Applicant: ACHA Housing Application

Arkansas County Housing Authority
P 870.946.2622
Monday - Friday • 8:00 am - 4:30 pm
105 W. 4th Street • P.O. Box 447 • DeWitt AR, 72042
[email protected]

Equal Housing, Handicap Accessible, and Accessibility Icons.

APPLICATION INFORMATION & INSTRUCTIONS
To review the Application Information & Instructions, please click here.

REQUIRED HUD FORMS

HUD-9886-A - Authorization for the Release of Information/Privacy Act Notice to the U.S. Department of Housing and Urban Development and the Housing Agency/Authority (HA)
HUD-52675 - Debts Owed to Public Housing Agencies and Terminations
HUD-92006 - Supplement To Application For Federally Assisted Housing

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

APPLICATION FOR PARTICIPATION

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Source of Income","name":"TANFTEA---Source-of-Income","className":"col-lg-4","subtype":"text"},{"type":"text","label":"TANF/TEA - Amount per Month","name":"TANFTEA---Amount-per-Month","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive Other Income?","inline":true,"name":"Does-the-Household-Member-Receive-Other-Income","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Other Income - Name of Family Member","name":"Other-Income---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Income - Source of Income","name":"Other-Income---Source-of-Income","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Other Income - Amount per Month","name":"Other-Income---Amount-per-Month","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does anyone outside of your household assist with bills or expenses regularly?","inline":true,"name":"Does-anyone-outside-of-your-household-assist-with-bills-or-expenses-regularly","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If anyone assists with bills or expenses regularly, explain:","name":"If-anyone-assists-with-bills-or-expenses-regularly-explain","subtype":"textarea","className":"col-md-6"},{"type":"textarea","label":"List the name(s) of any household members 18 or older who are a full-time student and the school they attend:","name":"List-the-names-of-any-household-members-18-or-older-who-are-a-full-time-student-and-the-school-they-attend","subtype":"textarea","className":"d-block"},{"type":"textarea","label":"List the name(s) of any household members 18 or older who are employed in a job training program and the name of the training program:","name":"List-the-names-of-any-household-members-18-or-older-who-are-employed-in-a-job-training-program-and-the-name-of-the-training-program","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Has anyone in the household applied for any benefits that are in the process of being approved?","inline":true,"name":"Has-anyone-in-the-household-applied-for-any-benefits-that-are-in-the-process-of-being-approved","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If anyone is in the household is in the process of being approved for benefits, explain:","name":"If-anyone-is-in-the-household-is-in-the-process-of-being-approved-for-benefits-explain","subtype":"textarea","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Entitled to Child Support?","inline":true,"name":"Entitled-to-Child-Support","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Entitled Child Support Amount","name":"Entitled-Child-Support-Amount","value":"$","className":"col-md-6","subtype":"text"},{"type":"radio-group","required":true,"label":"Receiving the entitled Child Support?","inline":true,"name":"Receiving-the-entitled-Child-Support","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Received Child Support Amount","name":"Received-Child-Support-Amount","value":"$","className":"col-md-6","subtype":"text"},{"type":"radio-group","required":true,"label":"Entitled to Alimony?","inline":true,"name":"Entitled-to-Alimony","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Entitled Alimony Amount","name":"Entitled-Alimony-Amount","value":"$","className":"col-md-6","subtype":"text"},{"type":"radio-group","required":true,"label":"Receiving the entitled Alimony?","inline":true,"name":"Receiving-the-entitled-Alimony","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Receiving Alimony Amount","name":"Receiving-Alimony-Amount","value":"$","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"III. ASSETS","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Checking Account?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Checking-Account","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Checking Account - Name of Family Member","name":"Checking-Account---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Checking Account - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Checking-Account---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Checking Account - Total Market Value","name":"Checking-Account---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Savings Account?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Savings-Account","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Savings Account - Name of Family Member","name":"Savings-Account---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Savings Account - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Savings-Account---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Savings Account - Total Market Value","name":"Savings-Account---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Certificate of Deposit?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Certificate-of-Deposit","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Certificate of Deposit - Name of Family Member","name":"Certificate-of-Deposit---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Certificate of Deposit - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Certificate-of-Deposit---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Certificate of Deposit - Total Market Value","name":"Certificate-of-Deposit---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Stocks or Bonds?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Stocks-or-Bonds","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Stocks or Bonds - Name of Family Member","name":"Stocks-or-Bonds---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Stocks or Bonds - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Stocks-or-Bonds---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Stocks or Bonds - Total Market Value","name":"Stocks-or-Bonds---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Trusts?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Trusts","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Trusts - Name of Family Member","name":"Trusts---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Trusts - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Trusts---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Trusts - Total Market Value","name":"Trusts---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Pension / Retirement Funds?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Pension--Retirement-Funds","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Pension / Retirement Funds - Name of Family Member","name":"Pension--Retirement-Funds---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Pension / Retirement Funds - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Pension--Retirement-Funds---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Pension / Retirement Funds - Total Market Value","name":"Pension--Retirement-Funds---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Real Estate?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Real-Estate","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Real Estate - Name of Family Member","name":"Real-Estate---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Real Estate - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Real-Estate---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Real Estate - Total Market Value","name":"Real-Estate---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Insurance Settlements?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Insurance-Settlements","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Insurance Settlements - Name of Family Member","name":"Insurance-Settlements---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Insurance Settlements - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Insurance-Settlements---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Insurance Settlements - Total Market Value","name":"Insurance-Settlements---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Alimony?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Alimony","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Alimony Asset - Name of Family Member","name":"Alimony-Asset---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Alimony Asset - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Alimony-Asset---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Alimony Asset - Total Market Value","name":"Alimony-Asset---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Military Income?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Military-Income","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Military Income - Name of Family Member","name":"Military-Income---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Military Income - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Military-Income---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Military Income - Total Market Value","name":"Military-Income---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Income from Rental Property (or other Assets)?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Income-from-Rental-Property-or-other-Assets","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Income from Rental Property or other Assets - Name of Family Member","name":"Income-from-Rental-Property-or-other-Assets---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Income from Rental Property or other Assets - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Income-from-Rental-Property-or-other-Assets---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Income from Rental Property or other Assets - Total Market Value","name":"Income-from-Rental-Property-or-other-Assets---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does the Household Member Receive the following Asset: Regular Cash or Contributions?","inline":true,"name":"Does-the-Household-Member-Receive-the-following-Asset-Regular-Cash-or-Contributions","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Regular Cash or Contributions Asset - Name of Family Member","name":"Regular-Cash-or-Contributions-Asset---Name-of-Family-Member","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Regular Cash or Contributions Asset - Source of Asset","placeholder":"Bank Name, Address, Etc.","name":"Regular-Cash-or-Contributions-Asset---Source-of-Asset","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Regular Cash or Contributions Asset - Total Market Value","name":"Regular-Cash-or-Contributions-Asset---Total-Market-Value","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Has any asset been given away or sold for less than its fair market value in the last 2 years?","inline":true,"name":"Has-any-asset-been-given-away-or-sold-for-less-than-its-fair-market-value-in-the-last-2-years","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, what assets?","name":"If-yes-what-assets","subtype":"textarea","className":"col-md-6"},{"type":"text","label":"Market Value of Assets Sold","name":"Market-Value-of-Assets-Sold","value":"$","className":"col-md-6","subtype":"text"},{"type":"text","label":"Amount Received for Assets","name":"Amount-Received-for-Assets","value":"$","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"IV. Medical Expenses","className":"d-block"},{"type":"paragraph","subtype":"p","label":"(Complete this section only it the Head of Household or Spouse is is disabled or 62 years of age of older)<div><br></div><div>List all medical expenses the household anticipates paying during the next 12 months that will NOT be reimbursed by insurance or other outside sources. Do NOT include life or burial insurance premiums.</div>","className":"d-block"},{"type":"text","required":true,"label":"Medical Insurance Amount","name":"Medical-Insurance-Amount","value":"$","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Doctor's Visits Amount","name":"Doctors-Visits-Amount","value":"$","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Prescription Insurance Amount","name":"Prescription-Insurance-Amount","value":"$","className":"col-lg-4","subtype":"text"},{"type":"textarea","required":true,"label":"List Other Expense Types","name":"List-Other-Expense-Types","subtype":"textarea","className":"col-md-6"},{"type":"text","required":true,"label":"Other Amount","name":"Other-Amount","value":"$","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"V. Pets","className":"d-block"},{"type":"radio-group","required":true,"label":"Does anyone in the household have a pet?","inline":true,"name":"Does-anyone-in-the-household-have-a-pet","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, describe the pet:","name":"If-yes-describe-the-pet","subtype":"textarea","className":"col-md-6"},{"type":"radio-group","label":"Is your pet an assistant Animal?","inline":true,"name":"Is-your-pet-an-assistant-Animal","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, describe the assistant Animal:","name":"If-yes-describe-the-assistant-Animal","subtype":"textarea","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"V. Miscellaneous Information","className":"d-block"},{"type":"paragraph","subtype":"p","label":"List ALL vehicles that household members will be parking on PHA property","className":"d-block"},{"type":"text","required":true,"label":"Vehicle 1 - Year","name":"Vehicle-1---Year","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - Make","name":"Vehicle-1---Make","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - Model","name":"Vehicle-1---Model","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - Color","name":"Vehicle-1---Color","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - Amount","placeholder":"$","name":"Vehicle-1---Amount","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Vehicle 2 - Year","name":"Vehicle-2---Year","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Vehicle 2 - Make","name":"Vehicle-2---Make","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Vehicle 2 - Model","name":"Vehicle-2---Model","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Vehicle 2 - Color","name":"Vehicle-2---Color","className":"col-md-6","subtype":"text"},{"type":"text","label":"Vehicle 2 - Amount","placeholder":"$","name":"Vehicle-2---Amount","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"VIII. Child Care and/or Disability Assistance Expenses","className":"d-block"},{"type":"radio-group","required":true,"label":"Does anyone in the household pay for Child Care for children aged 12 or younger while working or attending school?","inline":true,"name":"Does-anyone-in-the-household-pay-for-Child-Care-for-children-aged-12-or-younger-while-working-or-attending-school","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Name of Provider","name":"Name-of-Provider","className":"col-md-6","subtype":"text"},{"type":"text","label":"Amount Paid per Month","placeholder":"$","name":"Amount-Paid-per-Month","className":"col-md-6","subtype":"text"},{"type":"text","label":"Provider Street Address","name":"Provider-Street-Address","className":"col-md-6","subtype":"text"},{"type":"text","label":"Provider City","name":"Provider-City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"Provider State","name":"Provider-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","selected":true},{"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","label":"Provider Zip Code","name":"Provider-Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","subtype":"tel","label":"Phone # of Provider","name":"Phone--of-Provider","className":"col-md-6 col-lg-3"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does anyone in the household pay for Attendant Care or auxiliary apparatus for a disabled household member for them or any other family member to work?","inline":true,"name":"Does-anyone-in-the-household-pay-for-Attendant-Care-or-auxiliary-apparatus-for-a-disabled-household-member-for-them-or-any-other-family-member-to-work","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Amount Paid per Month for Attendant Care or Auxiliary Apparatus for a disabled household member to work?","placeholder":"$","name":"Amount-Paid-per-Month-for-Attendant-Care-or-Auxiliary-Apparatus-for-a-disabled-household-member-to-work","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"VIIl. Criminal History","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Has any household member (regardless of age) been arrested, charged, or convicted for any of the following?","className":"d-block"},{"type":"radio-group","required":true,"label":"Violent criminal activity?","inline":true,"name":"Violent-criminal-activity","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"Violent Criminal Activity - If yes, explain:","name":"Violent-Criminal-Activity---If-yes-explain","subtype":"textarea","className":"col-md-6"},{"type":"radio-group","required":true,"label":"Alcohol related activity?","inline":true,"name":"Alcohol-related-activity","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"Alcohol Related Activity - If yes, explain:","name":"Alcohol-Related-Activity---If-yes-explain","subtype":"textarea","className":"col-md-6"},{"type":"radio-group","required":true,"label":"Manufacture of methamphetamines?","inline":true,"name":"Manufacture-of-methamphetamines","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"Manufacture of Methamphetamines - If yes, explain:","name":"Manufacture-of-Methamphetamines---If-yes-explain","subtype":"textarea","className":"col-md-6"},{"type":"radio-group","required":true,"label":"Possession, Sale, or Distribution of Illegal Drugs?","inline":true,"name":"Possession-sale-or-distribution-of-illegal-drugs","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"If yes, list name/date/disposition of case:","name":"If-yes-list-namedatedisposition-of-case","subtype":"textarea","className":"col-md-6"},{"type":"textarea","label":"List the name(s) of any household member who is required to register as a lifetime sex offender:","name":"List-the-names-of-any-household-member-who-is-required-to-register-as-a-lifetime-sex-offender","subtype":"textarea","className":"d-block"},{"type":"text","label":"If required to report, list the Probation/Parole Officer's Name:","name":"If-required-to-report-list-the-ProbationParole-Officers-Name","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"tel","label":"Probation/Parole Officer Phone Number","name":"ProbationParole-Officer-Phone-Number","className":"col-md-6"},{"type":"radio-group","required":true,"label":"Has any household member participated in drug rehabilitation during the past 12 months?","inline":true,"name":"Has-any-household-member-participated-in-drug-rehabilitation-during-the-past-12-months","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"Drug Rehabilitation - If yes, explain:","name":"Drug-Rehabilitation---If-yes-explain","subtype":"textarea","className":"col-md-6"},{"type":"radio-group","required":true,"label":"Has any household member been evicted from federally assisted housing in the past 3 years?","inline":true,"name":"Has-any-household-member-been-evicted-from-federally-assisted-housing-in-the-past-3-years","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"Evicted from Federally Assisted Housing - If yes, explain who and where:","name":"Evicted-from-Federally-Assisted-Housing---If-yes-explain-who-and-where","subtype":"textarea","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"IX. 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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":"Landlord Zip Code","name":"Landlord-Zip-Code","className":"col-lg-4","subtype":"text"},{"type":"radio-group","required":true,"label":"Prior Residence: Have you ever been late with your rent 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18?","inline":true,"name":"Has-any-household-member-lived-in-Public-Housing-or-participated-in-the-Section-8-housing-assistance-program-after-reaching-the-age-of-18","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"If yes, under what name:","name":"If-yes-under-what-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Housing Agency's Name","name":"Housing-Agencys-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Housing Agency's City","name":"Housing-Agencys-City","className":"col-md-6","subtype":"text"},{"type":"date","label":"Start Date at Housing Agency","name":"Start-Date-at-Housing-Agency","className":"col-md-6"},{"type":"date","label":"End Date at Housing Agency","name":"End-Date-at-Housing-Agency","className":"col-md-6"},{"type":"radio-group","label":"Housing Agency: Have you ever been late with your rent 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All information provided on this application and at any interviews performed is subject to verification. All family members aged eighteen (18) and older should review the information on this form, the Federal Privacy Act, and all required releases, and they MUST sign all documents for this application to be considered for our programs).<br><br>By my signature below, I do hereby swear and attest that all information on this application is true and correct. I understand that I must report any changes in income, assets, family composition, address, or telephone number to the Housing Authority within ten (10) days of such change for my application to remain valid. By my signature, I grant permission for the Housing Authority to verify information necessary to determine my eligibility and suitability for housing. I further understand that false statements or information are grounds for denial of this application.<br>","className":"d-block"},{"type":"header","subtype":"h4","label":"All family members 18 years of age or older MUST sign below.<br>PLEASE REVIEW ALL INFORMATION PROVIDED ON THIS APPLICATION.","className":"d-block"},{"type":"text","required":true,"label":"Head of Household Signature","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Head-of-Household-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of HOH Signature","name":"Date-of-HOH-Signature","className":"col-md-6"},{"type":"text","label":"Family Member 1 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Family-Member-1-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 1 Date of Signature","name":"Family-Member-1-Date-of-Signature","className":"col-md-6"},{"type":"text","label":"Family Member 2 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Family-Member-2-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 2 Date of Signature","name":"Family-Member-2-Date-of-Signature","className":"col-md-6"},{"type":"text","label":"Family Member 3 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Family-Member-3-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 3 Date of Signature","name":"Family-Member-3-Date-of-Signature","className":"col-md-6"},{"type":"text","label":"Family Member 4 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Family-Member-4-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Family Member 4 Date of Signature","name":"Family-Member-4-Date-of-Signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Criminal History Background Check","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Anyone over 18 years of age or older must complete this form.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Housing Commissions are authorized under Section 9(b) of Public Law 104-120, signed March 28, 1996, to obtain national criminal history records of adult applicants for, or tenants of, public housing for purposes of applicant screening, lease enforcement, and eviction. (24 CFR Part 5, Subpart J)<div><br></div><div>Criminal history background checks will be conducted for drug-related activity, violent criminal activity (including sex crimes), and alcohol-related criminal activity. If any state or national history is revealed in this search, the specific information will be verified for the Arkansas County Housing Authority by the State, the FBI, and/or NCIC.<div><br></div><div>The applicant/tenant authorizes criminal history checks for all adult household members during both the application process and during occupancy by signing the original application for housing or continued occupancy, without the requirement of future signatures, releases, or additional authorization. Failure to provide authorization is grounds for denial of the application.</div></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I hereby agree, release, and hold harmless the Arkansas County Housing Authority to complete a background check on me.","className":"d-block"},{"type":"text","required":true,"label":"Background Check - First Name","name":"Background-Check---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Background Check - Middle Name","name":"Background-Check---Middle-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Background Check - Last Name","name":"Background-Check---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Background Check - Maiden or Other Names Used","name":"Background-Check---Maiden-or-Other-Names-Used","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Background Check - Social Security Number","name":"Background-Check---Social-Security-Number","className":"col-md-6","subtype":"text"},{"type":"text","label":"Background Check - ID Number","name":"Background-Check---ID-Number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Background Check - Street Address","name":"Background-Check---Street-Address","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Background Check - City","name":"Background-Check---City","className":"col-lg-4","subtype":"text"},{"type":"select","required":true,"label":"Background Check - State","name":"Background-Check---State","className":"col-lg-4","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR","selected":true},{"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":"Background Check - Zip Code","name":"Background-Check---Zip-Code","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Background Check - Date of Birth","name":"Background-Check---Date-of-Birth","className":"col-lg-4"},{"type":"text","required":true,"label":"Background Check - Race","name":"Background-Check---Race","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Background Check - Sex","name":"Background-Check---Sex","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Background Check - Applicant/Tenant Signature","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Background-Check---ApplicantTenant-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Background Check - Date of Applicant/Tenant Signature","name":"Background-Check---Date-of-ApplicantTenant-Signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Authorization for Release of Information","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I hereby grant permission to any Federal, State, local, or private agency, organization, business, or individual to release to the Arkansas County Housing Authority [ACHA] any information or materials, including any criminal history or financial information, needed to complete and verify my application for participation, or for continued assistance, in the Section 8 Voucher Rental Assistance Program and/or the Low Rent Public Housing Program administered by the Arkansas County Housing Authority.<div><br></div><div>I understand that the U.S. Department of Housing and Urban Development [HUD] may conduct computer matching programs to verify the information supplied on my application for participation or re-certification. I, agree that the SHA and/or HUD may release information from my file concerning my rental history, including, but not limited to, my payment history, lease violations, or policy violations, to credit bureaus, collection agencies, or current and prospective landlords.</div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I further agree that a photocopy of this signed authorization may be used for the above purposes.","className":"d-block"},{"type":"text","required":true,"label":"Release of Information - Head of Household Signature","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Release-of-Information---Head-of-Household-Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Release of Information - Date of HOH Signature","name":"Release-of-Information---Date-of-HOH-Signature","className":"col-md-6"},{"type":"text","label":"Release of Information - Family Member 1 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Release-of-Information---Family-Member-1-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Release of Information - Family Member 1 Date of Signature","name":"Release-of-Information---Family-Member-1-Date-of-Signature","className":"col-md-6"},{"type":"text","label":"Release of Information - Family Member 2 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Release-of-Information---Family-Member-2-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Release of Information - Family Member 2 Date of Signature","name":"Release-of-Information---Family-Member-2-Date-of-Signature","className":"col-md-6"},{"type":"text","label":"Release of Information - Family Member 3 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Release-of-Information---Family-Member-3-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Release of Information - Family Member 3 Date of Signature","name":"Release-of-Information---Family-Member-3-Date-of-Signature","className":"col-md-6"},{"type":"text","label":"Release of Information - Family Member 4 Signature (18 years of age or older)","placeholder":"Disclaimer: By typing your name you are signing this document.","name":"Release-of-Information---Family-Member-4-Signature-18-years-of-age-or-older","className":"col-md-6","subtype":"text"},{"type":"date","label":"Release of Information - Family Member 4 Date of Signature","name":"Release-of-Information---Family-Member-4-Date-of-Signature","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Upload Supporting Documents","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Please attach the requested completed HUD forms listed at the top of this form.","className":"d-block"},{"type":"file","label":"Please select one or more files for upload. ","description":"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\".","name":"Please-select-one-or-more-files-for-upload","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"FOR ACHA USE ONLY","className":"d-block"},{"type":"text","subtype":"disabled","label":"Criminal Record?","name":"Criminal-Record","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"Registered Sex Offender?","name":"Registered-Sex-Offender","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"Occupancy Specialist:","name":"Occupancy-Specialist","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"Date","name":"Date","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"Time","name":"Time","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"Bedroom Size","name":"Bedroom-Size","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"PHA Rep","name":"PHA-Rep","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"},{"type":"text","subtype":"disabled","label":"Date Approved","name":"Date-Approved","value":"ACHA USE ONLY","className":"col-md-6 col-lg-3"}]