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1. Head of Household This section is complete This section is incomplete
2. Referral Information This section is complete This section is incomplete
3. Household Composition This section is complete This section is incomplete
4. Household Members This section is complete This section is incomplete
5. Additional Household Members This section is complete This section is incomplete
6. Assets This section is complete This section is incomplete
7. Application Certification This section is complete This section is incomplete

Head of Household

Head of Household Information
More information and documents will be required at your first interview. These items include but are not limited to, social security cards, birth certificates, state identification cards and proof of residency.
Name
Email Address
Address
City
State
Zip Code
Phone
Alternate Phone
Sex
List any other name(s) you have used other than the one you are presently using:
Do you owe any unpaid rent and or damages to any Public Housing Agency?
If yes, list the agency and amount.
Check where applicable:
1. Do you have a Housing Choice Voucher (Section 8)?
2. Have you ever resided in public housing and or received a voucher?
3. Are you a resident of Butler County, Pennsylvania?
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Referral Information

To be completed only if you are working with a social service agency.
Referring Agency
Agency Contact
Phone
Email
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Household Composition

Number of Adults
Number of Childen
Is anyone in the home disabled?
1. Yes
1. No
Is anyone in the household Limited English Proficiency (LEP)??
1. Yes
1. No
Do you or any of your household have any special housing needs?
If yes, please explain.
Are you or any household members currently using an illegal controlled substance?
If yes, please explain.
Have you or any member of your household been convicted of illegal usage, distribution, or manufacture of a controlled substance?
If yes, please explain.
Have you or any of your household members ever been convicted of any felony or misdemeanor other than traffic violations?
If yes, please explain.
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Household Members

Member 1
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
Member 2
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
Member 3
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
Member 4
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
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Additional Household Members

Member 5
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
Member 6
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
Member 7
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
Member 8
First Name
Last Name
Relationship to Head of Household
Sex
Date of Birth
Date of Birth
Source, Rate & Type of Income
If applicable.
Present Monthly Income
If applicable.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Any ADULT household member must complete.
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Assets

Type of Account
Balance/ Value/ Name of Institution
Type of Account
Balance/ Value/ Name of Institution
Type of Account
Balance/ Value/ Name of Institution
Type of Account
Balance/ Value/ Name of Institution
Type of Account
Balance/ Value/ Name of Institution
Type of Account
Balance/ Value/ Name of Institution
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Application Certification

It is the applicant’s responsibility to notify the Redevelopment Authority office for all change of addresses, telephone number and status of preference change.

All applications will be reviewed, and a preliminary determination and an approximate waiting time will be accessed by letter to the applicant within two weeks of the date the Redevelopment Authority receives your application.

We/I acknowledge the Redevelopment Authority may be considering information from any one or all of the following sources to determine eligibility: Interviews, Landlord References, Home Housekeeping Visit, Credit Report, Registry Check and/or Criminal Reports.

WARNING NOTICE: 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 or the Department of the Housing and Urban Development. NOTICE: Any attempt to obtain Public Housing, any rent subsidy or rent reduction by false information, impersonation, failure to disclose or other fraud (and any act of assistance to such attempt) is a crime under Federal Law.

I understand that this is not a contract and does not bind either party. The above information is full, true, and complete to the best of my knowledge. I have no objects to inquiries being made for the purpose of verifying any or all statements made herein.
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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Hard to House (BAR) Application

Steps

Head of Household

Referral Information

Household Composition

Household Members

Additional Household Members

Assets

Application Certification