Wausaukee Public Housing Online Application

(Units located in Wausaukee, WI only)

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 or click here to download the PDF.

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

"*" indicates required fields

Select Apartment Facility You are Applying For:*

Evergreen Plaza

Edgewood Apartment

Part 1: Head of Household

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Social Security #*

Home Phone

Cell Phone

Birth Date*

MM slash DD slash YYYY

Gender*

Male

Female

Are you disabled?*

Yes

Part 2: Household Compostition Information

Name - Occupant 2

First Last

Birth Date

MM slash DD slash YYYY

Social Security #

Gender

Male

Female

Are you disabled?

Yes

Relationship

Name - Occupant 3

First Last

Birth Date

MM slash DD slash YYYY

Social Security #

Gender

Male

Female

Are you disabled?

Yes

Relationship

Name - Occupant 4

First Last

Birth Date

MM slash DD slash YYYY

Social Security #

Gender

Male

Female

Are you disabled?

Yes

Relationship

Name - Occupant 5

First Middle Last

Birth Date

MM slash DD slash YYYY

Social Security #

Gender

Male

Female

Are you disabled?

Yes

Relationship

Name - Occupant 6

First Last

Birth Date

MM slash DD slash YYYY

Social Security #

Gender

Male

Female

Are you disabled?

Yes

Relationship

Part 3: Name & Phone Numbers of Two Friends or Relatives

Name (Friend or Relative 1)

First Last

Phone

Name (Friend or Relative 2)

First Last

Phone

Part 4: Racial Group Identification (used for statistical purposes only)

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

Select Racial Group

White

Black

American Indian

Spanish American

Oriental (Japanese, Korean, Chinese, Filipino)

Other

Other Racial Group

Part 5: Family Income

(Examples of other income sources: Social Security, SSI, Disability benefits, pensions, alimony, child support, annuities, unemployment benefits, Foodshare, TANF, etc.). List total gross income and payments received by each family member age 18 or older.

Household Member Name

Employer or other income source:

Current Gross Earnings $

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

How often?

Weekly

Bi-Weekly

Monthly

Yearly

Household Member Name

Employer or other income source:

Current Gross Earnings $

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

How often?

Weekly

Bi-Weekly

Monthly

Yearly

Household Member Name

Employer or other income source:

Current Gross Earnings $

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

How often?

Weekly

Bi-Weekly

Monthly

Yearly

Household Member Name

Employer or other income source:

Current Gross Earnings $

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

How often?

Weekly

Bi-Weekly

Monthly

Yearly

Part 6: Assets

Checking Account, Savings Account, Stocks, Bonds, CD's, Investments, Real Estate, Life Insurance, & Other Assets

Checking Account: Cash Value of Asset

Checking Account: Income Earned from Asset

Savings Account: Cash Value of Asset

Savings Account: Income Earned from Asset

Stocks: Cash Value of Asset

Stocks: Income Earned from Asset

Bonds: Cash Value of Asset

Bonds: Income Earned from Asset

CD's: Cash Value of Asset

CD's: Income Earned from Asset

Investments: Cash Value of Asset

Investments: Income Earned from Asset

Real Estate: Cash Value of Asset

Real Estate: Income Earned from Asset

Life Insurance: Cash Value of Asset

Life Insurance: Income Earned from Asset

Other: Cash Value of Asset

Other: Income Earned from Asset

Part 7: Medical and Other Expenses

Medical Insurance Expense per week

Medical Insurance Expense per month

Hospitalization Expense per week

Hospitalization Expense per month

Outstanding Medical Expense per week

Outstanding Medical Expense per month

Anticipated Health Expense per week

Anticipated Health Expense per month

Prescription Expense per week

Prescription Expense per month

Childcare Expense per week

Childcare Expense per month

Other Expenses per week

Other Expenses per month

Part 8: Current Rental Information

Monthly Rent Amount $

Number of person(s) in household

Number of bedrooms

Utilities paid by you (check all that apply):

Heat

Electric

Hot Water

Water & Sewer

Other

Other Utilities paid by you

Part 9: Program Information

All applicants are subject to a criminal background check. If there are any incidents of drug activity or violent behavior within the past three years for misdemeanor, or seven years for a felony, the applicant may be ineligible for the program. Registered sex offenders are ineligible for the program.

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

Yes

Are you receiving Medicare benfits?*

Yes

Are you a registered sex offender?*

Yes

Have you had a felony conviction in the last 7 years?*

Yes

Have you had a misdemeanor in the last 3 years?*

Yes

Have you ever been evicted from public housing? If so, how long ago?

How did you hear about our program?

Digital Signature

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

Part 10: U.S. Citizenship Notification and Certification

Housing may be contigient upon the submission and verification of evidence of citizenship or eligible immigration status prior to the time housing is made available. Based on the evidence submitted at that time, assistance may be proprated, denied or terminated following appeals and informal hearing processes. I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000, or imprisoned up to five years, if I furnish false or incomplete information.

Applicant Signature*

Type Your Name

Date*

MM slash DD slash YYYY

Additional Notes:

I) All enrolled household members are screened and recertified annually.
II) Unreported household members or unreported income will result in program termination, housing fraud charges, and potential small claims court judgement requiring repayment of assisted funds.
III) Providing false information on your application is grounds for denial.

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

To submit, what is 25+500=*

Name

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