Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Physical Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

Only if different from your physical address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Status *

Single

Married

Widowed

Domestic Partner

Name of Family Member

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name of Family Member

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name of Family Member

First Name

Last Name

Date of Birth

MM

DD

YYYY

Name of Family Member

First Name

Last Name

Date of Birth

MM

DD

YYYY

Household Member Name *

First Name

Last Name

Household Member Name

First Name

Last Name

Household Member Name

First Name

Last Name

Household Member Name

First Name

Last Name

Has any household member received Housing and Urban Development (HUD) or Bureau of Indian Affairs Housing Improvemtn Program (HIP) assistance before? *

Yes

No

Does any family member who permanently resides with you have a severe health problem, handicap or permanent disability?

Yes

No

Has any household member ever been evicted from a residence? *

Yes

No

Has any household member been convicted of a felony? *

Yes

No

Is any family member residing with you a Veteran? *

Yes

No

Do you or anyone in your household own any other property? *

Yes

No

Check one *

Own

Rent

Share

Homeless

Other

Do you receive any assistance Rent/Mortgage *

Yes

No

Facilities

Flush Toilet

Tub

Shower Only

Electricity

Yes

No

Please select all that apply

City/Town Sewer

Community Septic/Wastewater

Private Septic

City/Town Water

Well

Community Well

If yes, please check the following conditions that apply

Plumbing Defects

Heating System Defects

Overcrowding

Electrical Defects

Entrance/Exit Defects

Inadequate Elderly/Handicapped Access

Structural Defects

Unsafe Site Materials

Inadequate Weatherization

Applicant Certification *

I/We understand the information provided above is obtained to determine if I/WE are eligible to receive Housing Program assistance. I/We hereby certify that all the information provided herein is true and correct. I/We understand that providing false statements or information is grounds for termination of housing assistance and is punishable under federal law. I agree to provide all necessary documentation within 30 days, or I understand that my application will be deemed incomplete and will be procedurally denied. I also agree if I return to the department for financial assistance as second time, I will be required to meet with the Mashpee Housing Department Commission and participate in financial education.

I agree