WIA Residential Application
Name (Last, First, M.I.)
 Home Phone No.
Address
 Apt. No.
 City
 State
 Zip
Date of Birth

Social Security No.
 If you do not receive SSI, are you willing to have a physician certify you meet the federal definition of handicapped? Yes No
If you do not receive SSI and are not willing to have certification of a handicapping condition, you will not be eligible for admission to West-In-Arms.
Provide contact information of two friends or relatives that we can contact if we are unable to reach you.
Name

Telephone
 Name

Telephone
Graduate or Professional
Other Schooling
Present Landlord's Name

Landlord's Telephone
 Landlord's Address
Rent Utilities
Reason for Leaving
Prior Landlord's Name

Landlord's Telephone
 Landlord's Address
Rent Utilities
Reason for Leaving
Employment Record:
List all full or part-time employment. If not presently employed, list all prior employees, full or part-time, and actual earnings. If ever self-employed, please include:
Name and Address of Employer
 Gross Earnings
Per
Name and Address of Employer
 Gross Earnings
Per
Name and Address of Employer
 Gross Earnings
Per
Other Sources of Income: (Examples: Welfare, Social Security, S.S.I., pensions, disability compensation, unemployment compen sation, interest, babysitting, caretaking, alimony, child support, annuities, dividends, income from rental property, armed forces reserves, scholarships, and/or grants.
Date First Received Source Amount
$ per
$ per
$ per
$ per
Assets:
Checking Account Amount Bank Acct.#
Passbook Savings Amount Bank Acct.#
Savings Certificates Amount Bank Acct.#
Credit Union Shares Credit Union Name
Address
Money Market Funds Amount Bank Acct.#
Stocks & Bonds (value) War Bonds (value)
Do you have any assets? Yes No If yes, what is its value?
Did you ever dispose of any assets at fair market value? Yes No
If yes, when and for what value
If not at fair market value, what was the value 		Do you have access to trusts?
 Yes No
List below any life insurance policy numbers that you may have and addresses of insurance companies:
Policy No. Name
Address
Policy No. Name
Address
Policy No. Name
Address
Medical & Unusual Expenses:
Are you receiving Medicare Benefits? Yes No
 Are you receiving Medical Assistance through the Welfare Dept.? Yes No
Do you pay for any medical/insurance/hospitalization (such as Blue Cross, etc.)? Yes No
Is this a Payroll deduction? Yes No If yes, how often and how much?
Are making payments on outstanding medical bills? Yes No
 Do you take prescription drugs on a regular basis? Yes No
Do you anticipate any health care related expenses for the next 12 months which are not covered by health insurance? Yes No
If yes, explain
Program Information:
Have you ever been displaced by a fire, flood, tornado, or public action, such as urban renewal or construction of a highway or school? Yes No
Have you ever applied for or participated in a rent assistance program? Yes No
If yes, explain
Have you ever been evicted or violated your lease? Yes No
If yes, explain
How did you hear about West-in-Arms?
The following information is required for statistical purposes so the Department of HUD may determine the degree to which its programs are utilized by minority families. Response is optional.

White Black American Indian Spanish American Oriental (Japanese, Korean, Chinese, Filipino) Other

Note:
The information you have provided on this form will be kept as confidential as possible, however, we feel you should be aware that the information yo report to us may possibly be seen by someone other than an employee. For example, an auditor.
I hereby authorize West-In-Arms, Inc. and its staff to contact any agencies, offices, groups, or organizations to obtain any information or materials which is deemed necessary to complete my application . I certify that all statements are complete and correct to the best of my knowledge and belief.
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