THIS BOX IS FOR OFFICE USE ONLY
STANDARD APPLICATION FOR STATE-AIDED
PUBLIC HOUSING, MRVP & AHVP
Date of receipt: __________________________
Time of Receipt: _________________________
Control Number: _________________________
Barrier Free: ____________________________
First Floor:______________________________
Elderly/Handicapped:______________________
Race: __________________________________
Priority Category: _________________________
Preference Category: ______________________
Language: ______________________________
Incomplete applications will not be processed. Please complete all information requested on the application. If a
question is not applicable, please write N/A. Make sure you sign the last page. If you need additional space to
provide an answer, please attach an additional sheet(s).
1.
Name of Applicant: __________________________________________________________
Address of Current Residence: ___________________________________ Apt. No.: ______
City/Town: ______________________State:__________________ Zip Code: ____________
Mailing Address: ______________________________________________Apt. No.: _______
City/Town_______________________ State: ______________Zip Code: _________________
Home Telephone (
2.
)
Work Telephone (
) __________________
Type of Public Housing you are applying for: (Check one)
a. Elderly
b. Non-Elderly Handicapped c. Congregate Elderly/Handicapped
d. Family
e. MRVP
f. AHVP
Note: To be eligible for elderly/handicapped housing you must be at least 60 years old or a person with a
handicap. If you have a handicap, the handicap must be other than a history of alcohol or drug abuse. If you
have a handicap, you must provide certification by a doctor clearly stating that you have a handicap and it is
expected to be of long and indefinite in duration lasting at least six months. In addition, the LHA will need
to determine that certain special architectural design features OR low rent housing is not available in the
private market AND that the applicant is faced with living in an institution or decadent substandard housing
OR the applicant is paying excessive rents.
3.
If you want to apply for Emergency Housing you must select one of the categories below:
Note: To be eligible for Emergency applicant status you must be "homeless," which is defined by state
regulations as: an applicant who is without a place to live or who is in a living situation in which there is a
significant, imme diate and direct threat to life or safety that would be alleviated by placement in an
appropriate unit, who has not caused or substantially contributed to the situation, who has made reasonable
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 1 of 7
4/30/04
efforts to prevent or avoid the situation and to locate alternative housing, and who is displaced from his/her
primary residence for one of the following reasons. Please check the reason that applies to your situation:
____Displaced by Natural Forces (i.e. Fire, Flood, Earthquake)
____Displaced by Public Action (i.e. Urban renewal, eminent domain)
____Displaced by Public Action (i.e. Condemnation of home, code violations)
____Displaced by No-fault loss of housing, Severe Medical emergency and/or Victim of Abuse
(domestic violence) where the housing situation significantly contributes to or is a direct threat to the
life and safety of the applicant.
If you have selected one of the above emergency categories, you must complete an emergency application in
addition to the standard application. All emergency applications must be accompanied by third party written
documentation. Click here for Emergency Application and description of process.
4.
Local Preference: In addition to receiving local preference for the City or Town where you principally reside,
you may receive local preference based on where you are employed. Please answer the following:
a. Provide the name of the city/town in which you are employed____________________________
Provide the dates of employment: From ____________ to _________________
5.
Veteran’s Preference:
a. (Only for Family Housing) You may apply for Veteran’s Preference if you are a wartime Veteran, the
spouse, surviving spouse, dependent parent or child or divorced spouse with a dependent child of a
wartime Veteran.
b. (Only for Elderly/Handicapped Housing) You may apply for Veteran’s Preference if you are a wartime
Veteran who resides in this City or Town.
If you wish to apply for Veteran’s Preference, list dates of U.S. Military service.
From ____________, ______ to ______________, _______
A copy of the Veteran’s Department of Defense Form DD214 must be submitted with this application.
6.
Do you have any special needs due to a disability or need a reasonable accommodation such as a first floor
unit for medical reasons? Specify:
_____________________________________________________________________________________
7.
8.
9
10.
Do you need a wheel chair accessible apartment? (Check One)
YES
NO
Number of Bedrooms Needed: (Check one)
1
2
3
4
5
Please note that most elderly/handicapped housing developments have only one bedroom units.
Are you currently living in non-permanent transitional housing which is subsidized under the
Massachusetts Alternative Housing Voucher Program? (Check One)
YES
NO
If yes, you must attach documentation verifying AHVP participation.
Racial Designation: (Responding to this question is optional.) Your status with respect to tenant
selection procedures may be affected by this information. If anyone in your household is a Minority,
you may classify your household in that Minority Category. (Circle one)
American-Indian
Asian
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Black
Hispanic
Page 2 of 7
White
Other (specify)____________
4/30/04
11.
Does anyone in your household own a car? (Check one)
12.
YES
NO
Make of Car
Year
Reg. Number _______________________
Make of Car
Year
Reg. Number _______________________
Members of household to live in Unit, including Head of Household:
Name: First, Middle, Last
Relationship
Social Security
Number *
Sex
Date of
Birth
Occupation
(Employed, At
Home, Handicapped,
Or Student)
HEAD
*
13.
This information will be used to verify income, assets, and criminal record information.
Is a change in the household composition expected? (Check one)
YES
If YES, what type of change?
NO
When?_____________
14. INCOME BEFORE DEDUCTIONS - Estimate the Gross Income anticipated for ALL Household
Members from all sources for the next 12 months. Specify all sources.
Household Member
Name
Name and Address of
Employer or Source
of Income
Gross Income For Next
12 Months
Salaries, Wages,
Including Overtime/Tips
Salaries, Wages,
Including Overtime/Tips
$
Net Income From
Business or Profession
$
Trust Income,
Interest & Dividends
Unemployment or
Disability Compensation
Pensions and Annuitie s
$
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
$
$
$
Page 3 of 7
4/30/04
Household Member
Name
Name and Address of
Employer or Source
of Income
Gross Income For Next
12 Months
Regular Social Security
Benefits and/or SSI
$
VA Disability Income
$
T. A. F. D. C.
or Public Assistance
$
Regular Alimony
Support Payments, Gifts
Other Income
$
$
0
TOTAL GROSS INCOME $ ______________________
15. EXPENSES
Unreimbursed Medical Expenses
$
Alimony or Child Support Payments
$
Health Insurance
$
Other (i.e. expense for care of children or sick incapacitated person if
necessary for employment)
$
0
TOTAL EXPENSES: $________________________
16. ASSETS
Do you own any real estate? (Check one.)
YES
NO
If yes, please provide the address? _________________________________________________
List below the assets of everyone to live in the unit. Include all bank accounts, stocks and bonds,
trusts, real estate, etc. DO NOT include clothing, furniture, or cars. Use additional paper if necessary.
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 4 of 7
4/30/04
Household
Member
Asset Type
Asset Value Or
Current Balance
$
Name of
Financial Institution
Account
Number
$
$
$
$
$
$
17. Have you sold, transferred or given away any real property or assets in the last three (3) years?
YES
If YES:
NO
(Check one)
Date of Sale/Transfer: Month________ Day_________Year__________
Amount of the sale/transfer:_______________________________________
Value of the sale/transfer:_______________________________________
18.
References: List two references. These should not be relatives or household members.
(1) Name:
Telephone #: (
Address:
City:
(2) Name:
Telephone #: (
Address:
City:
)
State:
Zip: ______
)
State:
Zip:_______
19. List Addresses for each Adult Household Member for the Last Five Years in Reverse Order. Please
list primary lease holder (head of household) if someone other than yourself. (Use additional sheet if
necessary.)
(1) Address:
Apt. No.:
Dates: from_______ to present
Name of Primary leaseholder:______________________________
City/Town:____________________________________State:________ Zip: __________
Name of Landlord:
Telephone: ( )____________
Landlord Address:_______________________ City:_____________ State:_____ Zip:______
Did this landlord bring any court action against the leaseholder or you? Check One
Did this landlord return your security deposit?
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Check One
Page 5 of 7
Yes
No
Yes
No
N/A
4/30/04
(2) Address:
Apt. No.:
Dates: from_______ to______
Name of Primary leaseholder:______________________________
City/Town:____________________________________State:_________ Zip: ___________
Name of Landlord:
Telephone: ( )____________
Landlord Address:_______________________ City:_____________ State:_____ Zip:______
Did this landlord bring any court action against the leaseholder or you? Check One
Yes
No
Did this landlord return your security deposit?
Check One
Yes
No
N/A
(3) Address:
Apt. No.:
Dates: from_______ to______
Name of Primary leaseholder:______________________________
City/Town:____________________________________State:_________ Zip: ___________
Name of Landlord:
Telephone: ( )____________
Landlord Address:_______________________ City:_____________ State:_____ Zip:______
Did this landlord bring any court action against the leaseholder or you? Check One
Yes
No
Did this landlord return your security deposit?
Check One
Yes
No
N/A
20.
Have you, or any member or your household, ever received housing assistance from this or any other
housing agency? (Check one)
YES
NO
If YES: Name of Head of Household at that time: ______________________________
Relation to Present Applicant: ______________________________________
Name of Housing Agency: _________________________________________
Date Moved Out: ________________________________________________
Reason Moved Out:_______________________________________________
When you moved out were you in compliance with the lease and other program requirements?
(Check one)
YES
NO
If NO, please explain: _________________________________________________________
_________________________________________________________
_________________________________________________________
21.
Are you a Board Member, employee, or a member of the immediate family of an employee or
a Board Member of this Housing Authority? (If so, this will not necessarily disqualify your
application.) (Check one)
YES
NO
If YES, please explain: _________________________________________________________
___________________________________________________________________________
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 6 of 7
4/30/04
22.
Do you have any pets? (Check one)
YES
NO
If YES, how many? ______________
Please describe:________________________________________________________________
______________________________________________________________________________
23.
Emergency Reference: Name of a relative or friend NOT planning to live with you. We will
contact this person if we are not able to reach you or in case of an emergency.
Name:
Relationship:_____________________________
Address: __________________________________________________________________________
City/Town: __________________________
Telephone: (
24.
_ State: __________________Zip: _______________
)_____________________ (
) ________________________________
Criminal Record:
Have you or any member of your household who will live in the unit been convicted
of a felony or misdemeanor? (Check one)
YES
NO
If YES, please explain:_______________________________________________________________
__________________________________________________________________________________
25.
Do you or any member of your household who will live in the unit have any criminal matters
pending?
(Check one)
YES
NO
If YES, please explain ___________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________________
APPLICANT’S CERTIFICATION:
I understand that this application is not an offer of housing. I understand that a Housing Authority will make no more than one offer of
an appropriate public housing unit. If I do not accept that offer, my application will be removed from the waiting list; and, if I reapply,
my application will not receive any priority or preference that was granted on the prior application for a three (3) year period.
Based on this application I understand I should not make any plans to move or end my present tenancy until I have received a written
Unit Offer from a Housing Authority. I understand that it is my responsibility to inform the Housing Authority in writing of any
change of address, income, or household composition. I authorize the Housing Authority to make inquiries to verify the information I
have provided in this application. I certify that the information I have given in this application is true and correct. I understand that
any false statement or misrepresentation may result in the denial of my application. I understand that the Housing Authority will
request Criminal Offender Record Information from the Criminal History Systems Board and perform credit checks and internet searches
for all adult members of the household.
I acknowledge receipt of the Fair Information Practices Act Statement of Rights for all adult members of the household.
SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY. I understand that a photocopy of this
signature is as valid as the original.
Applicant’s signature:
Date: __________
Reviewer’s Signature:
Date: __________
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 7 of 7
4/30/04
Fair Information Practices Act
Statement of Rights
Local Housing Authorities collect information about applicants and tenants for their
housing programs as required by law in order to determine eligibility, amount of rent, and
correct apartment size. The information collected is used to manage the housing
programs, to protect the public’s financial interest, and to verify the accuracy of
information submitted. Where permitted by law, it may be released to government
agencies, other housing authorities, and to civil or criminal investigators and prosecutors.
Otherwise, the information will be kept confidential and only used by housing authority
staff in the course of their duties.
The Fair Information Practices Act established requirements governing hous ing
authorities’ use and disclosure of the information it collects. Applicants and tenants may
give or withhold their permission when requested by the housing authority to provide
information. However, failure to permit the housing authority to obtain the required
information may result in delay, ineligibility for programs, or termination of tenancy or
housing subsidy. The provision of false or incomplete information is a criminal offense
punishable by fines and/or imprisonment.
As an applicant or tenant, you have the following rights in regards to the information
collected about you.
1. No information may be used for any purpose other than those
described above without your consent.
2. No information may be disclosed to any person other than those
described above without your consent. If we receive a legal order to
release the information, we will notify you.
3. You or your authorized representative have a right to inspect and copy
any information collected about you.
4. You may ask questions and receive answers from the housing
authority about how we collect and use your information.
5. You may object to the collection, maintenance, dissemination, use,
accuracy, completeness, or type of information we hold about you. If
you object, we will investigate your objectio n and will either correct
the problem or make your objection part of the file. If you are
dissatisfied, you may appeal to the Executive Director who will notify
you in writing of the decision and of your right to appeal to the
Department of Housing and Community Development.
I have read and understand this Fair Information Practices Statement of Rights and have
received a copy for future reference. This form must be signed, dated and mailed with
your application to each authority where you apply for housing.
Date_________________
Signature_______________________________
NOTICE TO ALL APPLICANTS:
REASONABLE ACCOMMODATIONS ARE AVAILABLE FOR APPLICANTS WITH
MENTAL AND/OR PHYSICAL DISABILITIES
Local Housing Authority (LHA) does not discriminate against applicants on the basis of mental or
physical disabilities. In addition, the LHA has an obligation to provide “reasonable accommodation”
on account of a disability if an applicant or a household member is limited by the disability and for this
reason needs such an accommodation. A reasonable accommodation is a change that the LHA can
make to its facilities or practices that will assist an otherwise eligible person with a disability to
overcome the limitations imposed by his or her disability and to be able to participate in the LHA’s
housing or programs. Such a change must be financially and programmatically feasible for the housing
authority.
An applicant household which has a member with a mental and/or physical disability must still be able
to meet essential obligations of tenancy (for example, the household must be able to pay rent, to care for
the apartment, to report required information to the LHA, and to avoid disturbing neighbors), but an
accommodation may be the basis by which the household is able to meet those obligations of tenancy.
The LHA has an Accommodation Coordinator. If you need an accommodation because of a disability,
please complete the attached form and return it to the LHA. You must also submit medical
documentation verifying the existence of a disability, and the need for an accommodation to overcome
these limitations and to participate in the LHA’s housing or programs. Within thirty (30) days of
receipt of your request and documentation, the Accommodation Coordinator will contact you to discuss
what the LHA can reasonably do to accommodate you on account of your disability.
If you or a member of your household has a mental and/or physical disability, and as a result you need
an accommodation, you may request it at any time. However, you are not obliged to make such a
request, and if you prefer not to do so that is your right.
5/7/04
REQUEST FOR ACCOMMODATION
To: Accommodation Coordinator
______________________ Housing Authority
Authority Address:_____________________________________________
Authority Address:_____________________________________________
From: ______________________________
Applicant Name (please print)
______________________________
Address
______________________________
Town/City, State, Zip
__(____)________________________
Area Code/Telephone Number
_____________________
Control Number
1. I have a disability which limits me in the following ways (describe): ____________
____________________________________________________________________
____________________________________________________________________
2. On account of these limitations, I request the following be done in order to permit
me to participate fully in the Housing Authority’s housing programs. (Describe)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3. Documentation verifying the existence of my disability, my limitations on account of
it, and my need for accommodation is attached. (Attach appropriate documentation)
4.
I attest that the foregoing information is true and correct.
_______________________________________
Signature of Applicant
_______________________
Date
5/7/04
Department of Housing & Community Devleopment
1
Name of Physician_____________________________________
Physician’s Address____________________________________
____________________________________
Date___________________
PHYSICIAN’S VERIFICATION OF HANDICAPPED STATUS FOR
STATE-AIDED ELDERLY/HANDICAPPED HOUSING
_____________________________________
Applicant’s Name
_______________________
Applicant’s Control Number
_____________________________________
_____________________________________
Applicant’s Address
I herby authorize release of the following information: __________________________
Applicant’s Signature
The Housing Authority is required by state regulations to obtain a physician’s certification
documenting that an applicant has a qualifying physical or mental impairment in order to
determine the applicant’s eligibility for elderly/handicapped housing. The applicant has
authorized above your release of the requested information. We would appreciate your prompt
response to the questions on the reverse side of this letter. If you have questions, please contact
our office. Thank you for your anticipated cooperation.
Sincerely,
___________________________________________
Executive Director or Tenant Selection Coordinator
5/7/04
Department of Housing & Community Development
1
TO BE COMPLETED BY PHYSICIAN
1. The applicant must have a physical or mental impairment which substantially
or her ability to live independently?
impedes his
Comment:___________________________________________________
_________________________________________________________________
2. The applicant must have an impairment other than a history of alcohol or substance abuse.
Comment: __________________________________________________
_________________________________________________________________
3. What is the anticipated duration of the Applicant’s impairment? (If indefinite so specify, and
estimate the approximate duration to the best of your
ability).___________________________________________________________
4. Would suitable housing conditions improve the applicant’s ability to live independently and,
if so, what sort? Be specific. _________________________
__________________________________________________________________
5. Other comment: _________________________________________________
__________________________________________________________________
__________________________________________________________________
PHYSICIAN’S CERTIFICATION
I certify that the information provided above represents my professional judgment and is true
and correct to the best of my knowledge and belief.
_______________________________
Signature
MD
Date:____________________________
Name:___________________________ Address:_________________________
Telephone No. (
)
5/7/04
Department of Housing & Community Development
2
EMERGENCY APPLICATION PACKAGE
Dear Applicant:
In order to apply for Emergency Housing, you must fill out and provide doucments specific to
the prioirty you are requesting as described on the Checklist of Required Verification
Documents for Priority Status. You will also need to provide other documents that the LHA
needs to determine your eligibility for Emergency Case Status as well as for the program(s)
for which you have applied. Your Emergency Application will not be processed until you have
provided everything required. A complete application will contain:
1. Standard Application for State-Aided Housing with required verifications attached.
2. Emergency Application for State-Aided Housing with required verifications attached.
3. Verification of income and assets for all household members (for example, last
ten (10) weeks pay stubs, letter from Dept. of Transitional Assistance, Bank
statements).
4. Family Housing- proof of children’s ages.
5. Elderly/Handicapped Housing - proof of age or handicap (handicapped status
must be verified on form).
6. Declaration of Residency and Authorization to Release Information
You may submit your Emergency Application now or at a later time when you believe that
your circumstances meet the Emergency Case criteria. When your application is complete,
the Housing Authority will notify you. If you decide that you do not want to apply for
Emergency Case Status now, you do not need to submit anything further at this time.
5/7/04
Department of Housing & Community Devleopment
1
Date of receipt: __________________________
Time of Receipt: _________________________
Control Number: _________________________
Barrier Free: ____________________________
First Floor:______________________________
Elderly/Handicapped:______________________
Race: __________________________________
Priority Category: _________________________
Preference Category: ______________________
Language: ______________________________
EMERGENCY APPLICATION FOR
STATE-AIDED HOUSING
Incomplete applications will not be processed. Please complete all information requested on the application.
If a question is not applicable, please write N/A. Make sure you sign the last page.
(PLEASE PRINT)
Name of Applicant: ______________________________________________________
Mailing Address of Applicant: _____________________________________________
City/Town:___________________________ State:________ Zip Code: __________
Telephone Number that Applicant can be Reached at: ___________________________
This Emergency Application must include written verification by a third party as to the priority status that you
are claiming. The Housing Authority will not accept this application without third party verification, and
a completed Standard Application. Verification includes letters from social workers, shelters, social service
agencies, or code enforcement agencies that confirm that you meet the definition of “homeless applicant”. Your
application will not be processed until you have provided everything required by the Emergency Application
Package and a completed Standard Application.
In order to be found eligible for Emergency Case Status, you must be a “Homeless Applicant” as defined
below AND qualify for one of the priorities listed below.
Definition of Homeless Applicant
An applicant who:
(a) is without a place to live or is in a living situation in which there is a significant, immediate, and is a direct
threat to the life or safety of the applicant or a household member which situation would be alleviated by
placement in a unit of appropriate size, and
(b) has made reasonable efforts to locate alternative housing, and
(c) has not caused or substantially contributed to the safety or life threatening situation, and
(d) Has pursued available ways to prevent or avoid the situation by seeking assistance through the courts or
appropriate administrative or enforcement agencies, and
(e) is displaced from the residence in which the applicant household lived at least nine (9) months of the year.
5/7/04
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 1 of 3
1.
Do you meet each of the requirements of the definition of “Homeless Applicant” set out on the previous
page? (Check one)
YES
NO
If YES, describe how you meet each of the above requirements:_____________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2.
On what date did you become, or will you become, displaced from your
Day__________ Month_____________ Year_______________
primary residence?
3.
Local Preference, Emergency Applicants Only. If you are homeless an applying for Emergency Housing
you may choose to be considered a resident from the city/town from which you were displaced or a resident in
the city/town in which you are temporarily housed:
Please provide the name of the community you choose to be declared a resident for the
purposes of tenant selection
ALL EMERGENCY APPLICANTS MUST ATTACH PROOF OF HOMELESSNESS. ACCEPTABLE
VERIFICATION INCLUDES LETTERS FROM SOCIAL WORKERS, SHELTERS, SOCIAL
SERVICE AGENCIES, OR CODE ENFORCEMENT AGENCIES THAT CONFIRM THAT YOU
MEET THE DEFINITION OF “HOMELESS APPLICANT”.
3. Check off the priority category below that you believe applies to your situation:
_____PRIORITY 1: Displaced by Natural Forces such as a fire not due to the negligence or intentional act of
applicant, or member of applicant’s household, or by an earthquake, or flood, or by a disaster declared or
formally recognized under disaster relief laws.
If you have checked off Priority 1, you must attach proof of Displacement by Natural Forces such as report
from Fire Department, letter from Board of Health or other government agency documenting destruction of
your residence by earthquake, flood or other disaster.
_____PRIORITY 2: Displaced by Public Action such as the building of a low rent public housing project, a
public slum clearance, urban renewal project or
other public improvement.
If you have checked off Priority 2, you must attach proof of Displacement by Public Action such as Relocation
Notice, letter from Urban Renewal Agenc y or other government agency documenting displacement for public
works project.
______PRIORITY 3: Displacement due to enforcement of minimum standards of fitness for human
habitation established by Article 2 of the State Sanitary Code or local ordinances.
5/7/04
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 2 of 3
If you have checked off Priority 3, you must attach proof of Displacement due to State Sanitary Code enforcement such as
a copy of the complaint listing code violations, placard, notices or letter from Board of Health documenting
condemnation.
PRIORITY 4 - EMERGENCY CASE PLAN CATEGORIES
_____ A. Homeless and Facing a Significant Immediate and Direct Threat to the Life or Safety of the Applicant or
any Household Member for Caus es Other Than the Fault of the Applicant or Member of the Applicant Household.
If you have checked off Priority 4A, you must attach: Proof of No-Fault Loss of Housing such as summary process
summons and complaint, court decision and execution from the court.
______ B. Severe Medical Emergencies. An applicant is suffering a severe medical emergency if the applicant or
member of the applicant household is suffering from an illness or injury posing a severe and medically documented
threat to life or safety which has been significantly caused by the lack of suitable housing or as to which the
lack of suitable housing is a substantial impediment to treatment or recovery.
If you have checked off Priority 4B, you must attach:
1. Proof of Medical Condition such as certification by physician on Housing Authority form.
2. Proof of Unsuitable Housing such as letter from landlord, visiting nurse or Board of Health documenting unsuitability of
current housing, or photographs of current housing showing unsuitable features.
______ C. Abusive Situation. An applicant is in an abusive situation if the applicant or member of the applicant
household is determined by the LHA to be a victim of abuse as defined in the Abuse Prevention Act (G.L. c.209A, §1),
which abuse constitutes a significant and direct threat to life or safety. The Abuse Prevention Act defines “abuse” as the
occurrence of one or more of the following acts between “family or household members”: (1) attempting to cause or
causing physical harm; (2) placing another in fear of imminent serious physical harm; or (3) causing another to engage
involuntarily in sexual relations by force, threat or duress. “Family or household members” are individuals who are
related by blood or marriage, have a child together, or who now or formerly resided in the same household or dated each
other.
If you have checked off Priority 4C, you must attach: Proof of abusive situation such as copies of medical reports, police
reports, restraining orders, applications for criminal complaints, social service evaluations.
EMERGENCY APPLICATIONS SUBMITTED WITHOUT REQUIRED DOCUMENTATION WILL BE DENIED.
APPLICANT’S CERTIFICATION:
I certify that the information that I have given in this application is true and correct, and I understand that any false statement
or misrepresentation may result in the rejection of my application. I authorize the Housing Authority to make inquiries to
verify the information that I have provided in this application.
SIGNED UNDER THE PAINS AND PENALTIES OF PERJURY. I understand a photocopy of this signature is as
valid as the original.
______________________________
Applicant’s Signature
________________________
Date
______________________________
Reviewer’s Signature
________________________
Date
(Attach supporting documentation and return with complete Emergency Application Package)
5/7/04
© 2004 Commonwealth of Massachusetts
Department of Housing & Community Development
Page 3 of 3
Name of Physician_____________________________________
Physician’s Address____________________________________
____________________________________
Date___________________
PHYSICIAN’S VERIFICATION OF SEVERE MEDICAL EMERGENCY
_____________________________________
Applicant’s Name
Control No._____________
_____________________________________
Applicant’s Address
I hereby authorize release
of the requested information.
________________________
Applicant’s Signature
_____________________________________
Dear Dr. _____________________:
The above named applicant is seeking state-aided housing with this Authority and has indicated that he/she is
being displaced or has been displaced from his/her current housing because of a severe medical emergency.
In order to determine whether to grant priority status for this applicant, we must secure verification of a
qualifying severe medical emergency. Therefore, we would appreciate your completing the verification on the
reverse and returning this form directly to the Housing Authority. A representative of the Authority may contact
you at a later date to confirm the information.
Sincerely,
_________________________________________
Executive Director or Tenant Selection Coordinator
Department of Housing & Community Development
1
PHYSICIAN’S VERIFICATION OF SEVERE MEDICAL EMERGENCY
1.
Is the applicant or member of the applicant’s household suffering from an illness or injury
poses a severe and medically documented threat to life or safety? (circle one)
YES
NO
which
NO OPINION
If YES, please explain:______________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
2.
Is the applicant’s current housing situation a cause of the illness or injury or is it a
impediment to treatment or recovery from this illness or injury? (circle one)
YES
NO
substantial
NO OPINION
If YES, please explain:________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3.
How long has the applicant or household member been your patient? ____________________
4.
For what are you currently treating the patient?_______________________________________
PHYSICIAN’S CERTIFICATION
I certify that the information provided above represents my professional judgment and is true and correct to the
best of my knowledge and belief.
___________________________________,MD
Signature
Name:_____________________________
Address:____________________________
_____________________________
Telephone: (____)_____________________
Department of Housing & Community Development
2
______________________
Date
Control No._____________
APPLICANT’S DECLARATION OF RESIDENCY
AND AUTHORIZATION TO RELEASE INFORMATION
I hereby declare that I am “homeless” as defined by the state regulations, and that I am
a resident of ___________________________ the City/Town:
(check one)
______ from which I was displaced through no fault of my own.
______ in which I am temporarily housed.
I certify that I have not declared myself a resident in any other city or town for the purpose of obtaining
local resident preference, and I hereby authorize other local housing authorities and nonprofit agencies to
release information to the Housing Authority to verify this certification. If my temporary address changes,
and I need to change my declaration of local residency, I will immediately notify the Housing Authority,
and I authorize other local housing authorities and nonprofit agencies to immediately notify the Housing
Authority of the change.
Signed under the pains and penalties of perjury.
Dated:_______________________
X__________________________________
Signature of Applicant
5/7/04
Department of Housing & Community Development
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