(715) 856-6114 info@mcha-wha.org

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Online Application

Section 8 Housing Choice Voucher Rental Assistance Program

Marinette County Housing Authority • 926 Main Street • Wausaukee, WI 54177
Phone: 715-856-6114 • Fax: 715-856-6928 • Email: info@mcha-wha.org

Please fill out the online application below in it’s entirety.

Within 10 working days, after receipt of your application the Housing Authority will notify all applicants in writing of the preliminary eligibility/ineligibility determination. Applicants found preliminary eligible will be placed on a waiting list and notified of the approximate waiting list.

Applicants will be notified by mail, when they reach the top of the waiting list. It is the applicant’s responsibility to notify the Housing Authority of any change in address.

If you have any question regarding the application feel free to call.

"*" indicates required fields

Date*

MM slash DD slash YYYY

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Social Security #*

Email

Contact Info for 2 Friends or Relatives

Please provide the Names and Phone Numbers of two friends or relatives that we can contact if we are unable to reach you at the phone number(s) listed above:

Friend or Relative Name 1*

First Last

Phone*

Friend or Relative Name 2*

First Last

Phone*

Current Household Info

Present Monthly Rent*

Number of Bedrooms*

Check Utilities Paid By You*

Heat

Electric

Hot Water

Water & Sewer

None

Who will be living with you?

List all persons who will live in the rental unit while you are on this program:

Head of Household - Name*

First Middle Last

Gender

Male

Female

Birthdate

Place of Birth (City & State)

Relationship

Occupation

Full Name - Occupant 2

First Middle Last

Gender

Male

Female

Birthdate

Place of Birth (City & State)

Relationship

Occupation

Full Name - Occupant 3

First Middle Last

Gender

Male

Female

Birthdate

Place of Birth (City & State)

Relationship

Occupation

Full Name - Occupant 4

First Middle Last

Gender

Male

Female

Birthdate

Place of Birth (City & State)

Relationship

Occupation

Full Name - Occupant 5

First Middle Last

Gender

Male

Female

Birthdate

Place of Birth (City & State)

Relationship

Occupation

Full Name - Occupant 6

First Middle Last

Gender

Male

Female

Birthdate

Relationship

Place of Birth (City & State)

Occupation

Income

List all full and/or part time employment for all household members (other than minor dependent children). Include self-employed earnings.

Household Member Name

Name of Employer

Employer 1 Address

Street Address Address Line 2 City State ZIP Code

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Household Member Name

Name of Employer 2

Employer 2 Address

Street Address Address Line 2 City State ZIP Code

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Household Member Name

Name of Employer 3

Employer 3 Address

Street Address Address Line 2 City State ZIP Code

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Household Member Name

Name of Employer 3

Employer 4 Address

Street Address Address Line 2 City State ZIP Code

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Other Sources Of Income

(Examples: Governmental assistance, social security, S.S.I., pensions, disability compensation, unemployment compensation, interest, baby sitting, caretaking, alimony, child support, annuities, dividends, income from rental property, Armed Forces Reserves, scholarships and/or grants, etc.).

Household Member Name

Source of Income

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Household Member Name

Source of Income

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Household Member Name

Source of Income

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Household Member Name

Source of Income

Current Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Anticipated Gross Earnings $

Please specify if this amount is Per Hour, Per Week, Per Month or Per Year

Assets

Checking Account - Bank 1 Name

Account # - Bank 1

Amount $ - Bank 1

Checking Account - Bank 2 Name

Account # - Bank 2

Amount $ - Bank 2

Passbook Savings Account - Bank 1 Name

Passbook Savings Account # - Bank 1

Passbook Savings Amount $ - Bank 1

Passbook Savings Account - Bank 2 Name

Passbook Savings Account # - Bank 2

Passbook Savings Amount $ - Bank 2

Savings Certificates Account - Bank 1 Name

Savings Certificates Account # - Bank 1

Savings Certificates Amount $ - Bank 1

Savings Certificates Account - Bank 2 Name

Savings Certificates Account # - Bank 2

Savings Certificates Amount $ - Bank 2

Credit Union Shares - C.U. Name

Credit Union Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Union Shares Account # - Bank 1

Credit Union Shares Amount $ - Bank 1

Stocks and Bonds (value): $

War Bonds (value): $

Do you NOW own real estate?*

Yes

No

If “yes” what is the value of your real estate?

Have you ever owned real estate?*

Yes

No

If “yes” when?

Life Insurance Policy

List below any life insurance policy and numbers that you may have and names and addresses of insurance companies:

Policy 1 #

Policy 1 ~ Name

Policy 1 Company Address

Street Address Address Line 2 City State ZIP Code

Policy 2 #

Policy 2 Name

Policy 2 Company Address

Street Address Address Line 2 City State ZIP Code

Policy 3 #

Policy 3 Name

Policy 3 Company Address

Street Address Address Line 2 City State ZIP Code

Medical and Unusual Expenses

Do you pay for child care while a family member is employed?*

Yes

No

If “yes” list child care provider’s name, address and telephone number:

Child Care Cost Per Month $

Are you receiving Medicare Benefits?*

Yes

No

Are you receiving Medical Assistance through the Welfare Department?*

Yes

No

Do you pay for any medical insurance / hospitalization (such as Blue Cross, etc.?)*

Yes

No

Is this medical insurance / hospitalization a payroll deduction?

Yes

No

If “yes” how often and how much?

Are you making payments on outstanding medical bills?*

Yes

No

Do you take prescription drugs on a regular basis?*

Yes

No

Do you anticipate any health care related expenses for the next 12 months which are not covered by health insurance?*

Yes

No

Program Information

Have you ever applied for or participated in a rental assistance program?*

Yes

No

If “yes”, explain:

How did you hear about the program?*

Are you or any household member a registered sex offender?*

Yes

No

Digital Signature

By signing below you agree all application information you have provided is TRUE and Complete to the best of my knowledge.

Date*

MM slash DD slash YYYY

Applicant 1 Signature*

If Applicable - Applicant 2 Digital Signature

RACIAL GROUP INDENTIFICATION (used for statistical purposes only).

The following information is required for statistical purposes so the Department of HUD may determine the degree to which its programs are utilized by minority families.

Your Racial Group

White

Black

American Indian

Spanish American

Oriental (Japanese, Korean, Chinese, Filipino)

Other

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any Department or Agency of the U.S. as to any matter within its jurisdiction.

Marinette County Housing Authority • PO Box 438 • Wausaukee, Wisconsin 54177

To submit, what is 2000+25=*

Comments

This field is for validation purposes and should be left unchanged.

Location

Marinette County Housing Authority
926 Main Street
Wausaukee, WI 54177

Contact Information

Phone: 715-856-6114
Fax: 715-856-6928
Email: info@mcha-wha.org

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Section 8
Wausaukee WI Only Public Housing
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