Income and Assets | Anacortes Housing Authority | Affordable Public Housing Washington | Apply for low income housing waiting lists in Anacortes, Washington

Household Member Name:*

First Last

Email address:*

INCOME

Are you employed or have a verifiable start date within the next 12 months?*

Yes
No

Employment Information (including self employment):

Employer Name and Address*

Employer Name Employer Address City State ZIP Code

Employer phone number*

Employer fax number

$ per hour*

# hours per week*

Hire Date*

Add second employer?*

Yes
No

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Second Employer

Employer Name and Address

Employer Name Employer Address City State ZIP Code

Employer phone number

Employer fax number

$ per hour

# hours per week

Hire Date

This field is hidden when viewing the form

End of employment

Are you receiving Social Security (SSA) and/or Supplemental Social Security (SSI) or WA State SSI for yourself or on behalf of any other member of the household?*

Yes
No

Monthly gross income (before any deductions)

Are you receiving public assistance (TANF, GAU, FIP, ADATSA)?*

Yes
No

Monthly gross income*

Are you a member of the Armed Forces (Active, National Guard or Reserves)?*

Yes
No

Monthly gross income*

Are you receiving income from a pension, annuity, retirement fund, insurance policy payments, death benefits or Veteran’s Benefits (not GI Bill benefits)?*

Yes
No

Monthly gross income*

Are you receiving money regularly from your family, church, friends, or any other form of regular/periodic income (such as rent and utility payments)?*

Yes
No

Monthly gross income*

If you are a student, do you receive financial aid?*

Yes
No
N/A

Total amount of Aid received*

Do you receive child support?*

Yes
No

Monthly amount received*

Do you have any bank accounts?*

Yes
No

Bank Name*

Type of Account

Checking
Savings
Other

Account #*

Balance*

Bank Name

Type of Account

Checking
Savings
Other

Account #

Balance

Bank Name

Type of Account

Checking
Savings
Other

Account #

Balance

Do you have any money market account(s)?*

Yes
No

Do you have any life insurance policies?*

Yes
No

Do you own any treasury bills, certificate(s) of deposit (CD), or stocks/bonds, NOT held in a retirement plan?*

Yes
No

Do you receive money from a trust fund?*

Yes
No

Do you have a 401 (k)/IRA/Keogh?*

Yes
No

Do you have net income from rental property (attach signed tax return with Schedule E)?*

Yes
No

Do you own OR are you in the process of selling any real estate, or do you hold a contract for real estate sold?*

Yes
No

Do you own personal property held strictly as investment assets (art, coins, etc)?*

Yes
No

Have you disposed of assets within the last two years for less than fair-market value?*

Yes
No

Do you have income from assets or sources other than those listed above?*

Yes
No

Income Verification*

Paystub, social security award letter, child support, etc.

Drop files here or

Accepted file types: pdf, gif, jpg, jpeg, png, Max. file size: 20 MB, Max. files: 6.

EXPENDITURES

Do you pay any child care expenses?*

Yes
No

If you are elderly or disabled, do you pay out of pocket medical expenses?*

Yes
No
N/A

Under penalty of perjury, I certify that the information presented in this application is true and accurate to the best of my knowledge and belief. I further understand that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of my application or tenancy, and/or prosecution.

Print Applicant/Resident Name*

Date*