PRELIMINARY APPLICATION


Lafayette County Housing Authority

1415 S. Odell

Marshall, MO 65340

Full Name (Head of Household):

Address:

City:    State:    Zip Code:

Are you currently homeless?   

Legal Address if different from mailing address:

Note: If your legal or mailing address changes, you must notify this office to maintain your waiting list status.

Evidence of legal address claimed at the time of application must accompany this form when submitted. Acceptable evidence includes copy of driver's license or other official document listing head of household, spouse, or co-head at claimed legal address. Preliminary Applications returned without evidence of legal address cannot be accepted.

 

Part 1: Head of Household

Social Security Number       Date of Birth       Sex 

Home Telephone       Other Telephone      

Specify (if other) 

Email Address      

Do you qualify for a reasonable accommodation due to a disability?   

Race (Check all that apply)
Ethnicity (Check one box)

 

Part 2: Household Information

List information for adults first, then children under age 18. Use "F" or "M" to indicate sex. If a household member qualifies for a reasonable accommodation due to a disability select "Y". If not, select "N". List relationship of each person to the Head of Household.

First Name MI Last Name SSN DOB Sex Disabled Relationship

 

Part 3: Family Income and Assets

List total gross income (before taxes) and payments received by each family member age 18 and older for wages, military pay, pensions, social security, SSI, welfare, child support, unemployment, business, profession, or any other source. Include payments made to family members 18 or older on behalf of other family members under 18.

First Name Gross Income How Often Employer Address (if income is from wages)

 

List total cash value and total income received for assets owned by all family members.

Type of Asset Cash Value of Asset Income Received from Asset
Checking Accounts
Savings Accounts
Stocks, Bonds, CDs, Investments
Real Estate
Other

 

 

Part 4: Eligibility and Preferences

Your response to the following statements will help determine your eligibility for rental assistance and if you are entitled to a preference when placed on the program's waiting list. Select each item that applies to your current status.

N/A

Applicants outside our coverage area must lease within our area for at least one year when becoming a participant of our Housing Choice Voucher Program. Our coverage area is: Carroll, Chariton, Johnson, Lafayette, Pettis, and Saline Counties in Missouri.


If your address or phone number changes after applying to the waitlist, you must submit the information in writing to your local MVCAA office or submit the information directly to our central office at:

MVCAA

Lafayette County HA

1415 S. Odell Ave.

Marshall, MO 65340

 

 

Part 5: U.S. Citizenship Notification and Certification

Housing may be contingent upon the submission and verification of evidence of citizenship or eligible immigration status prior to the time housing is made available. Based on the evidence submitted at that time, assistance may be prorated, denied, or terminated following appeals and information hearing processes.

I certify that the information on this form is true and complete to the best of my knowledge and belief. I understand that I can be fined up to $10,000 or imprisoned up to five years if I furnish false or incomplete information.

Completion of this application doesn't determine eligibility for the Housing Choice Voucher Program.

 

Upload proof of address

Please keep in mind that an application isn't complete if you don't provide us with an official proof of residence.

Examples of proof of address are (but not limited to): mail from a local/state/federal government program, mail from school or a bill with your physical street address.

Mail from any subscriptions/memberships will not suffice.

 

If you are homeless, you must provide us with a letter with information of where you're physically living at. If you're staying at a homeless/women's shelter, please have that organization write you a letter with information of your stay. If you’re staying with another individual/family, please have that individual/family write you a letter with information of your stay. Please make sure there's a signature, date, and contact information (on your letter) for the organization/individual/family.

 

You may take a photo of your document and upload it for proof of address. Please make sure your uploaded document is clear and easy to read or our housing authority may reject your application.

 

 

Signed on: September 24, 2021

Leave this empty:

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Signature Certificate
Document name: PRELIMINARY APPLICATION
lock iconUnique Document ID: 36150c7a81f7e5b6bca6abf08d7156d64c15b889
Timestamp Audit
July 30, 2020 10:38 pm CDTPRELIMINARY APPLICATION Uploaded by Axel Najera - najeraa@mvcaa.net IP 34.103.70.253
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