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Pre-Application
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All information MUST be completed correctly. Please be sure all information is accurate
before submitting.
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List all sources of Income and assets for all adults of your household, (anyone 18 years or older)
Use Gross income. Then select the Gross income Value example: Gross Monthly income.
Name
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Source of Income
(Employment (include address), Assets,
Other)
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Gross Income
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*Do you Own a Home? If Yes, what is it's market Value?
Name
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Other assets (Bank, CD, Stock, Bonds,
Estimated Value)
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Gross Value
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Name(s)
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Relationship
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Birthdate
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Sex
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Social Security#
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List all persons, Beginning with Head of Household, who Will live in the rental Unit:
Please select the number of Children
(under 18 years old)
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Please select the number of adults (18
years or older)
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Were you or any family member (applying for residence) ever arrested and/or
convicted for Drug related or Violent Criminal Activity? If Yes, please specify Below, if
no, leave space blank.
Are you or any of your Family members registered sex
offenders? If yes, please explain and list the offenders.
Full Name of Applicant:
Phone Number(s)
Address1:
Address2:
City/Zip/State:
(ex: Seymour, CT 06483)
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Unusual Expenses:
Were you ever Evicted from Section 8 or in Public Housing?
Do you owe money to any Housing Authority? If so, How much?
Estimate how much do you spend out of your pocket in medical
expenses.?
Do you Spend money on Day Care? If so Whats the estimated
Costs?
Please highlight/Select
which form of housing
you are applying for:
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Medical Expenses
for Elderly or Disabled families ONLY:
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Are you receiving Medicare Benefits?
Are you receiving Medical assistance through welfare?
Are you making payments on any outstanding medical bills?
Do you take prescription drugs on a regular basis?
Do you pay for any medical/hospitalization Insurance?
Please specify any special housing needs that your household
has or will need that you can document? (ex: Doctor's note):
I certify that the information given to the Seymour Housing Authority
on family composition, income, assets, and allowances, is accurate
and complete to the best of my/our knowledge and our belief. I/We
understand that false statements or information are grounds for
disqualifying this application. Misrepresentations are in violation of
State and Federal Law.
Type your name in first box, and social security in second, to verify
you understand this statement, and click submit.
