This Form is for Elderly & Disabled Applicants Only

INSTRUCTIONS FOR APPLYING FOR PUBLIC HOUSING

All potential applicants must follow the instructions listed below to be placed on our public housing waiting list. Failure to send all information requested will result in a delay of your application process.

We must receive the following:

1. Complete this application;

2. A copy (Front & Back) of driver’s license or other PICTURE ID for EACH adult in the household. (Front & Back of ID is required by the state for your criminal back ground check and can NOT be processed without it)

3. A copy of your birth certificate;

4. A copy of your social security card;

5. Criminal Record Check Release Form (click here to download)

If you own any real estate property or have you sold any within the past 2 years, including your own home, we will also require verification of the value. Verification we will accept include a real estate or bank appraisal or a copy of the most recent tax bill.

All the above copies of ID's, birth certificate, social security card and tax bills can be uploaded at the appropriate place in this application, brought to or mailed to the office at;

Westerly Housing Authority

C/O Application for Housing

5 Chestnut St.

Westerly, RI. 02891

or emailed to

We thank you for your interest in our sites.

If you are not Elderly or Disabled your form submission will automatically be rejected.

Are You Elderly or Disabled

Elderly-Disabled?*

Agree & Continue

All items with an * are required on all pages. You will not be able to proceed to the next page unless they are filled in. Please make sure all information is accurate before proceeding. Incorrect information will delay your application and a properly filled out application will secure your place in the waiting list.

First Name

Head of Household First Name*

Last Name

Head of Household Last Name*

Social Security Number

Head of Household Social Security Number*

Marital Status

Head of Household Marital Status*

Home Phone Number

Home Phone*

Work Phone Number

Work Phone

Address 1

Address 1*

Address 2

City

City*

State

State*

Zip Code

Zip Code*

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In this section of the application you will list points of contact, others who will live with you and citizenship.

In the fields below list the names and phone numbers of two friends or relatives that we can contact if we are unable to reach you.

Friend / Relatives Contact Info #1

Friend / Relative 1* Friend / Relative 1 Phone*

Friends / Relatives Contact Info #2

Friend / Relative 2* Friend / Relative 2 Phone*

List all persons including yourself, who will live in this rental unit while you are on this program. List all persons (head of household first).

Head ofHousehold

Full Name* Place of Birth* Relationship to Head of Household* Sex* Date of Birth* Social Security Number* School or Employer*

Household Member #2

Full Name Place of Birth Relationship to Head of Household Sex Date of Birth Social Security Number School or Employer

Household Member #3

Full Name Place of Birth Relationship to Head of Household Sex Date of Birth Social Security Number School or Employer

Household Member #4

Full Name Place of Birth Relationship to Head of Household Sex Date of Birth Social Security Number School or Employer

Household Member #5

Full Name Place of Birth Relationship to Head of Household Sex Date of Birth Social Security Number School or Employer

Citizenship

Are you a U.S. citizen?* If No, please explain:

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In this section all household income will be recorded.

List all full and/or part-time employment anticipated within the next 12 months for all household members (other than minor, dependent children under the age of 18) in the below fields. There are corresponding sections for previously recorded members of the household.

If self-employed use net income from business. (depreciation of property is allowed, and should be based on the straight line method used for tax purposes.)

Head of Household

Full Name Name & address of Employer Gross Ernings Per Week/Month/Year

Household Member #2

Full Name Name & address of Employer Gross Ernings Per Week/Month/Year

Household Member #3

Full Name Name & address of Employer Gross Ernings Per Week/Month/Year

Household Member #4

Full Name Name & address of Employer Gross Ernings Per Week/Month/Year

Household Member #5

Full Name Name & address of Employer Gross Ernings Per Week/Month/Year

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This section is where you will record other sources of income.

List all income anticipated within the next 12 months by each family member.

Head Of Household