HOUSING AUTHORITY OF SABINE PARISH
210 NORTH HIGHLAND DRIVE
P O BOX 1565
MANY, LA 71449
318-256-3359 (OFFICE)
318-256-0835 (FAX)

INITIAL APPLICATION FOR HOUSING

If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the Housing Authority of Sabine Parish.
JURISDICTION YOU ARE APPLYING FOR *
  Sabine Parish
* you must check at least one option
Public Housing - Many
Public Housing - Pleasant Hill
Public Housing - Zwolle
Public Housing - Converse
 

Full legal name of
head of household
Street Address
City, State Zip

  
Mailing Address (if different)
City, State Zip

  
Phone number
Alternate phone

Contact person (who could we contact if we are unable reach you?)
Name
Phone
Address

INFORMATION ABOUT MEMBERS OF THE HOUSEHOLD

List all persons who will be living in the home, beginning with the head of household. Each box must be completed for each member. No one except those listed on this form may live in the unit. Applications with missing Social Security Numbers or Date of Birth will be rejected.
Name  Relation
 to Head 
 U.S.
 Citizen 
 Disabled   Sex  Date of Birth Social Security or
Registration #
HEAD // --
// --
// --
// --
 
CHILDREN 17 AND YOUNGER

List all children who will be living in the home, oldest to youngest.
Name  Relation
 to Head 
 U.S.
 Citizen 
 Disabled   Sex   Date of Birth Social Security or
Registration #
School Name
// --
// --
// --
// --
// --
// --

RACE AND ETHNICITY OF HEAD OF HOUSEHOLD

Race
Ethnicity

INFORMATION ABOUT INCOME OF MEMBERS OF THE FAMILY

Income includes money or contributions from any and all sources paid to or on behalf of a family member.

List the sources and amounts of all income (money) expected for the coming 12 months for all family members from any and all sources.
Family Member Name Income Source Amount $ Frequency

Do you claim any of the following preferences?
Working, Elderly, Handicapped, or Disabled

YOU ARE REQUIRED TO NOTIFY THE HOUSING AUTHORITY (IN WRITING) OF ANY CHANGES. IF WE CANNOT CONTACT YOU AT THE ABOVE ADDRESS, YOUR NAME WILL BE REMOVED FROM THE WAITING LIST, AND YOU WILL HAVE TO RE-APPLY. YOU ARE RESPONSIBLE FOR KEEPING YOUR APPLICATION UPDATED. IF YOU FAIL TO DO SO YOUR APPLICATION WILL BE REJECTED.

WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES AND SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISONED FOR NOT MORE THAN FIVE YEARS OR BOTH.