APPLICATION FOR THE PUBLIC HOUSING PROGRAM

1 APPLICATION FOR THE PUBLIC HOUSING PROGRAM Please check this box if you are a person with a disability and need helpwith reading or filling out this form. You have the right to ask HABC tomake a reasonable accommodation for you. To make such a request, pleasecall the Admissions and Leasing Center at 410-396-3225 or TTY 410-342-0294 or the Maryland Relay System 711 or 1-800-201-7165. You may also refer to the PublicHousing PROGRAM General Information Guide for a list of organizations that will assist you. If at anytime your address or contact information changes, contact the Admissions and Leasing Center to makethe appropriate changes. This document is available in alternative highlighted areas must be completed or the APPLICATION will not be processed.

2 Please mailapplications to: Customer Relations Office, 1225 Pratt Street Baltimore, MD 21223 About the ApplicantLast Name:First Name:Middle Initial:Social Security Number:Date of Birth: check this box if you areelderly, at least 62 years of InformationHome Address:City:State:Zip Code:Home Telephone:Work or Cellular Telephone:Mailing Address(Complete only if different than above; can be P0. Box, family, friend or Service Provider)Mailing Address:City:State:Zip Code:Emergency Contact(May be your caseworker or family friend.)Name:Telephone:Address:City:Stat e:Zip Code:OFFICE USE ONLY-- 2 -- HOUSING OptionsRefer to the PUBLIC HOUSING General Information Guide for more information on these programs youmay apply for more than one.

3 Family Developments Senior Buildings (Available for those persons 62 years of age and older.) Mixed Population Developments (Efficiencies and one bedroom apartments available fornon-elderly persons with a disability, elderly and near elderly.)Family InformationFirst list the applicant, or the head of household. Second, list the spouse or co-applicant. Next list allchildren that live with you in order of age (oldest to youngest). Then list others that will live with you expect more people to live with you, please explain ( live-in aide, pregnancy or legalcustody change) . Please attach another sheet of paper if you need to add more people. Please provideall requested information for each additional use the Race / Ethnicity Chart below and choose a corresponding letter for each member of thehousehold.

4 Put that letter in the column marked Race/Ethnicity in the table and Last NameRelationship toApplicantDate ofBirthSex M/FSoc .Sec. #(Persons 6 years+) Race / Ethnicity**Applicant or Head or **Race and Ethnicity Chart (This information is requested for statistical purposes only.)A. White HispanicB. White Non-HispanicC. Black HispanicD. Black Non-HispanicE. American Indian / Alaskan / HispanicF. American Indian / Alaskan / Non-HispanicG. Asian or Pacific Islander HispanicH. Asian or Pacific Islander Non-HispanicI. Other-- 3 --Household IncomeList below income for ALL household Member NameType of Income TANF, SSI, SSDI, TEMHA,Veteran s Pension, Employmentor OtherAmount ReceivedPer MonthApplicant or Head of or information about the applicantCheck ( ) all that apply.

5 I do not have a fixed, regular and adequate nighttime residence. I have a lease and utility bill in my name and I am currently paying more than 50% of myincome toward rent and utilities. I am paying $_____ per month for rent and utilities. I am unable to fully use my current HOUSING due to inaccessibility of my unit because I, or amember of my family, have/has a mobility impairment or other impairment. I am a person with a disability (if you need a reasonable accommodation because of yourdisability, please complete the Reasonable Accommodation Information section of this APPLICATION ). I must vacate my current home as a result of a disaster (fire, flood, earthquake, etc.)

6 That hascaused the unit to be uninhabitable or because of Federal, State or local government action related tocode enforcement, PUBLIC improvement or development. I am living in a home that does not provide adequate shelter, or does not have one of thefollowing: operable indoor plumbing; safe electrical service; heat; or a usable tub or shower, or isover crowded according to HQS or local/state or BOCA codes, or is dilapidated and endangers thehealth, safety, and well being of the 4 --Job / Training InformationCheck ( ) all that apply. I am currently employed. My employer is _____. I am currently self-employed. My business is _____. I am enrolled in a verifiable job training PROGRAM .

7 The PROGRAM is _____. I am an honorably discharged HistoryI understand that the information requested will be used to conduct a criminal record screening which isrequired as part of the eligibility determination process. I hereby consent and authorize HABC to conduct acriminal conviction record check as part of this APPLICATION process. I also understand that the results of thiscriminal record check or false statements or information are grounds for denial of HOUSING assistance and/ortermination of HOUSING assistance (eviction). In the table below, please check ( ) Yes or No .Have you, or any family member, ever been convicted of a violent or drug related crime?

8 YES NOHave you, or any family member, ever been required to register as a sex offender? YES NOAre you, or any family member, currently on parole, probation or home monitoring? YES NOYour signature below indicates your consent for HABC to conduct the criminal conviction record (18 years and older) must sign below. Parents or legal guardians may sign for minors (17 andyounger)._____Date:_____Applicant____ _Date:_____Co-applicant_____Date:_____Ho usehold member_____Date:_____Household member_____Date:_____Household member_____Date:_____Household member-- 5 --Reasonable AccommodationCheck ( ) Yes or No .Do you or your co-applicant have a disability? YES NODo you or any member of your household need an accessible unit because of disabilitymobility impairment, or do you need a special feature due to a disability?

9 (for example: wheelchair or difficulty walking) YES NOIf you answered "Yes" to the above question(s), please check what type of accommodations you with the APPLICATION process. YES NOHelp with understanding or using the PUBLIC HOUSING PROGRAM because of your disability. YES NOA unit for persons with vision impairments (blind, limited vision). YES NOA unit for persons who are deaf or hard of hearing. YES NOAn extra bedroom for a live-in aid or attendant. YES NOA unit all on one level, with no steps, including to enter/exit. YES NOA ramp to gain entry/exit the unit. YES NOA bedroom and bathroom on the first floor. YES NOModifications to bathroom. YES NOA unit accessible to a person using a wheelchair.

10 YES NOAccessible parking space. YES NOOther modifications; please describe: YES NO-- 6 --PLEASE READ CAREFULLY AND SIGNI understand that the HABC requests this information as part of the preliminary APPLICATION . Someinformation is being obtained for statistical purposes only. The HABC is an equal opportunity housingprovider and does not discriminate on the basis of race, color, national origin, religion, sex, age, disability,family status or any other basis prohibited by law in the administration of programs and HABC services are implemented in compliance with Title VI of the Civil Rights Act of 1964; Title II ofthe Americans with Disabilities Act of 1990; Title VIII of the Civil Rights Act of 1968, as amended; Section504 of the Rehabilitation Act of 1973, as amended; the Fair HOUSING Amendments Act of 1988; and allother applicable Civil Rights and Fair HOUSING requirements.