Mississippi Regional Housing Authority No. VII
Section 8/Housing Choice Voucher Program
TTY Telephone: 1-800-582-2233
P. O. Box 430 - McComb, MS 39649  -  Phone: (601)-684-9503, Ext 7022 – Fax: (601)-684-3312
Online Waiting List Website: mrha7.housingmanager.com
Online Waiting List Phone: (601)-684-9503, Ext. 7022
HCV Program Email: hcv@mrha7.org
Pre-Application For Section 8/Housing Choice Voucher Program

	This form is a Pre-Application. The information on this form will be used to determine your position on the Waiting List. This ORIGINAL completed Pre-Application form must be returned to our office for processing.  (DO NOT SEND THIS FORM TO US BY FAX!)  Please PRINT in a NEAT and CLEAR handwriting. You must be Twenty-One (21) years old, or an Emancipated Minor. If any field is left blank, your Pre-Application will not be accepted and you will have to re-apply. 

Applicant's Name			 Phone Number: Home (or) Cell                                                     Marital Status
                                                                                                                                                                                                         
Current Mailing Address						City	                  State	        Zip Code                 
__________________________________________________________________________________________________
Current Street Address						City	                  State	        Zip Code                    
_________________________________________________________________________________________________
Email Address   									             County You Live In

Additional Contact (Optional): Name_______________________________________ Relationship: ________________ 
            Mailing Address Of Contact: ___________________________________________________________________
            Phone Number: ______________________ Email Address: _____________________________________
   
LOCAL PREFERENCES: Please answer ‘YES’ or ‘NO’
1.   Have you been the victim of a Federally-Declared Natural disaster in the last 6 months?  ______ If you answered YES, you must provide us with a COPY of your FEMA Letter.
2.   Are you a client with the state of Mississippi Department Of Medicaid program called Bridge To Independence? _____. If you answered YES, you must provide us with a letter from the Department of Medicaid confirming your B2I status.             

ANSWER ALL OF THE QUESTIONS BELOW – DO NOT LEAVE BLANK
1. 	Which county do you live in?                   ___________________________________________________________      
2. 	Is the head of household enrolled full-time (or) part-time in an institution of higher education (college or vocational classes)? YES or NO. ( If ‘YES’, please give the name of the college/school)  ____________________________________
3.          Is the head of household elderly (at least 62 years old)?    YES   or    NO      
4.         Is the head of household handicapped or disabled? )?    YES   or    NO      	
5. 	What is your Race? _____________________(required by Federal Regulations)  Ethnicity: Hispanic   or   Non-Hispanic
6. 	Have you or any person listed on your Pre-Application, ever been arrested or convicted of a crime? YES   or    NO   If YES, please explain. _______________________________________________________________________________
7.	 Are you or anyone in your household registered with any state as a lifetime sex offender? YES   or    NO        If YES, please list the names of these household members. ___________________________________________________ Please list ALL states where they have lived: _____________________________________________________________.
8. 	Have you previously resided in Section 8 Housing or Public Housing?  YES   or    NO        What date did you move in? ________________    What date did you move out? _________________
Name of previous Housing Authority? _____________________________________________   Did you leave owing a balance with the previous Housing Authority? YES   or    NO        
9. 	Have you or any household member ever committed fraud or been requested to repay for knowingly misrepresenting information in a Federally assisted housing program? YES or NO If YES, please explain. __________________________________________________________________________________________________
10. 	Have you or any other adult members ever used any name(s) or Social Security number(s) other than the one currently being used? YES   or    NO   If YES, please explain _________________________________________________ 
11.          Are you homeless? YES   or    NO      If YES, please explain briefly why you are homeless and describe your current housing situation. _____________________________________________________________________________
__________________________________________________________________________________________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++	
FOR OFFICE USE ONLY
Date Received:  _____________    Time Received:  _________      Staff Initials: _______   WL County: ___________  Preference (Y/N) ___
Student(Y/N): ____   Age of HOH: _____   # Dependents: ____ Lifetime Registry (Y/N) ____  Debts Owed(Y/N): _____   Eld/Disab(Y/N): ____

Total Household Income: (DO NOT LEAVE BLANK) List all money earned or received by EVERYONE who will live in your household, including money from wages, self-employment, child support, cash contributions, Social Security, disability payments (SSI), workman’s compensation, retirement benefits, TANF, Veterans benefits, rental property income, stock dividends, income from bank accounts, alimony, help from family and ALL other sources.  

Household Member Name	Monthly Wages	Monthly 
TANF	Monthly 
Child Support	Monthly 
Social Security or SSI	Monthly Unemployment or Worker’s Comp	ALL 
OTHER 
INCOME	

							

HOUSEHOLD DATA: In the chart below, please PRINT CLEARLY everyone who will be living in your household if you receive Section 8 Assistance.  You MUST use the name for each household member as listed on the Social Security card. 
	Name	Date Of Birth	Sex	Relationship	Social Security Number	
Head of Household						
Member #2						
Member #3						
Member #4						
Member #5						
Member #6						
Member #7						
Member #8						
PLEASE READ AND FOLLOW THE INSTRUCTIONS BELOW
1. 	If we contact you by mail, but the letter is returned by the Postal Service for ANY reason, you will be dropped, Therefore, please provide us with a complete and accurate mailing address. If you omit ANY information on this application, your name will NOT be placed on the waiting list. 
2. 	Changes to your address must be reported IN WRITING to this office. They will not be taken over the telephone. 
3.	 You may send clear and legible COPIES of Birth Certificates, Social Security Cards, for everyone in your household back to us along with this Pre-Application. However, if you do not have all the Birth Certificates and Social Security cards, then send us what you have. Please do not send originals, but send COPIES.
4.	 A PHOTO ID is required for everyone in your household who is 18 years of age or older. 
5. 	If neither the head of household nor the spouse is a resident of the jurisdiction of this Housing Authority at the time the pre-application is submitted, the family will be required to rent a unit in the jurisdiction of this Housing Authority during the first year of their rental assistance. This authority administers a Section 8 program in these counties: Adams, Amite, Franklin, Jefferson, Jeff Davis, Lawrence, Lincoln, Pike, Walthall, and Wilkinson.
REASONABLE ACCOMMODATIONS
Disability Rights in Private and Public Housing: Regardless of whether you live in private or public housing, Federal laws provide the following rights to persons with disabilities. IF YOU REQUIRE REASONABLE ACCOMMODATIONS, PLEASE CONTACT MRS. ALICE BISHOP AT (601)-684-9503, EXT. 7012
●    	Prohibits discrimination against persons with disabilities. It is unlawful for a housing provider to refuse to rent or sell to a person simply because of a disability. A housing provider may not impose different application or qualification criteria, rental fees or sales prices, and rental or sales terms or conditions than those required of or provided to persons who are not disabled. 
●  	Requires housing providers to make reasonable accommodations for persons with disabilities. A reasonable accommodation is a change in rules, policies, practices, or services so that a person with a disability will have an equal opportunity to use and enjoy a dwelling unit or common space. A housing provider should do everything s/he can to assist, but s/he is not required to make changes that would fundamentally alter the program or create an undue financial and administrative burden. Reasonable accommodations may be necessary at all stages of the housing process, including application, tenancy, or to prevent eviction. 
●	Requires housing providers to allow persons with disabilities to make reasonable modifications. A reasonable modification is a structural modification that is made to allow persons with disabilities the full enjoyment of the housing and related facilities. Reasonable modifications are usually made at the resident's expense. However, there are resources available for helping fund building modifications. Additionally, if you live in federally assisted housing the housing provider may be required to pay for the modification if it does not amount to an undue financial and administrative burden.
●	      People with Disabilities in Federally Assisted Housing: Federal law makes it illegal for an otherwise qualified individual with a disability to be excluded, solely because of his or her disability, from programs receiving federal financial assistance. For more information on the rights of persons with disabilities in federally assisted housing as well as the responsibilities of housing providers who receive federal financial assistance, visit our Section 504: Disability Rights in HUD Programs site.

I have read the information above concerning my Pre-Application for housing assistance.  I certify that the information I have given is true and correct to the best of my knowledge.  
________________________________________        _______________________________	                                           
	           Signature				    Social Security Number		                 Date
WARNING: Title 18 Section 1001 of the United States Code states that a person who - knowingly and willingly makes false or fraudulent statements or representation; falsifies, conceals, or covers up any trick, scheme, or device; or makes or uses any false writing or document - to any department or agency of the Government of the United States shall be fined and imprisoned.