Personal Declaration Form

Unique ID
Personal Information
Name*
First Last
Last 4 of SSN*
Date
MM slash DD slash YYYY
Program Enrolled*
- Housing Choice Voucher Program
- Tenant Based Rental Assistance Program
Phone Number
Home Cell Work Message
Changes Being Made to:*
- Address
- Household Members
- Income

Change of Address
Change of Address To:
Street Address City State ZIP Code
Date that it is effective:*
MM slash DD slash YYYY

Change of Household Members
List all persons living in your home now.
People currently living in your home.
First Name Middle Initial Last Name
List only those persons below whom you are adding to or removing from your home.
Adding or Removing People
People Added / Removed from Household

Change in Income:
Change of Income Explanation*

Questionnaire
Children and Disability
1. Do you have custody of minor children living with you?*
- YES
- NO
- Not Applicable
2. Are you working with an agency to obtain custody? (If yes, provide name of agency)*
- YES
- NO
- Not Applicable
Agency used to obtain custody*
3. Do you have a Reintegration Plan for children to return to the home?*
- YES
- NO
- Not Applicable
4. Do you wish to declare you or your spouse disabled or handicapped? (Please identify household member(s) by name)*
- YES
- NO
Household members names declared as disabled*
First Name Last Name
Previous Subsidies
5. Have you been assisted in other Federal Subsidized Housing programs in the past?*
- YES
- NO
Agency where money is owed?*
Name of Agency When Where
6. Have you or a member of your household been evicted from a Federal Subsidized Housing in the past five (5) years? (If yes, why)*
- YES
- NO
Reason for Eviction*
Education History
7. Are you or a member of your household a full time student? (Please identify household member(s) by name and school)*
- YES
- NO
Household member(s) by name and school*
Household member's name School
Criminial History
8. Have you or any member of your household been evicted from federally assisted housing due to drug related or criminal activity in the past three (3) years? (Please identify household member(s) by name)*
- YES
- NO
Household members with criminal activity by name*
First Last
9. Are you or any member of your household subject to registration to meet the requirements by a state sex offender registration program? (Please identify household member(s) by name)*
- YES
- NO
Sex Offenders by Name*
First Last
10. Have you or any member of your household ever been convicted for production or the manufacturing of methamphetamine? (Please identify household member(s) by name)*
- YES
- NO
Members of household convicted for production or the manufacturing of methamphetamine*
First Last
11. Have you or any member of your household been convicted or arrested for drug related or other criminal activity in the past three (3) years? (Please identify household member(s) by name)*
- YES
- NO
Household members convicted or arrested for drug related or other criminal activity in the past three (3) years*
First Last
12. Are you or any member of your household currently on community corrections, probation, or parole? (identify household member(s) by name)*
- YES
- NO
Household members currently on community corrections, probation, or parole identified by name)*
First Last
13. Are you or any member of your household currently on community corrections, probation, or parole, check all that apply
- Select All
- Community Corrections
- Probation
- Parole

Consent*
I agree to the certification statement.
APPLICANT/TENANT CERTIFICATION STATEMENT:
I/We certify that the information given to the Pittsburg Public Housing Authority (PHA) on
household composition, income, net family assets, allowances and deductions is accurate
and complete to the best of my/our knowledge and belief. I/We understand that false
statements or information are punishable under Federal and State law. I/We also understand
that false statements or information are grounds for termination of housing assistance.

Please review all of your submitted information for accuracy before submitting
{all_fields}

Personal Declarations

Personal Information

Change of Address

Change of Household Members

Adding or Removing People

Change in Income:

Questionnaire

Children and Disability

Previous Subsidies

Education History

Criminial History

Income and/or Benefit sources

Assets that Exceed $5,000

Deductions

Expenses

Please review all of your submitted information for accuracy before submitting

Contact Information

First Name	Middle Initial	Last Name

First Name	Last Name

Name of Agency	When	Where

Household member's name	School