Campbell County, Kentucky

Family Composition

Head of Household Full Name*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Email*

Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Date of Birth*

MonthDay Year,

Social Security Number*

SSN 1-SSN 2-SSN 3

Please Do Not Complete The Following Field

What is Your Marital Status?*

Spouse or other adult's full name

Date of Birth

MonthDay Year,

Phone number

Phone Area Code-Phone 3-Phone 4 ext Extension

Social Security Number

SSN 1-SSN 2-SSN 3

Have you or anyone in your household ever used any name(s) or Social Security Number(s) other than the one you are currently using?*

If yes, explain

List all household members who reside in your assisted unit at least 50% of the time

List Name, Relationship, Date of Birth MM/DD/YYYY, Name of School, Race and Name of Absent Parent for Minor for each household member

Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Household Member 7

Are there any other persons not mentioned above who live or will live in your household?*

If yes explain

Are you or any member of the household subject to a lifetime sex offender registration, or any sex offender registration requirements, in any state or country?*

If yes, please give the name of the household member

Please give the terms of the registration requirement

Income

Does the household have income?*

This includes money from wages, self-employment, child support, contributions, Social Security, disability payments (SSI), Workers Compensation, retirement/pensions, AFDC, Welfare, Veteran Benefits, unemployment benefits, rental property income, property settlement, stock dividends, interest from bank accounts and stock dividends, alimony, and all other income.

If yes, please list all income received by and for everyone in your household

Have you and/or any other adult in the household been employed during the last 12 months?*

If yes, please list all places of employment in the last 12 months.

Does anyone outside of your household pay any of your bills or give you money?*

If "yes", please provide their name, address, and phone number

Student Status

Are you currently enrolled or attending a college or university?*

If yes, are you full-time or part-time?

Name of school you are attending

Assets

Do you or any household member own or have any interest in any real estate/ boat/ mobile home?*

Have you disposed of any real estate or asset in the last 2 years for less than fair market value?*

Do you own any stocks, bonds, CDs, life insurance policies or other like assets?*

Do you have a bank account (savings or checking account) ?*

If “yes,” to any asset question, please list detailed information as to the type and organization where the asset is held (for example: savings account at U.S. Bank)

Expenses

How much rent do you currently pay?*

Are you responsible for utilities?*

If yes, please list the utilities you are responsible for per your lease agreement?

Do you have other monthly expenses (unreimbursed childcare/medical expenses)?*

If yes, please list other monthly expenses.

Do you own the refrigerator in the assisted unit?*

Do you own the stove in the assisted unit?*

Program Integrity

Have you or any member of your household ever lived in or been on any Section 8 Program or lived in Public Housing?*

If yes, list when and where

Have you ever committed any fraud in a Federal housing assistance program or been requested to repay any money for misrepresenting information for such programs?*

If yes, please explain

Have you ever been evicted from, charged with a debt to, required to pay money back to, or currently owe money to, any Federal housing assistance program for any reason?*

If yes, please explain and give amount owed, if applicable

Do you or any household member have any convictions of any drug-related activity or violent criminal activity in the past 5 years?*

If “yes” explain

Do you or any household member have any active warrants or criminal charges pending against you at this time?*

If “yes” explain

Have you or any household member ever been convicted of production or manufacturing of methamphetamine on the premises of federally assisted housing?*

If “yes” explain

If you are a Program Participant, please certify that you have performed a cursory review of your unit and notified the housing authority of any repairs/defects that have not been addressed by your landlord by initialing here to certify).*

Note any defects/repairs needed here:

Family Obligations	Determination Of Family Unit (Voucher) Size	Notice Of Right To Reasonable Accommodation
Ineligibility Time Frames	How The Family Total Tenant Payment Is Determined	Steps To Take If You have Maintenance Issues In Your Subsidized Unit
Criminal Activity	Appointments Are Required	Is Fraud Worth It?
Portability Policy	Submitting Paperwork To CCDH	Key Housing Provisions In VAWA 2013
Voucher Term And Extensions	CCDH Policy Regarding Providing Information To Property Owners	HUD Release of Information (HUD-9886)
Request For Tenancy Approval (RTA)	CCDH Guest Policy	Debt Notice (HUD-52675)
Current Agency Payment Standards	Informal Reviews And Hearings	What You Should Know About EIV Notice

Campbell County, Kentucky

Welcome to the official website of Campbell County, Kentucky!

Submit Housing Personal Declaration

Submit Housing Personal Declaration

Family Composition

List all household members who reside in your assisted unit at least 50% of the time

Income

Student Status

Assets

Expenses

Program Integrity

Acknowledgements

Connect

Dialog Title

Campbell County, Kentucky

Welcome to the official website of Campbell County, Kentucky!

Submit Housing Personal Declaration

Submit Housing Personal Declaration

Family Composition

List all household members who reside in your assisted unit at least 50% of the time

Income

Student Status

Assets

Expenses

Program Integrity

Acknowledgements

Live

Visit

Business

Government

Department

Connect

Dialog Title