Application for Admission

The Housing Authority of Danville
www.danvillehousingagency.com
859.236.6116
Physical Address:
1014 Rosemont Avenue
Danville, KY 40422
Mailing Address:
P.O Box 666
Danville, KY 40423-0666
Office hours:
Monday - Wednesday 8:00am - 5:00 pm
Friday: 8:00 am - 4:00 pm
(Closed to Public on Thursday)

Fields marked with * must be completed or form will not submit.

Application Instructions

Applicant must be 18 years of age to apply.
Applicant must provide a photo ID for everyone on the application 18 and over.
A certified birth certificate and social security card for everyone on the application.
HAD will make a copy of the documents and return the originals.
A contact phone number and/or address must be listed for an applicant, even if homeless. Make sure that your phone number and address are kept current. If we cannot contact you at the address and/or phone number given, your application may be withdrawn.
Do not list family members as personal references.

PLEASE NOTE: If information is incomplete or illegible, it will slow down the application process. If you have questions or need assistance completing the application forms, please contact the Admissions Office at 859-236-6116.

Please note that supplying fraudulent information and/or purposely omitting information is reason for an ineligible determination.

HUD Forms to attach:

[{"type":"file","required":true,"label":"<div>Attach HUD-52675 here.</div><div>Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking 'Open'.</div>","placeholder":"No file chosen","name":"HUD-52675","subtype":"file","multiple":true,"className":"d-block"},{"type":"file","required":true,"label":"<div>Attach HUD-92006 here.</div><div>Please select one or more files for upload. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking 'Open'.</div>","placeholder":"No file chosen","name":"HUD-92006","subtype":"file","multiple":true,"className":"d-block"},{"type":"header","subtype":"h3","label":"Applicant / Resident Certification","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I / We certify that the information* given to the Housing Authority of Danville on household composition, income, net family assets, and allowances and deductions is accurate and complete to the best of my / our knowledge and belief. I / We understand that false statements or information are punishable under Federal law. I / We also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy.","inline":true,"name":"Applicant--Resident-Certification","className":"d-block","values":[{"label":"I / We Certify.","value":""}]},{"type":"text","required":true,"label":"Head of Household Signature - Applicant / Resident Certification","name":"HOH-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date - Applicant / Resident Certification","name":"Date---Applicant","className":"col-md-6"},{"type":"text","required":true,"label":"Spouse or Other Adult Signature - Applicant / Resident Certification","name":"Spouse-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date - Spouse or Other Adult - Applicant / Resident Certification","name":"Date---Spouse","className":"col-md-6"},{"type":"checkbox-group","required":true,"label":"<span>If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity national toll-free hot line at 1-800 424-8590. (Within the Washington, D.C. Metropolitan area, call 426-3500.)</span><br><br><span>*After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development on Form HUD-50058 (Tenant Data Summary), a computer-generated facsimile of the form or on magnetic tape. See the Federal Privacy Act Statement for more information about its use.</span>","inline":true,"name":"App-Certification","className":"d-block","values":[{"label":"I acknowledge","value":""}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div>Note: Use Legal Names Only</div>","className":"d-block"},{"type":"header","subtype":"h3","label":"Head of Household","className":"d-block"},{"type":"text","required":true,"label":"Head of Household Name","placeholder":"(Last/First/Middle)","name":"HoH-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Sex","name":"HoH-Sex","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Social Security Number","name":"HoH-SS","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Head of Household Date of Birth","name":"HoH-DOB","className":"col-lg-4"},{"type":"text","required":true,"label":"Head of Household Race","name":"HoH-Race","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Ethnicity","placeholder":"(Hispanic/Non-Hispanic)","name":"HoH-Eth","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Source of Income","name":"HoH-Income","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Income Amount","name":"HoH-Amount","className":"col-md-6","subtype":"text"},{"type":"header","subtype":"h3","label":"Other Adults","className":"d-block"},{"type":"text","label":"Other Adult 1 Name","placeholder":"(Last/First/Middle)","name":"OA-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Adult 1 Sex","name":"OA-Sex","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Adult 1 Relationship to Head","name":"OA-Relationship","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Adult 1 Social Security Number","name":"OA-SSN","className":"col-md-6","subtype":"text"},{"type":"date","label":"Other Adult 1 Date of Birth","name":"OA-DOB","className":"col-md-6"},{"type":"text","label":"Other Adult 1 Race","name":"OA-Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Adult 1 Ethnicity","placeholder":"(Hispanic/Non-Hispanic)","name":"OA-Eth","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Adult 1 Source of Income","name":"OA-Income","className":"col-lg-4","subtype":"text"},{"type":"textarea","label":"List Additional Other Adults Below:","placeholder":"Name (Last/First/Middle), Sex, Relationship to Head, Social Security Number, Date of Birth, Race, Ethnicity (Hispanic/Non-Hispanic), Source of Income","name":"List-OA","subtype":"textarea","className":"d-block"},{"type":"header","subtype":"h3","label":"Minors","className":"d-block"},{"type":"text","label":"Minor 1 Name","placeholder":"(Last/First/Middle)","name":"M-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Minor 1 Sex","name":"M-Sex","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Minor 1 Relationship to Head","name":"M-Relation","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Minor 1 Social Security Number","name":"M-SSN","className":"col-md-6","subtype":"text"},{"type":"date","label":"Minor 1 Date of Birth","name":"M-DOB","className":"col-md-6"},{"type":"text","label":"Minor 1 Race","name":"M-Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Minor 1 Ethnicity","placeholder":"(Hispanic/Non-Hispanic)","name":"M-Eth","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Minor 1 Birthplace","name":"M-Birthplace","className":"col-lg-4","subtype":"text"},{"type":"textarea","label":"List Additional Minors Below:","placeholder":"Name (Last, First, Middle), Sex, Relationship to Head, Social Security Number, Date of Birth, Race, Ethnicity (Hispanic/Non-Hispanic), Birthplace","name":"Add-Minors","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","required":true,"label":"Enter your present Street Address","name":"Add","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Present City","name":"city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Present State","name":"Present-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Present Zip Code","name":"Pres-Zip","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"How long?","name":"Pres-How-Long","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Day Phone Number","name":"Pres-Day-Numb","className":"col-lg-4"},{"type":"text","subtype":"tel","required":true,"label":"Evening Phone Number","name":"Pres-Even-Numb","className":"col-lg-4"},{"type":"text","required":true,"label":"Enter your present Mailing Address","name":"Pres-Mail-Add","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Mailing City","name":"Mail-City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Mailing State","name":"Present-Mail-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Mailing Zip Code","name":"Pres-Mail-Zip","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Landlord's Name","name":"LL-Name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Landlord's Phone Number","name":"LL-Numb","className":"col-lg-4"},{"type":"text","required":true,"label":"Rent","name":"LL-Rent","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Emergency Contact Name","name":"Emer-Con-Name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Emergency Contact Day Phone Number","name":"Emer-Con-Day-Numb","className":"col-lg-4"},{"type":"text","subtype":"tel","required":true,"label":"Emergency Contact Evening Phone Number","name":"Emer-Con-Even-Numb","className":"col-lg-4"},{"type":"text","subtype":"email","required":true,"label":"Head of Household Email","name":"HoH-Email","className":"col-md-6"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"HoH-Email-Conf","className":"col-md-6"},{"type":"checkbox-group","required":true,"label":"<span>Notice: You are required to notify the Housing Authority (in writing) of any change of address. If we cannot contact you at the above address, your name may be removed from the Waiting List and you will have to re-apply. </span>","inline":true,"name":"Check-Changes-Con","className":"d-block","values":[{"label":"I acknowledge","value":""}]},{"type":"radio-group","required":true,"label":"<span>Is English your primary language?</span>","inline":true,"name":"Radio-Eng-Prim","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"If no, please list primary language.","name":"Prim-Lang","className":"col-lg-4","subtype":"text"},{"type":"radio-group","required":true,"label":"<span>Do you have limited ability to read, write, and understand English?</span>","inline":true,"name":"radio-under-Eng","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"checkbox-group","label":"<span>Do you claim any of the following preferences? If yes, please check all that apply. </span>","name":"checkbox-pref","other":true,"className":"d-block","values":[{"label":"Paying more than 50% of monthly income towards rent","value":""},{"label":"Living in substandard facility","value":""},{"label":"Involuntarily displaced","value":""},{"label":"Mobility impairment","value":""},{"label":"Hearing impairment","value":""},{"label":"Sight impairment","value":""},{"label":"Working","value":""},{"label":"None","value":""}]},{"type":"radio-group","required":true,"label":"<span>Have you ever violated a previous family obligation in connection with a HUD program?</span>","inline":true,"name":"radio-HUD","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""},{"label":"","value":""}]},{"type":"radio-group","required":true,"label":"<span>Have you ever engaged in the use/possession of drugs?</span>","inline":true,"name":"radio-drugs","className":"col-md-6","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Do you owe any money to a Public Housing Authority?</span>","inline":true,"name":"radio-owe-debt","className":"col-md-6","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Has any household member listed on this application ever lived in another state besides Kentucky since they turned the age of 18?</span>","inline":true,"name":"radio-state-not-KY","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"textarea","label":"If yes, please list who and what state they lived in.","name":"textarea-other-state","subtype":"textarea","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<span>I do hereby certify that all information I have provided is complete and accurate. </span>","inline":true,"name":"checkbox-accurate","className":"d-block","values":[{"label":"I certify.","value":""}]},{"type":"text","required":true,"label":"Head of Household Signature","name":"text-hoh-sign","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Head of Household Signature Date","name":"date-hoh-date","className":"col-lg-4"},{"type":"text","required":true,"label":"Head of Household Signature Time","name":"text-hoh-time","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h3","label":"Fingerprint Submission Form","className":"d-block"},{"type":"text","required":true,"label":"Name","placeholder":"Last, First, Middle Initial","name":"text-fp-name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Maiden Name","name":"text-fp-mn","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Name of Head of Household","name":"text-fp-hoh-name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Address","name":"text-fp-address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"City","name":"text-fp-city","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"State","name":"fp-state","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL","selected":true},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Zip Code","name":"text-fp-zip","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Telephone","name":"text-fp-phone","className":"col-lg-4"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"text-fp-email","className":"col-lg-4"},{"type":"text","subtype":"email","required":true,"label":"Confirm Email ","name":"text-fp-confirm-email","className":"col-lg-4"},{"type":"text","label":"Employee Requesting Prints:","name":"text-fp-employ","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Location to be charged:","name":"text-fp-location","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Date","name":"date-fp-date","className":"col-lg-4"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h3","label":"Applicant Privacy Notification Policy","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<div class=\"mb-2\">Notification: The Housing Authority of Danville (HAD) provides low-income housing for applicants, and as a part of the application process, performs criminal background checks through local law enforcement for all adult household members. If the results of the criminal background check indicate there may have been past criminal activity, but the results are inconclusive, the Housing Authority of Danville will request a fingerprint card and will request information from the National Crime Information Center (NCIC). </div><div class=\"mb-2\">Record Challenge/Correction: If you choose to challenge the accuracy of your criminal record or need to correct or update your criminal record your have 180 days to do so. The procedures for challenging an FBI record are set forth in 28 CFR 16.30 through 16.34. HAD will provide you with a copy of your criminal history.</div><div class=\"mb-2\">Appeal Process: You are given an opportunity to appeal an adverse decision based on the criminal history record information provided from the fingerprint-based background check. The procedures for the appeal process are as follows:</div><div class=\"mb-2\">- Informal hearing with the Informal Hearing Officer. </div>","inline":true,"name":"checkbox-notify","className":"d-block","values":[{"label":"I understand.","value":""}]},{"type":"text","required":true,"label":"Applicant Privacy Notification Policy Signature","name":"text-app-priv-sign","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Applicant Privacy Notification Policy Signature Date","name":"date-app-priv-date","className":"col-md-6"},{"type":"header","subtype":"h3","label":"Applicant Record Notification","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<div class=\"mb-2\">Notification: Fingerprints submitted will be used to check the criminal history records of the FBI</div><div class=\"mb-2\">Obtaining Copy: Procedures for obtaining a copy of FBI criminal history record are set forth at Title 28. Code of Federal Regulations (CFR), Section 16.30 through 16.34 or go to the FBI website at Http://www.fbi.gov/about-us/cjis/background-checks</div><div class=\"mb-2\">Change, Correction, or Updating: Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34</div>","inline":true,"name":"checkbox-app-reco-noti","className":"d-block","values":[{"label":"I acknowledge.","value":""}]},{"type":"text","required":true,"label":"Applicant Record Notification Signature","name":"text-app-sign","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Applicant Record Notification Signature Date","name":"date-app-date","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<span>Noncriminal Justice Applicant's Privacy Rights</span><br><div class=\"mb-2\"><div class=\"mb-2\">As an applicant who is the subject of a national fingerprint-based criminal history record check for a noncriminal justice purpose {such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.</div><div class=\"mb-2\">- You must be provided written notification I that your fingerprints will be used to check the criminal history records of the FBI.</div><div class=\"mb-2\">- You must be provided, and acknowledge receipt of, an adequate Privacy Act Statement when you submit your fingerprints and associated personal information. This Privacy Act Statement should explain the authority for collecting your information and how your information will be used, retained, and shared.</div><div class=\"mb-2\">- If you have a criminal history record, the officials making a determination of your suitability for the employment, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.</div><div class=\"mb-2\">- The officials must advise you that the procedures for obtaining a change, correction, or update of your criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.</div><div class=\"mb-2\">- If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record (or decline to do so) before the officials deny you the employment, license, or other benefit based on information in the criminal history record. You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation, executive order, rule, procedure, or standard established by the National Crime Prevention and Privacy Compact Council. </div><div class=\"mb-2\">If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cji s/identity-history-summary-checks. If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI.</div><div class=\"mb-2\">Alternatively, you may send your challenge directly to the FBI. The FBI will then forward our challenge to the agency that contributed the questioned information and request the agency to verify or Correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.)</div></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h3","label":"Screening Questionnaire","className":"d-block"},{"type":"text","required":true,"label":"Applicant's Name","name":"App-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Applicant's Present Address","name":"App-Address","className":"col-md-6","subtype":"text"},{"type":"radio-group","required":true,"label":"<span>1. Has anyone listed on this application ever lived in Public Housing?</span>","inline":true,"name":"Radio-PH","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"paragraph","subtype":"p","label":"If yes, please list below:","className":"d-block"},{"type":"text","label":"Housing Authority Name:","name":"HA-Name","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Housing Authority Phone Number:","name":"HA-Phone","className":"col-md-6"},{"type":"date","label":"Housing Authority - Dates: From","name":"HA-Date-From","className":"col-md-6"},{"type":"date","label":"Housing Authority - Dates: To","name":"HA-Date-To","className":"col-md-6"},{"type":"text","label":"Housing Authority - Address you lived at:","name":"HA-Address","className":"d-block","subtype":"text"},{"type":"text","label":"Housing Authority - Lease in Name of:","name":"HA-Lease-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Housing Authority - Reason for Moving:","name":"HA-Reason","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"2. List names, addresses and phone numbers of the last five addresses beginning with your most recent address (even if you have not ever rented). If you lived with someone and were not on the lease, please indicate that in the 'Landlords Name' area.<div><br></div><div>Please note if the Landlord is a relative. You must provide a phone number for the landlord.</div><div>Landlord is the person that receives the rent for the apartment/house, not the person that you live with.</div>","className":"d-block"},{"type":"date","label":"Landlord 1: Dates: From","name":"LL1-Date-From","className":"col-lg-4"},{"type":"date","label":"Landlord 1: Dates: To","name":"LL1-Date-To","className":"col-lg-4"},{"type":"radio-group","label":"<span>Landlord 1: Is the Landlord a Relative?</span>","inline":true,"name":"LL1-Relative","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"Landlord 1: Name","name":"LL1-Name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Landlord 1: Phone Number","name":"LL1-Phone","className":"col-lg-4"},{"type":"text","label":"Landlord 1: Address","name":"LL1-Address","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Landlord 1: Lease in Name of:","name":"LL1-Lease-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Landlord 1: Reason for Moving:","name":"LL1-Reason","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"date","label":"Landlord 2: Dates: From","name":"LL2-From","className":"col-lg-4"},{"type":"date","label":"Landlord 2: Dates: To","name":"LL2-Dates-To","className":"col-lg-4"},{"type":"radio-group","label":"<span>Landlord 2: Is the Landlord a Relative?</span>","inline":true,"name":"LL2-Relative","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"Landlord 2: Name","name":"LL2-Name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Landlord 2: Phone Number","name":"LL2-Phone","className":"col-lg-4"},{"type":"text","label":"Landlord 2: Address","name":"LL2-Address","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Landlord 2: Lease in Name of:","name":"LL2-Lease-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Landlord 2: Reson for Moving:","name":"LL2-Reason","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"date","label":"Landlord 3: Dates: From","name":"date-LL3-Dates-From","className":"col-lg-4"},{"type":"date","label":"Landlord 3: Dates: To","name":"date-LL3-dates-to","className":"col-lg-4"},{"type":"radio-group","label":"<span>Landlord 3: Is the Landlord a Relative?</span>","inline":true,"name":"radio-group-LL3-relative","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"Landlord 3: Name","name":"text-LL3-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Landlord 3: Phone Number","name":"text-LL3-numb","className":"col-lg-4"},{"type":"text","label":"Landlord 3: Address","name":"text-LL3-add","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Landlord 3: Lease in Name of:","name":"text-LL3-lease-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Landlord 3: Reason for Moving:","name":"text-LL3-reason","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"date","label":"Landlord 4: Dates: From","name":"date-LL4-date-from","className":"col-lg-4"},{"type":"date","label":"Landlord 4: Dates: To","name":"date-LL4-date-to","className":"col-lg-4"},{"type":"radio-group","label":"<span>Landlord 4: Is the Landlord a Relative?</span>","inline":true,"name":"radio-group-LL4-relative","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"Landlord 4: Name","name":"text-LL4-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Landlord 4: Phone Number","name":"text-LL4-phone","className":"col-lg-4"},{"type":"text","label":"Landlord 4: Address","name":"text-LL4-address","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Landlord 4: Lease in Name of:","name":"text-LL4-lease-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Landlord 4: Reason for Moving:","name":"text-LL4-reason","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"date","label":"Landlord 5: Dates: From","name":"date-LL5-date-from","className":"col-lg-4"},{"type":"date","label":"Landlord 5: Dates: To","name":"date-LL5-date-to","className":"col-lg-4"},{"type":"radio-group","label":"<span>Landlord 5: Is the Landlord a Relative?</span>","inline":true,"name":"radio-group-LL5-relative","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"Landlord 5: Name","name":"text-LL5-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Landlord 5: Phone Number","name":"text-LL5-phone","className":"col-lg-4"},{"type":"text","label":"Landlord 5: Address","name":"text-LL5-address","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Landlord 5: Lease in Name of:","name":"text-LL5-lease-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Landlord 5: Reason for Moving:","name":"text-LL5-reason","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"<span>3. Have you ever been evicted from a residence?</span>","inline":true,"name":"radio-group-evicted-residence","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"paragraph","subtype":"p","label":"If yes, please list landlord's name, address, phone number and reason.","className":"d-block"},{"type":"text","label":"Landlord Name","name":"text-evicted-LL-name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Landlord Address","name":"text-evicted-LL-address","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Landlord Phone Number","name":"text-evicted-LL-phone","className":"col-lg-4"},{"type":"text","label":"Reason","name":"text-evicted-reason","className":"d-block","subtype":"text"},{"type":"radio-group","required":true,"label":"<span>4. Have any family members or expected visitors been banned from HAD Properties?</span>","name":"radio-group-banned","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"paragraph","subtype":"p","label":"If yes, list below:","className":"d-block"},{"type":"text","label":"Name of Banned Person:","name":"text-name-banned","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Relation to Banned Person:","name":"text-relation-banned","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Area Banned From:","name":"text-area-banned","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Dates Banned:","name":"text-date-banned","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"5. Give names, addresses and phone numbers of three (3) persons who can provide a reference. References must be 25 years or older and have known you for five (5) years or more. Do not include relatives.","className":"d-block"},{"type":"text","required":true,"label":"Reference 1 Name:","name":"text-reference1-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Reference 1 Phone Number:","name":"text-reference1-phone","className":"col-lg-4"},{"type":"text","required":true,"label":"Reference 1 Address:","name":"text-ref1-address","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Reference 2 Name:","name":"text-ref2-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Reference 2 Phone Number:","name":"text-ref2-phone","className":"col-lg-4"},{"type":"text","required":true,"label":"Reference 2 Address:","name":"text-ref2-address","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Reference 3 Name:","name":"text-ref3-name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Reference 3 Phone Number:","name":"text-ref3-phone","className":"col-lg-4"},{"type":"text","required":true,"label":"Reference 3 Address:","name":"text-ref3-address","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"mb-2\">WARNING:</div><div class=\"mb-2\">PENALITIES FOR MISUSING APPLICANT AND RESIDENT INFORMATION: Title18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false and fraudulent statements to any department of the United States Government. HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected from the applicant or resident. Any persons who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or resident may be subject to a misdemeanor and fined not more than 45,000. Any applicant or resident affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use.</div>","className":"d-block"},{"type":"text","required":true,"label":"Applicant Signature","name":"text-warning-signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Applicant Signature","name":"date-warning-app-signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"<span>Do you smoke?</span>","name":"radio-group-smoke","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Do you have a pet?</span>","name":"radio-group-1pet","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Do you have income?</span>","name":"radio-group-income","className":"col-lg-4","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","required":true,"label":"Applicant's Signature","name":"text-applicant-signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Applicant's Signature","name":"date-smoke-pet-income-signature","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"HAD Representative Signature","placeholder":"HAD Use Only","name":"text-HAD-signature","value":"HAD Use Only","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Date of HAD Representative Signature","placeholder":"HAD Use Only","name":"text-date-had-signature","value":"HAD Use Only","className":"col-md-6"},{"type":"header","subtype":"h3","label":"Notice to Applicants Concerning Preferences","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div><font><span><b>The Housing Authority of Danville selects its applicants for housing on a first come, first served basis, and several preferences that include a local preference.</b></span></font></div><div><font><span><b>Local preferences are as follows:</b></span></font></div><div><b><span>Victims of a Natural Disaster </span></b><span>who were or were not, prior to the disaster, receivingassistance from public housing or a housing choice voucher program.</span></div><div><b><span>Veterans of the Armed Forces</span></b></div><div><b>Elderly/Disabled     Families</b></div><div><u>Elderly</u> preference is availablewhen the head or spouse/significant other is aged 62 or older.</div><div><u><span>Disabled</span></u><span>preference is available when the applicant’s household will contain one or moremembers who are considered disabled as defined in HAD’s Housing Policy.</span></div><div><b>Employment</b></div><div><span>At least one adult family member must be (working atleast 20 hours per week). </span></div><div><b>School/Education/Job     Training</b></div><div><span>Applicants with an adult family member who is enrolledin college/vocational school (minimum of 6 or more credit hours) per semester;or enrolled in an employment training program; adult continuing educationprogram (e.g. JOBS, GED, etc.)</span></div><div><b><span>Homeless/Domestic Violence Victim </span></b></div><div><b><span>Boyle County Residents</span></b><font><span><b><br></b></span></font></div><div><p>Among applicants with the same preference points,date and time of application will be used to determine placement on the waitinglist.<b><o:p></o:p></b></p></div>","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<div class=\"mb-2\">If you feel that you may qualify for a preference, please advise this office and be prepared to provide verification. The Housing Authority is required to adequately verify any applicant’s claim for any preferences.</div><div class=\"mb-2\">CERTIFICATION</div><div class=\"mb-2\">The undersigned applicant hereby certifies that he or she was informed of the Housing Authority of Danville's preferences and was given an opportunity to show that he/she may qualify for a preference.</div>","inline":true,"name":"checkbox-group-preferences","className":"d-block","values":[{"label":"I Certify.","value":""}]},{"type":"text","required":true,"label":"Certification - Applicant Signature","name":"text-certification-sign","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Certification - Date of Applicant Signature","name":"date-certification-date-signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h3","label":"Declaration of Citizenship (Section 214) Status","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<span>Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully and sign and return to the Housing Authority of Danville's office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.</span>","inline":true,"name":"checkbox-group-declaration","className":"d-block","values":[{"label":"I acknowledge.","value":""}]},{"type":"text","required":true,"label":"Name of the Head of Household","name":"text-declaration-hoh-name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Social Security Number of Head of Household","name":"text-declaration-SSN","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"I, ____________________ certify, under penalty of perjury (refer to #1 below), that, to the best of my knowledge, I am lawfully within the United States because: (Please check the appropiate box)","name":"text-declaration-certify","className":"d-block","subtype":"text"},{"type":"radio-group","required":true,"label":"<span>Please check the appropriate response:</span>","name":"radio-group-declaration-response","className":"d-block","values":[{"label":"I am a citizen by birth, a naturalized citizen or a national of the United States; or ","value":""},{"label":"I have eligible immigration status and I am 62 years of age or older. Attach evidence of proof of age (refer to #2 below), or ","value":""},{"label":"I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing, eligible immigration status and signed verification consent form.","value":""},{"label":"Immigration status under şş101(a)(15) or 101(a)(201) of the Immigration and Nationality Act (INA) (refer to #3 below), or","value":""},{"label":"Permanent residence under ş249 of INA (refer to #4 below); or","value":""},{"label":"Refugee, asylum, or conditional entry status under şş207, 205 or 203 of the INA (refer to #5 below), or","value":""},{"label":"Parole status under ş212(d)(5) of the INA (refer to #6 below); or","value":""},{"label":"Threat to life or freedom under ş243(h) of INA (refer to #7 below); or","value":""},{"label":"Amnesty under ş245 of INA (refer to #8 below).","value":""}]},{"type":"text","required":true,"label":"Signature of Family Member","name":"text-declaration-signature-family","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature of Family Member","name":"date-declaration-date-signature-family","className":"col-md-6"},{"type":"checkbox-group","label":"<span>Check here if you are signing for minor child listed above and you are an adult residing in the unit who is responsible for that child.</span>","inline":true,"name":"checkbox-group-declaration-child","className":"d-block","values":[{"label":"I am responsible.","value":""}]},{"type":"text","subtype":"disabled","label":"Housing Authority: Enter INS/SAVE Primary Verification # and Date:","placeholder":"HAD Use Only","name":"text-ha-ins-save","value":"HAD Use Only","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"mb-2\">1. Warning: 18 U.S.C.1001 provides, among other things, that whoever knowingly and willfully makes or uses a document 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 that $100,000, imprisoned for not more than five years, or both. The following footnotes pertain to non-citizens who declare eligible immigration status in one of the following categories:</div><div class=\"mb-2\">2. Eligible immigration status and 62 years of age or older. For non-citizens 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, 2995. 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.</div><div class=\"mb-2\">3. Immigrant status under şş101(n)(15 or 202(a)(20) of INA. A non-citizen lawfully admitted for permanent residence, as defined by ş101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by ş101(a)(15) of the INA (8 U.S.C. 1101(a)(20) AND 1101(A (15), respectively (immigrant status). This category includes a non-citizen admitted under şş210 or şş210A of the INA (8 U.S.C. 1160 or 1161), (special agricultural worker status), who has been granted lawful temporary resident status.</div><div class=\"mb-2\">4. Permanent residence under ş249 of INA. A non-citizen 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 ş249 of INA (8 U.S.C. 1259) (amnesty granted under INA 249).</div><div class=\"mb-2\">5. Refugee, asylum, or conditional entry status under şş207, 205 or 203 of INA. A non-citizen who is lawfully present in the U.S. pursuant to an admission under ş207 of the INA (8 U.S.C. 1157) (refugee status); pursuant to the granting of asylum (which has not been terminated) under ş208 of the INA (8 U.S.C. 1158) (asylum status); or as a result of being granted conditional entry under ş203(a)(7) of the INA (U.S.C. 1153(a)(7) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity (conditional entry status).</div><div class=\"mb-2\">6. Parole status under ş212 (d)(5) of INA. A non-citizen 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 ş212 (d)(5) of INA (8 U.S.C. 1182(d)(5)) (parole status).</div><div class=\"mb-2\">7. Threat to life or freedom under ş243(h) of INA. A non-citizen who is lawfully present in the U.S. as a result of the Attorney General’s withholding deportation under ş243(h) of INA (8 U.S.C. 123(h) (Threat to life or freedom).</div><div class=\"mb-2\">8. Amnesty under ş245A of INA. A non-citizen lawfully admitted for temporary or permanent residence under ş245A of INA (8 U.S.C. 1255a) (amnesty granted under INA 245A).</div><div class=\"mb-2\">Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration status (other than for non-citizens age 62 or older and receiving assistance on June 19, 1995), HA must enter INS/SAVE Verification Number and date that it was obtained. A HA signature is not required. </div><div class=\"mb-2\"><div class=\"mb-2\">Instructions To Family Member For Completing Form: On opposite page, print or type first name, middle initial(s), and last name. Place an “X” or “!” in the appropriate boxes. Sign and date at bottom of page. Place an “X” or “!” in the box below the signature if the signature is by the adult residing in the unit who is responsible for Child.</div></div>","className":"d-block"},{"type":"header","subtype":"h3","label":"Special Unit Requirement(s) Questionnaire","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<span>This questionnaire is to be administered to every applicant for public housing at the Housing Authority of Danville (HAD) and residents (during re-certification). It is used to determine whether an applicant/resident family needs special features in their housing unit. The need for special adaptations must be verified in order to assure that the limited number of units with special features go to families that actually need the features. We ask that every applicant sign the bottom of the form to indicate receipt of the form, whether or not any special features are requested. No one is required to disclose a disability.</span>","inline":true,"name":"checkbox-group-special-unit-requirement-questionnaire","className":"d-block","values":[{"label":"I understand.","value":""}]},{"type":"paragraph","subtype":"p","label":"For Medical Reasons Only:","className":"d-block"},{"type":"radio-group","required":true,"label":"<span>Will you or any member of your family require any of the following:</span>","name":"radio-group-special-unit","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"checkbox-group","label":"<span>If yes, please check all that apply:</span>","name":"checkbox-group-special-unit-check-all","other":true,"className":"d-block","values":[{"label":"A separate bedroom","value":""},{"label":"Unit for Vision-Impaired","value":""},{"label":"Unit for Hearing-Impaired","value":""},{"label":"One-level Unit","value":""},{"label":"Bedroom & Bath on 1st Floor","value":""},{"label":"Live-in Aide","value":""},{"label":"Extra Bedroom","value":""}]},{"type":"radio-group","required":true,"label":"<span>Do you or any family members need any features not mentioned?</span>","name":"radio-group-features-not-mentioned","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"If yes, please indicate how HAD should accommodate your family:","name":"text-accommodate","className":"d-block","subtype":"text"},{"type":"text","label":"If you checked any of the above listed categories of units, please explain exactly what you need to accommodate your situation:","name":"text-explain-accommodations","className":"d-block","subtype":"text"},{"type":"text","label":"What is the name of the family member needing the features identified above?","name":"text-family-member-accommodations","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Applicant/Resident Signature","name":"text-applicant-signature-accommodations","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Applicant/Resident Signature","name":"date-applicant-signature-accommodations","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"HAD Representative Signature - Accommodations","placeholder":"HAD Use Only","name":"text-HAD-rep-accommodations","value":"HAD Use Only","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Date of HAD Representative Signature - Accommodations","placeholder":"HAD Use Only","name":"text-date-had-signature-accommodations","value":"HAD Use Only","className":"col-md-6"},{"type":"header","subtype":"h3","label":"Notice to All Applicants / Residents","className":"d-block"},{"type":"header","subtype":"h4","label":"Reasonable Accommodations for Applicants / Residents with Disabilities","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<span>The Housing Authority of Danville (HAD) is a public agency that provides low rent housing to eligible families, elderly families and single people. HAD is not permitted to discriminate against applicants on the basis of their race, religion, sex, national origin, or disability. In addition, HAD has a legal obligation to provide “reasonable accommodations” to applicants/residents if they or any family members have a disability.</span><div><span>A reasonable accommodation is some modification or change HAD can make to its apartments or procedures that will assist an otherwise eligible applicant with a legally recognized disability to take advantage of HAD's programs. Examples of reasonable accommodations would include the following:</span></div><divmaking alterations=\"\" to=\"\" a=\"\" had=\"\" unit=\"\" so=\"\" it=\"\" could=\"\" be=\"\" used=\"\" by=\"\" family=\"\" member=\"\" (resident)=\"\" with=\"\" wheelchair;<=\"\" span=\"\"><div><span>-Installing strobe type flashing light smoke detectors in an apartment for a family member with a hearing impaired member;</span></div><div><span>-Permitting a family to have a support animal necessary to assist a family member with a disability in a HAD family development where animals are not usually permitted;</span></div><div><span>-Making large type documents or a reader available to a vision-impaired applicant during the application process;</span></div><div><span>-Making a sign language interpreter available to a hearing impaired applicant during the interview;</span></div><div><span>-Permitting an outside agency to assist an applicant with a disability to meet the HAD's applicant screening criteria.</span></div><div><span><br></span></div><div><span>An applicant family that has a member with a disability must still be able to meet essential obligations of tenancy - they must be able to pay rent, to care for their apartment, to report required information to the Housing Authority, to avoid disturbing their neighbors, etc; however, there is no requirement that they be able to do these things without assistance.</span></div><div><span><br></span></div><div><span>If you or a member of your family has a disability, you may request a reasonable accommodation at the application process or after admission. This is up to you. If you would prefer not to discuss your situation with the Housing Authority, that is your right.</span></div><div><span><br></span></div></divmaking>","inline":true,"name":"checkbox-group-accommodations-disability-acknowledge","className":"d-block","values":[{"label":"I acknowledge.","value":""}]},{"type":"text","required":true,"label":"Signature of Applicant/Resident","name":"text-disability-signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature of Applicant/Resident","name":"date-date-signature-disability","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"HAD Representative Signature - Disabilities","placeholder":"HAD Use Only","name":"text-HAD-disabilities-signature","value":"HAD Use Only","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Date of HAD Representative Signature - Disabilities","placeholder":"HAD Use Only","name":"text-date-had-signature-disabilities","value":"HAD Use Only","className":"col-md-6"},{"type":"header","subtype":"h3","label":"Homeless Preference Questionnaire","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<span>In order for the Housing Authority of Danville to accurately report a new admission’s homelessness status on line 4c of the HUD Form 50058, please answer “Yes” or “No” to the following questions.</span>","inline":true,"name":"checkbox-group-homeless-understand","className":"d-block","values":[{"label":"I understand.","value":""}]},{"type":"checkbox-group","required":true,"label":"<span>Are you currently living in a car, on the street, or another place not meant for human habitation?</span>","name":"checkbox-group-homeless-car","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Are you currently living in an emergency shelter, transitional housing, Safe Haven, or a hotel/motel paid for by a charitable organization or by federal, state or local government programs for low-income individuals?</span>","name":"radio-group-homeless-current-status","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Are you exiting an institution, including a hospital, substance abuse or mental health treatment facility, or jail/prison, where you stayed for 90 days or less? If so, were you living in an emergency shelter or place not meant for human habitation immediately before entering that institution?</span>","name":"radio-group-homeless-exiting","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"radio-group","required":true,"label":"<span>Are you fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life threatening conditions for you or a family member, including a child, that has either taken place within your family’s primary nighttime residence or has made you afraid to return to your primary nighttime residence?</span>","name":"radio-group-homeless-fleeing","className":"d-block","values":[{"label":"Yes","value":""},{"label":"No","value":""}]},{"type":"text","label":"If yes, do you currently have nowhere else to live and also lack the resources or support networks, including family, friends, faith-based, or other social networks, to obtain other permanent housing?","name":"text-yes-homeless-explain","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"If the answer to any of the questions is yes, mark 'Y' for yes in field 4c of the HUD Form 50058. This information was obtained from HUD Notice: PIH 2013-15 (HA)","className":"d-block"},{"type":"header","subtype":"h3","label":"Violence Against Women Act (VAWA)","className":"d-block"},{"type":"text","required":true,"label":"I, ____________________ have received HUD Notice-5380 Occupancy Rights under the Violence Against Women Act and HUD Notice-5382 Certification of Domestic Violence, Dating Violence, Sexual Assault, or Stalking, and Alternate Documentation.","name":"text-vawa-received","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Applicant Signature - VAWA","name":"text-app-sign-vawa","className":"d-block","subtype":"text"},{"type":"date","required":true,"label":"Date of Applicant Signature - VAWA","name":"date-date-applicant-sign-vawa","className":"d-block"},{"type":"text","subtype":"disabled","label":"HAD Staff Signature","placeholder":"HAD Use Only","name":"text-had-staff-vawa","value":"HAD Use Only","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Date of HAD Staff Signature","placeholder":"HAD Use Only","name":"text-date-had-staff-vawa","value":"HAD Use Only","className":"col-md-6"}]