all people who will be living in the rental unit, including the applicant: Note: Completing the "Race or Ethnicity" code is voluntary. The information is collected for civil rights purposes, and the information will not be used in determining an applicant's eligibility. If you prefer, a separate form for completing the "Race or Ethnicity" section will be provided to you. Person #1 Name Relationship Birthdate (mm/dd/yy) US Citizen Yes No Sex M F Social Security Number Race or Ethnicity* .. White(1) Black(2) American Indian/Alaskan Native(3) Asian/Pacific Islander(4) Hispanic(5) Person #2 Name Relationship Birthdate (mm/dd/yy) US Citizen .. Yes No Sex .. M F Social Security Number Race or Ethnicity* .. White(1) Black(2) American Indian/Alaskan Native(3) Asian/Pacific Islander(4) Hispanic(5) Person #3 Name Relationship Birthdate (mm/dd/yy) US Citizen .. Yes No Sex .. M F Social Security Number Race or Ethnicity* .. White(1) Black(2) American Indian/Alaskan Native(3) Asian/Pacific Islander(4) Hispanic(5) Income: $ What is the current total household income? Include gross income (before deductions) of all household members over 18. Do not include income from school grants. Student status: Is any adult in your household a full-time student? Yes No If yes, what school(s) do they attend? .. Lane Community College University of Oregon Other Disability status: Do you or your spouse claim status as a person with a disability for eligibility purposes? Yes No   If yes, please describe disability:   If you have an advocate or case manager, you may list that contact person here. Do not list your own name here. Please inform your advocate or case manager that they may receive correspondence from us while you are an applicant for housing assistance. Name Mailing address City State Zip Telephone If you have a disability and need special features (such as visible emergency alarms, lowered kitchen counters/sinks, grab bars in bathroom, ramps, etc.), or a modification of program rules, policies, or procedures, or a change in the way we communicate with you or give you information, you may ask for this kind of change, which is called Reasonable Accommodation. You may pick up a Request for Reasonable Accommodation form at either one of our offices, or you may print one out from this web site. By clicking "submit," I agree that I understand that this is not a contract, but a pre-application for housing assistance. This pre-application does not guarantee that I will receive housing assistance. I swear that the information given on this application is correct and complete to the best of my knowledge. I understand that it is a crime to give false information and may result in the loss/denial of assistance. I authorize the release of information, and authorize the Housing Authority to obtain information, about me or my family that is pertinent to eligibility for, or participation in, assisted housing programs. The Housing Authority may also give my name and address to other housing organizations to aid me in obtaining housing. The information given above may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of the Housing Authority, except as permitted or required by law.