SECTION 8 PROJECT BASED APPLICATION

VILLAGE SQUARE ELDERLY
WAITING LIST APPLICATION (62 Years & Older) ONE BEDROOMS ONLY
82 NW 5th AVENUE, DELRAY BEACH, FLORIDA 33444
(561) 272-6766

HEAD OF HOUSEHOLD INFORMATION:

Last Name:

First Name:

Social Security:

Date of Birth: mm/dd/yyyy

Gender:
FemaleMale

Telephone:

Estimated Annual Family Income:

Email:

Mailing Address:

SPOUSE/OTHER ADULT INFORMATION:

Last Name:

First Name:

Social Security:

Date of Birth: mm/dd/yyyy

Gender:
FemaleMale

How many adults will be living in the unit?

FOR STATISTICAL PURPOSES ONLY:

Please identify your race and ethnicity by checking one box in each of the two categories below:
WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian/Other Pacific IslanderHispanic or LatinoNon-Hispanic/Latino

I CERTIFY THAT THE ABOVE INFORMATION IS ACCURATE AND COMPLETE. I UNDERSTAND THAT SUBMISSION OF FALSE INFORMATION OR MISREPRESANTATION MAY RESULT IN LOSS OF ELIGIBILITY TO PARTICIPATE IN THE SECTION 8 PROJECT BASED PROGRAM. ANY CHANGES IN CHANGES IN ADDRESS MUST BE SUBMITTED IN WRITING.

Signature of Head of Household

Please leave this field empty.

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561-272-6766

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