Rental Assistance Inquiry Form (Section 8)

First Name *

M.I. *

Last Name *

Street Address *

City *

State *—Please choose an option—AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming

Zip *

Home Phone 

Emergency Phone 

E-mail Address Please leave this field empty.

Do You Own or Rent? *OwnRentOther

Home Type *—Please choose an option—HouseTown HouseDuplexApartmentMobile Home

Rental Assistance for which County *FaribaultLe Sueur

Language Spoken in Home *

Date of Birth *

Years of Education Completed *

Check all that apply for all household members *Salary or WagesAlimony/Child SupportSocial SecuritySelf EmploymentRetirement/PensionMSAOther/InterestNo IncomeGeneral AssistanceReemployment Comp.TANF (AFDC, MFIP)SSIFood StampsHousingMedical Aid/Asst.Veterans Benefits

Number of Persons in Household *

Number in Household Employed *

Check Any That ApplyFarmMigrantSeasonal Farm Worker

Do you or anyone in your household have any disabilities? *YesNo

Check one of the following: *Single Parent/FemaleSingle Parent/MaleAdults with childrenSingle PersonAdults onlyOther

Checking/Savings *YesNo

Amount *

CD, Money Market, Stocks, Bonds *YesNo

Amount *

IRA *YesNo

Amount *

CFD, Real Estate *YesNo

Amount *

Proposed Unit/Address *

Proposed Unit County *

Landlord Name *

Type of Unit *—Please choose an option—HouseTown HouseDuplexApartmentMobile Home

Number of Bedrooms *

Rent Amount *

Lot Rent

Security Deposit Required *

Security Deposit Paid *

Have you ever participated in a subsidized housing program? *YesNo

If yes, when/where?

Have you ever participate in the Section 8 program? *YesNo

If yes, which agency?

Date

Under what name

How did you hear about the Section 8 Program?

Under current Federal and State legislation your right to privacy is protected. MVAC is asking you to supply us with private information concerning you, your family, and household. By Law you do not have to provide this information. MVAC needs information about you to determine if you can get help from any program. Without information about your household, MVAC may not be able to help you and the help may be late or less than what you may be eligible to receive. The purpose for this information is to inform you of eligibility for all programs at MVAC. MVAC may use information to research, plan, and evaluate programs. Information is used in determining compliance with Federal and State regulations. MVAC will use this information to make statistical and demographic reports to different agencies and funding sources. Never will information that identifies you or any member of your household be revealed unless you give your written permission. MVAC will also use this information to develop a mailing list. MVAC will use the mailing list to update you on the programs and program changes. At no time will the mailing list be revealed to anyone outside MVAC. To ensure that you are being served properly, only MVAC Staff whose jobs require the information will have access to it.

MVAC may share this information with state and local welfare agencies, community based organizations, local and state public and private human service agencies, the Minnesota Department of Economic Security, the United States Department of Labor, the United States Department of Health and Human Services and state and local educational programs, as allowed by law.

This Agency will keep this information for three years from the last date updated with you or until program audits are complete. You have the right to review your records at any time to request changes.

Would you like to be notified of any openings on the MVAC Board of Directors? *YesNo

Would you like to serve on the MVAC Board of Directors?  *YesNo

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