Dodge County Housing Authority

Dodge County Housing Authority

491 E. Center St.
Juneau, WI 53039-1374

Phone: (920) 386-2866
Fax: (920) 386-2725
Email: leasing@dodgehousing.org
www.dodgehousing.org

Please click here to download a printable version of the Dodge County Housing Authority - Affordable Apartment Program Rental Application and fill out manually

Application for Occupancy

Select the location you are applying for


Apartments for seniors (62+) or persons living with a disability regardless of age**

Apartments for ANY low income persons

**A person receiving SS, SSI, SSD or other disability benefit is eligible. If a person is not receiving SS, SSI, SSD or other disability benefit, an applicant may be eligible if a medical professional can verify the applicant meets the definition of disability.

Applicant Information

Last Name
*
First Name
*
Middle Initial
Date of Birth
*
Sex
*
Present Address
*
(PO Box/Mailing Address)
City
*
State
*
Zip Code
*
Home Phone
Cell Phone
*
Social Security Number
*

Ethnicity (Select one)***
Race (Select all that apply)***
*** There is no penalty for not disclosing this information. It is gathered for statistical purposes only.

Additional Household Member Information


Indicate the current status of all other adults and children that will live in the housing apartment. Add new members in the space provided below, including the full Social Security number for each.
Last Name
*
First Name
*
Middle Initial
Date of Birth
*
Sex
*
Social Security Number
*
Relation to Applicant
*

Ethnicity (Select one)***
Race (Select all that apply)***
*** There is no penalty for not disclosing this information. It is gathered for statistical purposes only.
What is your preferred moving date?
*

Please list names
*

Please list below all former addresses within the past 7 years, starting with the present:

Property Address
*
From Date (Month & Year)
*
To Date (Month & Year)
*
Own/Rent?
*
Name of Owner/Manager
*
Phone Number of Owner/Manager
*
Address of Owner/Manager
*

Asset Information

Name on Account
*
Type of Asset
*
Current Balance
*
Name of Institution
*
Address of Institution
*

Income Information

Applicant Name
*
Type of Income
*
Gross Income Amount
*
Indicate if income listed is hourly, weekly, monthly or annually.
Name of Income Source
*
Address of Income Source
*

Household Expenses

Out of pocket medical expenses (To be completed for households with persons who are disabled or age 62+ only) Include doctor, dentist, eye care, supplemental health insurance, hearing aid payments, monthly payments required on accumulated major medical bills, even over the counter medication your doctor recommends.

Applicant Name
*
Type of Expense
*
Amount
*
Indicate if amount listed is monthly or annually
Name of Medical Provider
*
Address of Medical Provider
*

All Adult Household Members Must Sign This Form Certifying Accuracy of Information Provided


I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that false or incomplete information is grounds for termination of housing assistance and/or termination of tenancy. 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
*
Date
*
The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, actingthrough the USDA/Rural Development, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin,religion, sex, familial status, age, and disability are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.

"The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disa-bility, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, orbecause all or a part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons withdisabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGETCenter at (202) 720-2600 (voice and TDD).To file a complaint of discrimination write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue,S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider, employer, and lender.”

This institution is an equal opportunity provider and employer.

Criminal History Disclosure


All adult applicants are required to disclose criminal history. If you have any criminal charges, misdemeanor or felony, you must disclose that information regardless of the date of occurrence. Court records and/or background check will be accessed for all applicants to verify this information. Indicate any criminal charges and sign below.
Applicant Name
*
List all states in which you have ever lived
*

Criminal History
*

Which state?
*
This information will be verified using the Dru Sjodin National Sex Offender database.
By signing this form I acknowledge that I have reported all criminal history. I understand that not disclosing criminal history information makes my application invalid and may be grounds for denial or termination of housing.
Signature
*
Date
*

Declaration of Citizenship Status (Section 214)

Complete for each household member.

NOTICE TO APPLICANTS AND TENANTS: In order to be eligible to receive the housing assistance you seek, you, as an applicant or current recipient of housing assistance, must be lawfully within the U.S. Please read the Declaration statements carefully, check that which applies to you, and sign and return the document to the Housing Authority Office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.

1/ Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses adocument or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, or both.

The following footnotes pertain to noncitizens who declare eligible immigration status in one of the following categories:

2/ Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required.

3/ Immigrant status under §§101(a)(15) or 101(a)(a)(20) of INA. A noncitizen lawfully admitted for permanent residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by §101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under §§210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status.

4/ Permanent residence under §249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under §249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249].

5/ Refugee, asylum, or conditional entry status under §§207, 208 or 203 of INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under §208 of the INA (8 U.S.C. 1158 [asylum status]; or as a result of being granted conditional entry under §203(a)(7) of the INA (U.S.C. 1153 (a)(7)) before April 1, 1980, because of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].

6/ Parole status under §212(d)(5) of INA. A noncitizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5)[parole status].

7/ Threat to life or freedom under §243(h) of INA. A noncitizen who is lawfully present in the U.S. as a result of the Attorney General’s withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h) [threat to life or freedom].

8/ Amnesty under §245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under §245A of the INA (8 U.S.C. 1255a)[amnesty granted under INA 245A].

I,
Household Member Name
*
, certify, under penalty of perjury 1/, that, to the best of my knowledge, I am lawfully within the United States because (please check the appropriate box):

Signature of Family Member
*
Date
*
Equal Housing Opportunity
This institution is an equal opportunity provider and employer.
Handicap Accessible