How Many Adults: ______
How Many Children: _____
SS#: ____________________________ Birth Date: _______________________
SFHA LOCAL PREFERENCE QUESTIONAIRE FOR PUBLIC HOUSING PRELIMINARY APPLICATION Please read the following Local Preference definitions carefully and mark the box in each category which applies to you. The information will be used to determine your status on the waiting list. At the eligibility interview, you
will be required to submit verification. Failure to submit preference verification with this form will result in the return of your application to the Public Housing Waitlist.
You are involuntarily displaced if you have vacated or will vacate your home due to one or more of the following reasons: ______(1) Natural Disaster: A disaster such as a fire, flood, or earthquake resulting in your home becoming uninhabitable. ______(2) Domestic Violence: Actual or threatened physical violence directed against you or one or more member of your family by a spouse or other household member or if you still live in housing with an individual who engages in violence. ______(3) Government Action: If you leave your home or will have to leave your home because of an action by government agency related to code enforcement or public improvement or development programs. ______(4) Housing Owner Action: An action by a housing owner which displaces you from your unit, where the reason for the ownerâ€™s action was beyond your ability to control or prevent, despite having met all previously imposed conditions of occupancy and the action is other than a rent increase. ______(5) Displacement to Avoid Reprisals: When you or a member of your family has provided information on criminal activities to a law enforcement agency and based on a threat assessment by the agency has recommended that the family be moved to avoid reprisals. ______(6) Displacement By Hate Crimes: Actual or threatened violence or intimidation against you or a member of your family or their property based on their race, ethnicity, color, religion, sex, sexual orientation, national origin, disability, or other physical or cultural characteristics which have either forced you to vacate your housing unit or has destroyed the peaceful enjoyment of your unit. ______(7) Displacement By Inaccessibility: When you or a member of your family has a mobility or other impairment which makes you unable to use critical elements of your housing unit and the legal owner is under no legal obligation to make the unit accessible. ______(8) Displacement Because of HUD Disposition of Multifamily Housing: An action by HUD to dispose of multifamily housing under Section 203 of the Housing and Community Development Amendments of 1978. updated 12/16/2010
HOMELESS IN DHS SHELTER
NO LOCAL PREFERENCE
_______ I am a Veteran and/or a surviving spouse of the Unites States Armed Forces Veteran.
______ I am living in a Department of Human Services Shelter.
______ I am living in standard permanent replacement housing which is defined as decent safe and sanitary and is adequate for your family, you cannot claim a Local Preference. ____________________________________________________________________________________________________________
OPTIONAL INFORMATION PLEASE CHECK ANY STATEMENT(S) WHICH APPLY TO YOU: (DISABILITY INFORMATION: You are not required to answer the following questions. This information is voluntary and shall be treated as confidential medical records. This information will be used to assist the SFHA in identifying housing that meets the needs of your disability in accordance with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.) 1. _______ The head of my household is 62 years of age or older. 2. _______ I and/or member (s) of my family have a physical or mental impairment that substantially limits one or more major life activities. Please check the following statement (s) which apply to you or a family member: _______ _______ _______ _______
Mobility Impairment Visual Impairment Hearing Impairment Other mobility or physical impairment. Please Specify: _______________________________________________________________________
ETHNICITY 1. 2. 3. 4. 5. 6.
_______Samoan _______Hispanic _______Vietnamese _______Cambodian _______Chinese _______Korean
LANGUAGE 7. 8. 9. 10. 11. 12.
_______Japanese _______Laotian _______Filipino _______Other Asian/Pacific Islander _______Other _______Russian
1. 2. 3. 4. 5. 6.
_______Cantonese _______Spanish _______Russian _______Vietnamese _______English _______Korean
7. 8. 9. 10. 11. 12.
_______Cambodian _______Samoan _______Laotian _______Farsi _______Mandarin _______Tagalog
RACE 1. ________White 3. _______Native American 5. _______Pacific Islander 2. ________Black 4. _______Asian ____________________________________________________________________________________________________________ SIGNATURE: