870.946.2622

Home Contact Us

Apply Online Pay Online

Apply Online Pay Online

Resident: Request for Continued Assistance

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.

Required HUD Forms:

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

If a field is not applicable, please type N/A or None.

[{"type":"text","required":true,"label":"Head of Household First Name","name":"Head-of-Household-First-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Last Name","name":"Head-of-Household-Last-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Co-Applicant First Name","name":"Co-Applicant-First-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Co-Applicant Last Name","name":"Co-Applicant-Last-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Mailing Street Address","name":"Mailing-Street-Address","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Mailing City","name":"Mailing-City","className":"col-lg-4","subtype":"text"},{"type":"select","required":true,"label":"Mailing State","name":"Mailing-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":"Mailing Zip Code","name":"Mailing-Zip-Code","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Head of Household Phone #","name":"Head-of-Household-Phone-","className":"col-md-6"},{"type":"text","subtype":"tel","required":true,"label":"Head of Household Work Phone #","name":"Head-of-Household-Work-Phone-","className":"col-md-6"},{"type":"text","subtype":"email","required":true,"label":"Email","name":"email","className":"col-md-6"},{"type":"text","subtype":"email","required":true,"label":"Email Confirmation","name":"email-confirmed","className":"col-md-6"},{"type":"text","subtype":"tel","required":true,"label":"Home Phone Number","name":"Home-Phone-Number","className":"col-md-6"},{"type":"text","subtype":"tel","required":true,"label":"Work Phone Number","name":"Work-Phone-Number","className":"col-md-6"},{"type":"radio-group","required":true,"label":"Please provide your LEGAL Marital Status. Are you CURRENTLY:","inline":true,"name":"Please-provide-your-LEGAL-Marital-Status-Are-you-CURRENTLY","className":"d-block","values":[{"label":"Single","value":"Single"},{"label":"Married","value":"Married"},{"label":"Divorced","value":"Divorced"},{"label":"Widowed","value":"Widowed"},{"label":"Legally Separated","value":"Legally Separated"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Part A: Information about Members of the Household","className":"d-block"},{"type":"checkbox-group","required":true,"label":"List ALL members age 18 or older who will be living in the home beginning with the Head of Household. Each box MUST be completed for each member. No one except those listed on this form may live in the unit.","inline":true,"name":"List-ALL-members-age-18-or-older-who-will-be-living-in-the-home-beginning-with-the-Head-of-Household-Each-box-MUST-be-completed-for-each-member-No-one-except-those-listed-on-this-form-may-live-in-the-unit","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"checkbox-group","required":true,"label":"Adults - Age 18 years and older - Please enter Spouse, Co-Head, Adult or Live-in Aide (must be verified annually) under Relationship to Head","inline":true,"name":"Adults---Age-18-years-and-older---Please-enter-Spouse-Co-Head-Adult-or-Live-in-Aide-must-be-verified-annually-under-Relationship-to-Head","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Adult 1","className":"d-block"},{"type":"text","required":true,"label":"Adult 1 - First Name","name":"Adult-1---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Adult 1 - Last Name","name":"Adult-1---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Adult 1 - Date of Birth","name":"Adult-1---Date-of-Birth","className":"col-lg-4"},{"type":"text","required":true,"label":"Adult 1 - Age","name":"Adult-1---Age","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Adult 1 - Race","name":"Adult-1---Race","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Adult 1 - Social Security # or Alien Registration #","name":"Adult-1---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","required":true,"label":"Adult 1 - US Citizen","inline":true,"name":"Adult-1---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","required":true,"label":"Adult 1 - Sex","inline":true,"name":"Adult-1---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","required":true,"label":"Adult 1 - Disabled","inline":true,"name":"Adult-1---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","required":true,"label":"Adult 1 - Student","inline":true,"name":"Adult-1---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"Adult 1 - School Name","name":"Adult-1---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"disabled","label":"Adult 1 - Relationship to Head","name":"Adult-1---Relationship-to-Head","value":"Head of Household","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Adult 2","className":"d-block"},{"type":"text","label":"Adult 2 - First Name","name":"Adult-2---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 2 - Last Name","name":"Adult-2---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Adult 2 - Date of Birth","name":"Adult-2---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Adult 2 - Age","name":"Adult-2---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 2 - Race","name":"Adult-2---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 2 - Social Security # or Alien Registration #","name":"Adult-2---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Adult 2 - US Citizen","inline":true,"name":"Adult-2---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Adult 2 - Sex","inline":true,"name":"Adult-2---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Adult 2 - Disabled","inline":true,"name":"Adult-2---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Adult 2 - Student","inline":true,"name":"Adult-2---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Adult 2 - School Name","name":"Adult-2---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Adult 2 - Relationship to Head","name":"Adult-2---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Adult 3","className":"d-block"},{"type":"text","label":"Adult 3 - First Name","name":"Adult-3---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 3 - Last Name","name":"Adult-3---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Adult 3 - Date of Birth","name":"Adult-3---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Adult 3 - Age","name":"Adult-3---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 3 - Race","name":"Adult-3---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 3 - Social Security # or Alien Registration #","name":"Adult-3---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Adult 3 - US Citizen","inline":true,"name":"Adult-3---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Adult 3 - Sex","inline":true,"name":"Adult-3---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Adult 3 - Disabled","inline":true,"name":"Adult-3---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Adult 3 - Student","inline":true,"name":"Adult-3---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Adult 3 - School Name","name":"Adult-3---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Adult 3 - Relationship to Head","name":"Adult-3---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Adult 4","className":"d-block"},{"type":"text","label":"Adult 4 - First Name","name":"Adult-4---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 4 - Last Name","name":"Adult-4---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Adult 4 - Date of Birth","name":"Adult-4---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Adult 4 - Age","name":"Adult-4---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 4 - Race","name":"Adult-4---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Adult 4 - Social Security # or Alien Registration #","name":"Adult-4---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Adult 4 - US Citizen","inline":true,"name":"Adult-4---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Adult 4 - Sex","inline":true,"name":"Adult-4---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Adult 4 - Disabled","inline":true,"name":"Adult-4---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Adult 4 - Student","inline":true,"name":"Adult-4---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Adult 4 - School Name","name":"Adult-4---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Adult 4 - Relationship to Head","name":"Adult-4---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"checkbox-group","required":true,"label":"Children - Age 17 years and younger - List ALL children who will be living in the home, oldest to youngest.","inline":true,"name":"Children---Age-17-years-and-younger---List-ALL-children-who-will-be-living-in-the-home-oldest-to-youngest","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"header","subtype":"h4","label":"Child 1","className":"d-block"},{"type":"text","label":"Child 1 - First Name","name":"Child-1---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 1 - Last Name","name":"Child-1---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Child 1 - Date of Birth","name":"Child-1---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Child 1 - Age","name":"Child-1---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 1 - Race","name":"Child-1---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 1 - Social Security # or Alien Registration #","name":"Child-1---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Child 1 - US Citizen","inline":true,"name":"Child-1---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 1 - Sex","inline":true,"name":"Child-1---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Child 1 - Disabled","inline":true,"name":"Child-1---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 1 - Student","inline":true,"name":"Child-1---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Child 1 - School Name","name":"Child-1---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Child 1 - Relationship to Head","name":"Child-1---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Child 2","className":"d-block"},{"type":"text","label":"Child 2 - First Name","name":"Child-2---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 2 - Last Name","name":"Child-2---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Child 2 - Date of Birth","name":"Child-2---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Child 2 - Age","name":"Child-2---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 2 - Race","name":"Child-2---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 2 - Social Security # or Alien Registration #","name":"Child-2---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Child 2 - US Citizen","inline":true,"name":"Child-2---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 2 - Sex","inline":true,"name":"Child-2---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Child 2 - Disabled","inline":true,"name":"Child-2---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 2 - Student","inline":true,"name":"Child-2---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Child 2 - School Name","name":"Child-2---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Child 2 - Relationship to Head","name":"Child-2---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Child 3","className":"d-block"},{"type":"text","label":"Child 3 - First Name","name":"Child-3---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 3 - Last Name","name":"Child-3---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Child 3 - Date of Birth","name":"Child-3---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Child 3 - Age","name":"Child-3---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 3 - Race","name":"Child-3---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 3 - Social Security # or Alien Registration #","name":"Child-3---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Child 3 - US Citizen","inline":true,"name":"Child-3---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 3 - Sex","inline":true,"name":"Child-3---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Child 3 - Disabled","inline":true,"name":"Child-3---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 3 - Student","inline":true,"name":"Child-3---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Child 3 - School Name","name":"Child-3---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Child 3 - Relationship to Head","name":"Child-3---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Child 4","className":"d-block"},{"type":"text","label":"Child 4 - First Name","name":"Child-4---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 4 - Last Name","name":"Child-4---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Child 4 - Date of Birth","name":"Child-4---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Child 4 - Age","name":"Child-4---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 4 - Race","name":"Child-4---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 4 - Social Security # or Alien Registration #","name":"Child-4---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Child 4 - US Citizen","inline":true,"name":"Child-4---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 4 - Sex","inline":true,"name":"Child-4---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Child 4 - Disabled","inline":true,"name":"Child-4---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 4 - Student","inline":true,"name":"Child-4---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Child 4 - School Name","name":"Child-4---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Child 4 - Relationship to Head","name":"Child-4---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Child 5","className":"d-block"},{"type":"text","label":"Child 5 - First Name","name":"Child-5---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 5 - Last Name","name":"Child-5---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Child 5 - Date of Birth","name":"Child-5---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Child 5 - Age","name":"Child-5---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 5 - Race","name":"Child-5---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 5 - Social Security # or Alien Registration #","name":"Child-5---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Child 5 - US Citizen","inline":true,"name":"Child-5---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 5 - Sex","inline":true,"name":"Child-5---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Child 5 - Disabled","inline":true,"name":"Child-5---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 5 - Student","inline":true,"name":"Child-5---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Child 5 - School Name","name":"Child-5---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Child 5 - Relationship to Head","name":"Child-5---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Child 6","className":"d-block"},{"type":"text","label":"Child 6 - First Name","name":"Child-6---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 6 - Last Name","name":"Child-6---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Child 6 - Date of Birth","name":"Child-6---Date-of-Birth","className":"col-lg-4"},{"type":"text","label":"Child 6 - Age","name":"Child-6---Age","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 6 - Race","name":"Child-6---Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Child 6 - Social Security # or Alien Registration #","name":"Child-6---Social-Security--or-Alien-Registration-","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Child 6 - US Citizen","inline":true,"name":"Child-6---US-Citizen","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 6 - Sex","inline":true,"name":"Child-6---Sex","className":"col-md-6 col-lg-3","values":[{"label":"Male","value":"Male"},{"label":"Female","value":"Female"}]},{"type":"radio-group","label":"Child 6 - Disabled","inline":true,"name":"Child-6---Disabled","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Child 6 - Student","inline":true,"name":"Child-6---Student","className":"col-md-6 col-lg-3","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","label":"Child 6 - School Name","name":"Child-6---School-Name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Child 6 - Relationship to Head","name":"Child-6---Relationship-to-Head","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"Have the household members changed since your last recertification?","inline":true,"name":"Have-the-household-members-changed-since-your-last-recertification","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"If yes, what members have changes in the household?","name":"If-yes-what-members-have-changes-in-the-household","className":"col-md-6","subtype":"text"},{"type":"radio-group","required":true,"label":"Did this person Move Out or Move In?","inline":true,"name":"Did-this-person-Move-Out-or-Move-In","className":"col-md-6","values":[{"label":"Move Out","value":"Move Out"},{"label":"Move In","value":"Move In"},{"label":"N/A","value":"N/A"}]},{"type":"text","required":true,"label":"Reason for leaving:","name":"Reason-for-leaving","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does anyone in your household require any type of Hearing, Mobility, or Vision accommodations to fully utilize our programs or services?","inline":true,"name":"Does-anyone-in-your-household-require-any-type-of-Hearing-Mobility-or-Vision-accommodations-to-fully-utilize-our-programs-or-services","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"If yes, who requires accommodations?","name":"If-yes-who-requires-accommodations","className":"col-md-6","subtype":"text"},{"type":"textarea","required":true,"label":"What do they require?","name":"What-do-they-require","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"Has any household member been convicted of violent, or drug related criminal activity in the past 3 years?","inline":true,"name":"Has-any-household-member-been-convicted-of-violent-or-drug-related-criminal-activity-in-the-past-3-years","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If yes, who was convicted?","name":"If-yes-who-was-convicted","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Are you or any person listed on this application subject to a lifetime registration in any State for a sex offender?","inline":true,"name":"Are-you-or-any-person-listed-on-this-application-subject-to-a-lifetime-registration-in-any-State-for-a-sex-offender","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If yes, list the State and the person's name.","name":"If-yes-list-the-State-and-the-persons-name","subtype":"textarea","className":"d-block"},{"type":"date","required":true,"label":"Date of Crime Conviction","name":"Date-of-Crime-Conviction","className":"col-md-6"},{"type":"text","required":true,"label":"What was the charge?","name":"What-was-the-charge","className":"col-md-6","subtype":"text"},{"type":"radio-group","required":true,"label":"Is any member of this household required to be a registered sex offender?","inline":true,"name":"Is-any-member-of-this-household-required-to-be-a-registered-sex-offender","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"If yes, who is required to be a registered sex offender?","name":"If-yes-who-is-required-to-be-a-registered-sex-offender","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Part B: Information About Household Income","className":"d-block"},{"type":"checkbox-group","required":true,"label":"List ALL income (money) currently being received for ALL family members from ALL sources. This includes gifts or monthly contributions from family members and or friends. Please list the gross amount of income (before any deductions).","inline":true,"name":"List-ALL-income-money-currently-being-received-for-ALL-family-members-from-ALL-sources-This-includes-gifts-or-monthly-contributions-from-family-members-and-or-friends-Please-list-the-gross-amount-of-income-before-any-deductions","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"radio-group","required":true,"label":"EMPLOYMENT: Does or will anyone in the household receive income from Employment?","inline":true,"name":"EMPLOYMENT-Does-or-will-anyone-in-the-household-receive-income-from-Employment","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"checkbox-group","required":true,"label":"If yes, please provide the most recent check stubs for the period within the last 30 days and complete information below:","inline":true,"name":"If-yes-please-provide-the-most-recent-check-stubs-for-the-period-within-the-last-30-days-and-complete-information-below","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"file","required":true,"label":"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\".","name":"file-1762791832566","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","required":true,"label":"Member 1 - First Name","name":"Member-1---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Member 1 - Last Name","name":"Member-1---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Member 1 - Income Source","name":"Member-1---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Member 1 - Amount","name":"Member-1---Amount","className":"col-md-6","subtype":"text"},{"type":"select","required":true,"label":"Member 1 - Pay Frequency","name":"Member-1---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --"},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"Member 2 - First Name","name":"Member-2---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 2 - Last Name","name":"Member-2---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 2 - Income Source","name":"Member-2---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 2 - Amount","name":"Member-2---Amount","className":"col-md-6","subtype":"text"},{"type":"select","label":"Member 2 - Pay Frequency","name":"Member-2---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --"},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"Member 3 - First Name","name":"Member-3---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 3 - Last Name","name":"Member-3---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 3 - Income Source","name":"Member-3---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 3 - Amount","name":"Member-3---Amount","className":"col-md-6","subtype":"text"},{"type":"select","label":"Member 3 - Pay Frequency","name":"Member-3---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --"},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"Member 4 - First Name","name":"Member-4---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 4 - Last Name","name":"Member-4---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 4 - Income Source","name":"Member-4---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 4 - Amount","name":"Member-4---Amount","className":"col-md-6","subtype":"text"},{"type":"select","label":"Member 4 - Pay Frequency","name":"Member-4---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --"},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"Member 5 - First Name","name":"Member-5---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 5 - Last Name","name":"Member-5---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 5 - Income Source","name":"Member-5---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 5 - Amount","name":"Member-5---Amount","className":"col-md-6","subtype":"text"},{"type":"select","label":"Member 5 - Pay Frequency","name":"Member-5---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --"},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"Member 6 - First Name","name":"Member-6---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 6 - Last Name","name":"Member-6---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 6 - Income Source","name":"Member-6---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 6 - Amount","name":"Member-6---Amount","className":"col-md-6","subtype":"text"},{"type":"select","label":"Member 6 - Pay Frequency","name":"Member-6---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --"},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","label":"Member 7 - First Name","name":"Member-7---First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 7 - Last Name","name":"Member-7---Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 7 - Income Source","name":"Member-7---Income-Source","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Member 7 - Amount","name":"Member-7---Amount","className":"col-md-6","subtype":"text"},{"type":"select","label":"Member 7 - Pay Frequency","name":"Member-7---Pay-Frequency","className":"col-md-6","values":[{"label":"-- Select One --","value":"-- Select One --","selected":true},{"label":"Weekly","value":"Weekly"},{"label":"Bi-Weekly","value":"Bi-Weekly"},{"label":"Monthly","value":"Monthly"},{"label":"Yearly","value":"Yearly"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"PUBLIC HOUSING ONLY:","className":"d-block"},{"type":"paragraph","subtype":"p","label":"List all vehicles that household members will be parking on Housing Authority property:","className":"d-block"},{"type":"text","required":true,"label":"Vehicle 1 - Year","name":"Vehicle-1---Year","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - Make/Model","name":"Vehicle-1---MakeModel","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - Color","name":"Vehicle-1---Color","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 1 - License #","name":"Vehicle-1---License-","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","required":true,"label":"Vehicle 2 - Year","name":"Vehicle-2---Year","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 2 - Make/Model","name":"Vehicle-2---MakeModel","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 2 - Color","name":"Vehicle-2---Color","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Vehicle 2 - License #","name":"Vehicle-2---License-","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"Do you receive court appointed child support?","inline":true,"name":"Do-you-receive-court-appointed-child-support","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","required":true,"label":"Do you receive non-court appointed child support?","inline":true,"name":"radio-group-1762794929425","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If yes, please list the child's name the support is for, the name of the person paying the support, and the monthly amount.","name":"If-yes-please-list-the-childs-name-the-support-is-for-the-name-of-the-person-paying-the-support-and-the-monthly-amount","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Do you anticipate any increase or decrease in the household income over the coming twelve (12) months?","inline":true,"name":"Do-you-anticipate-any-increase-or-decrease-in-the-household-income-over-the-coming-twelve-12-months","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If so, list each family member whose income will change and give an explanation for the increase or decrease.","name":"If-so-list-each-family-member-whose-income-will-change-and-give-an-explanation-for-the-increase-or-decrease","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"Do you or any member of your household own or have any legal interest in any type of asset?","inline":true,"name":"Do-you-or-any-member-of-your-household-own-or-have-any-legal-interest-in-any-type-of-asset","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"checkbox-group","required":true,"label":"Note: Assets include cash, checking, savings, stocks, bonds, treasury bills, money market, certificate of deposits, whole life insurance, real estate, and retirement accounts.","name":"Note-Assets-include-cash-checking-savings-stocks-bonds-treasury-bills-money-market-certificate-of-deposits-whole-life-insurance-real-estate-and-retirement-accounts","className":"d-block","values":[{"label":"Checking Account (including prepaid)","value":"Checking Account (including prepaid)"},{"label":"Savings Account","value":"Savings Account"},{"label":"Equity in Real Estate","value":"Equity in Real Estate"},{"label":"Access to Retirement or Pension Fund or Accounts","value":"Access to Retirement or Pension Fund or Accounts"},{"label":"CD, Money Market Funds, or Treasury Bills","value":"CD, Money Market Funds, or Treasury Bills"},{"label":"WHOLE Life Insurance Policy","value":"WHOLE Life Insurance Policy"},{"label":"Anticipation of ANY Lump Sum","value":"Anticipation of ANY Lump Sum"},{"label":"CASH (more than $5,000)","value":"CASH (more than $5,000)"},{"label":"Disposed of Asset for less than value in last 2 years","value":"Disposed of Asset for less than value in last 2 years"},{"label":"No Assets owned by any family member","value":"No Assets owned by any family member"}]},{"type":"radio-group","required":true,"label":"Does the combined total of ALL assets of ALL family members total more than $5,000?","inline":true,"name":"Does-the-combined-total-of-ALL-assets-of-ALL-family-members-total-more-than-5000","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If YES, list the name of the asset, gross, or market value of the asset, and provide the bank/institution that hold the account:","name":"If-YES-list-the-name-of-the-asset-gross-or-market-value-of-the-asset-and-provide-the-bankinstitution-that-hold-the-account","subtype":"textarea","className":"d-block"},{"type":"file","label":"Submit a copy of the last 3 months of bank statements:","description":"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\".","name":"Submit-a-copy-of-the-last-3-months-of-bank-statements","subtype":"file","multiple":true,"className":"d-block"},{"type":"checkbox-group","required":true,"label":"If NO, please note, that by signing this application you are certifying that the total value of all assets held by your ENTIRE family is less than $5,000.","inline":true,"name":"If-NO-please-note-that-by-signing-this-application-you-are-certifying-that-the-total-value-of-all-assets-held-by-your-ENTIRE-family-is-less-than-5000","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"radio-group","required":true,"label":"Have you closed a bank account in the last 12 months?","inline":true,"name":"Have-you-closed-a-bank-account-in-the-last-12-months","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If YES, please list the name of the bank/institution and the type of account:","name":"If-YES-please-list-the-name-of-the-bankinstitution-and-the-type-of-account","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","required":true,"label":"Does anyone in your household pay out of pocket for childcare for a child or children under the age of 13 years of age?","inline":true,"name":"Does-anyone-in-your-household-pay-out-of-pocket-for-childcare-for-a-child-or-children-under-the-age-of-13-years-of-age","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"If YES, what is the monthly amount for child care?","name":"If-YES-what-is-the-monthly-amount-for-child-care","className":"d-block","subtype":"text"},{"type":"radio-group","required":true,"label":"Does anyone in the household (if elderly or disabled) pay for medical expenses?","inline":true,"name":"Does-anyone-in-the-household-if-elderly-or-disabled-pay-for-medical-expenses","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"If YES, what is the monthly amount for medical expenses?","name":"If-YES-what-is-the-monthly-amount-for-medical-expenses","className":"d-block","subtype":"text"},{"type":"radio-group","required":true,"label":"Are you or anyone in your household a person with a disability requesting a reasonable accommodation due to a result of a disability? (A reasonable accommodation is a change in a policy, procedure, rule, proactive or program service that will allow equal opportunity for housing assistance)","inline":true,"name":"radio-group-1762795500555","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If YES, please explain the reasonable accommodation below:","name":"If-YES-please-explain-the-reasonable-accommodation-below","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"Have you or a member of your household been arrested within the past 3 years?","inline":true,"name":"Have-you-or-a-member-of-your-household-been-arrested-within-the-past-3-years","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","required":true,"label":"Have you or a member of your household been convicted of any drug-related or violent criminal activity within the past 3 years?","inline":true,"name":"Have-you-or-a-member-of-your-household-been-convicted-of-any-drug-related-or-violent-criminal-activity-within-the-past-3-years","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","required":true,"label":"Is any member of your household required to register as a sex offender?","inline":true,"name":"Is-any-member-of-your-household-required-to-register-as-a-sex-offender","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","required":true,"label":"If YES, to any of the following arrest, drug activity, or sex offender questions, please explain:","name":"If-YES-to-any-of-the-following-arrest-drug-activity-or-sex-offender-questions-please-explain","subtype":"textarea","className":"d-block"},{"type":"radio-group","required":true,"label":"If this is your Annual Recertification, do you plan on moving?","inline":true,"name":"If-this-is-your-Annual-Recertification-do-you-plan-on-moving","className":"col-md-6","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"text","required":true,"label":"If YES, when and have you notified your landlord?","name":"If-YES-when-and-have-you-notified-your-landlord","className":"col-md-6","subtype":"text"},{"type":"checkbox-group","required":true,"label":"What utilities do you pay?","inline":true,"name":"What-utilities-do-you-pay","other":true,"className":"d-block","values":[{"label":"Electric","value":"Electric"},{"label":"Gas","value":"Gas"},{"label":"Water","value":"Water"},{"label":"Sewer","value":"Sewer"}]},{"type":"checkbox-group","required":true,"label":"Arkansas County Housing Authority may require the following: Income: Payroll summery from your employer(s), or (3) consecutive paystubs, court-ordered child support verification, social security (SS, SSI, SSDI) award letter(s), or any other proof of household income that is received. Assets: Three (3) consecutive months of bank statements. Disability/Medical Expense(s): Previous year (past 12 months) Printouts from doctor, pharmacy, or any out of pocket medical/disability expense(s) incurred. Insurance Premiums: (current year). Childcare Expenses: Three (3) consecutive months of receipts from the childcare provider. Other","inline":true,"name":"Arkansas-County-Housing-Authority-may-require-the-following-Income-Payroll-summery-from-your-employers-or-3-consecutive-paystubs-court-ordered-child-support-verification-social-security-SS-SSI-SSDI-award-letters-or-any-other-proof-of-household-income-that-is-received-Assets-Three-3-consecutive-months-of-bank-statements-DisabilityMedical-Expenses-Previous-year-past-12-months-Printouts-from-doctor-pharmacy-or-any-out-of-pocket-medicaldisability-expenses-incurred-Insurance-Premiums-current-year-Childcare-Expenses-Three-3-consecutive-months-of-receipts-from-the-childcare-provider-Other","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Certification of the Applicant","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I hereby certify that all the information I have provided on this application is true and complete and hereby authorize the Arkansas County Housing Authority (ACHA) to obtain information from any source to verify information provided. False or incomplete information given will result in the ACHA (1) rejecting this Household Declaration and or (2) terminating tenancy assistance if false or incomplete information is discovered after occupancy or assistance begins. Further, ACHA may rely on the statements provided by the household as a certification of income, composition, deductions, or assets if ACHA is unable to secure third-party verification of information. The participant(s) would also be required to repay the ACHA for any assistance that was provided based on false or incomplete information by the participant(s). I/we understand that if we believe we have been discriminated against, we may call the Fair Housing and Equal Opportunity Hotline at 1-800-877-7353.","inline":true,"name":"checkbox-group-1762795853958","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"checkbox-group","required":true,"label":"I understand that I am required to notify the Housing Authority in writing within ten (10) working days of any changes in household income, if any member of the family moves out of the unit, and/or that I can not permit anyone to move in my unit prior to approval of the Housing Authority and my Landlord. I understand that I must notify the Housing Authority in writing of any changes in the household due to birth, adoption, or court-ordered custody. I also understand that any person who attempts to obtain housing assistance or rent reduction by making false statements, by impersonation, by failure to disclose or intentionally concealing information, or any act of assistance to such attempt is a crime under Federal and State law.","inline":true,"name":"I-understand-that-I-am-required-to-notify-the-Housing-Authority-in-writing-within-ten-10-working-days-of-any-changes-in-household-income-if-any-member-of-the-family-moves-out-of-the-unit-andor-that-I-can-not-permit-anyone-to-move-in-my-unit-prior-to-approval-of-the-Housing-Authority-and-my-Landlord-I-understand-that-I-must-notify-the-Housing-Authority-in-writing-of-any-changes-in-the-household-due-to-birth-adoption-or-court-ordered-custody-I-also-understand-that-any-person-who-attempts-to-obtain-housing-assistance-or-rent-reduction-by-making-false-statements-by-impersonation-by-failure-to-disclose-or-intentionally-concealing-information-or-any-act-of-assistance-to-such-attempt-is-a-crime-under-Federal-and-State-law","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"checkbox-group","required":true,"label":"Warning: Title 18, Section 1001 of the United States Code, states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States and shall be fined not more than $10,000 or imprisoned for not more than five (5) years or both.","inline":true,"name":"Warning-Title-18-Section-1001-of-the-United-States-Code-states-that-a-person-is-guilty-of-a-felony-for-knowingly-and-willingly-making-false-or-fraudulent-statements-to-any-department-or-agency-of-the-United-States-and-shall-be-fined-not-more-than-10000-or-imprisoned-for-not-more-than-five-5-years-or-both","className":"d-block","values":[{"label":"I acknowledge.","value":"I acknowledge."}]},{"type":"text","required":true,"label":"Signature of Head of Household","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"Signature-of-Head-of-Household","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Head of Household Signature","name":"Date-of-Head-of-Household-Signature","className":"col-md-6"},{"type":"text","required":true,"label":"Signature of Spouse or Co-Head","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"Signature-of-Spouse-or-Co-Head","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature of Spouse or Co-Head","name":"Date-of-Signature-of-Spouse-or-Co-Head","className":"col-md-6"},{"type":"text","required":true,"label":"Signature of Other Adult 1","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"Signature-of-Other-Adult-1","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature of Other Adult 1","name":"Date-of-Signature-of-Other-Adult-1","className":"col-md-6"},{"type":"text","required":true,"label":"Signature of Other Adult 2","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"Signature-of-Other-Adult-2","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature of Other Adult 2","name":"Date-of-Signature-of-Other-Adult-2","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Certification of PHA Representative","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I hereby certify by my signature that I have explained all questions on this application form and reviewed the answers provided with the Head of Household to ensure that these questions were fully understood and fully answered.","className":"d-block"},{"type":"text","subtype":"disabled","label":"Signature of PHA Representative","name":"Signature-of-PHA-Representative","value":"PHA Use Only","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Date of PHA Representative Signature","name":"Date-of-PHA-Representative-Signature","value":"PHA Use Only","className":"col-md-6"}]