Last Updated: 07/01/2008

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The Housing Authority of The City of North Las Vegas is currently only taking applications for elderly families (head of household is 62 years of age or older) or families applying for HOME or Thunderbird units. Please note any other applications will be rejected.   
Warning:  Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements of misrepresentation to any Department or Agency of the U.S. as to any matter within its jurisdiction.

All fields in Red are mandatory.

Fill in the information on the Head of Household.

Last Name                               First Name                      Mailing Address
 

City                                               State                       Zip Code
           

Home Phone Number               Work Phone Number          Message Phone Number
           

Email Address
Family Composition:  Beginning with yourself, list all persons who will be living with you including live-in aides.  You must fill out all information on each family member or your application will not be processed.

1 (Mandatory)
     Last Name                             First Name                                Middle Name                     
         

    Date of Birth              City of Birth                                   State of Birth         Country of Birth
                            

     Social Security Number                   Relationship to Applicant
               

 

 2. Last Name                              First Name                                 Middle Name 
                       

     Date of Birth              City of Birth                             State of Birth      Country of Birth
                             

    Social Security Number                    Relationship to Applicant
               

 3. Last Name                              First Name                                  Middle Name 
                       

     Date of Birth              City of Birth                             State of Birth    Country of Birth
                           

    Social Security Number              Relationship to Applicant
               

 4. Last Name                              First Name                                  Middle Name 
                       

     Date of Birth              City of Birth                             State of Birth      Country of Birth
                            

    Social Security Number              Relationship to Applicant
               

5. Last Name                               First Name                                  Middle Name 
                       

     Date of Birth              City of Birth                             State of Birth      Country of Birth
                            

    Social Security Number              Relationship to Applicant
               

6. Last Name                               First Name                                  Middle Name 
                       

      Date of Birth             City of Birth                              State of Birth       Country of Birth
                              

    Social Security Number              Relationship to Applicant
               

7. Last Name                              First Name                                   Middle Name 
                       

      Date of Birth             City of Birth                             State of Birth      Country of Birth
                            

    Social Security Number              Relationship to Applicant
               

8. Last Name                               First Name                                  Middle Name 
                       

     Date of Birth             City of Birth                             State of Birth      Country of Birth
                           

    Social Security Number             Relationship to Applicant
              

9. Last Name                               First Name                                 Middle Name 
                       

     Date of Birth             City of Birth                             State of Birth     Country of Birth
                          

    Social Security Number              Relationship to Applicant
               

10. Last Name                            First Name                                  Middle Name 
                       

      Date of Birth             City of Birth                             State of Birth      Country of Birth
                            

    Social Security Number             Relationship to Applicant
               

 

List Gross Income from all household members including yourself. (Examples of Income; Current Employment Income, Child Support, TANF, Social Security, SSI Disability, Workers Compensation, Unemployment, Pensions, VA Benefits, and/or any other types of income such as self employment or support from family or friends, ect.)
Do you currently have income in your household? Yes  No    If Yes, please complete the following information.  (Mandatory for applicants with income only)

1.  Last Name                          First Name                            Source or Type of Income
   

Address of Income                                    City                                            State            Zip Code
  

Monthly Amount     Hourly Wage Rate    Number of Hours Per Week
    

2. Last Name                          First Name                           Source or Type of Income
   

Address of  Income                                   City                                            State            Zip Code
  

Monthly Amount                Hourly Wage Rate                Number of Hours Per Week
    

3. Last Name                          First Name                           Source or Type of Income
   

Address of Income                                     City                                          State              Zip Code
  

Monthly Amount                Hourly Wage Rate                 Number of Hours Per Week
    

4. Last Name                          First Name                           Source or Type of Income
   

Address of Income                                    City                                           State             Zip Code
  

Monthly Amount               Hourly Wage Rate                 Number of Hours Per Week
    

 

Rental and Utility Expenses:

My monthly rent is:

My monthly utility bills are: Utility bills include gas, water, electric, trash & sewer)

 

Previous / Current Assistance:
 Have you received or are you currently receiving housing assistance?   Yes       No    
If yes, list when and where:

 

Specific Accommodations:
Are you or anyone in your family a person with disabilities requiring  a specific accommodation to fully utilize our programs and services? Yes   No

If yes, please list:

If you or anyone in your family is a person with disabilities, do you require an accessible unit?      Yes   No

If yes, what type of accessible unit do you require?      Mobility Impairment          Hearing Impairment          Visual Impairment

 

Program(s) Desired:

*Programs applying for:    Elderly Public Housing        Family Public Housing        Non-Assisted Affordable Housing        HOME Program

*You will only be added to the wait list of the program(s) selected if the wait list for that program is open.

 

Veteran or Spouse of a Deceased Veteran Preferences:

Do you feel your family qualifies for the Veteran or Spouse of a Deceased Veteran admission preference?    Yes   No

I understand that my claim will be verified to the satisfaction of Housing Authority staff before an admission preference is granted.
                                                                                                  Definition of Preference

If you need assistance, due to a disability, in filling out applications or other paperwork please let us know and one of our staff members will be happy to work with you.   TDD users may dial (702) 649-0085 for assistance.
 

Additional Information:

I have reviewed the information above and certify it to be correct.
            
Name                                                                            Date