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Y:\images\articles\1785\dvm4708aAff.HousingNewApp.DOC.doc Rev 05/15/13 FOR OFFICE USE ONLY ACCOUNT DATE: STAFF: AFFORDABLE RENTAL HOUSING PROGRAM INTEREST LIST ENROLLMENT HEAD OF HOUSEHOLD INFORMATION: SOCIAL SECURITY # LAST NAME: FIRST NAME: BIRTH DATE: MALE FEMALE STREET ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE: WORK OR MESSAGE PHONE: TOTAL ANNUAL GROSS INCOME (BEFORE TAXES): $ ANNUAL INCOME / YEAR INCLUDE TOTAL INCOME FOR ALL HOUSEHOLD MEMBERS COMBINED DOES ANY ADULT IN THE HOUSEHOLD WORK IN ANAHEIM? Yes No IF SO, WHERE? DISABILITY: ARE YOU, OR YOUR SPOUSE, OR THE CO-HEAD OF HOUSEHOLD, PERMANENTLY DISABLED? Yes No RACE: ASIAN AMERICAN INDIAN/ BLACK HAWAIIAN/ PACIFIC WHITE ETHNICITY: HISPANIC NON-HISPANIC ALASKA NATIVE ISLANDER S FIRST NAME LAST NAME MIDDLE INITIAL RELATION TO HEAD OF HOUSEHOLD (SPOUSE, SON, DAUGHTER, ETC BIRTHDATE SEX 1. M F 2. M F 3. M F 4. M F 5. M F 6. M F IMPORTANT: Please review this form to make sure it is complete. Incomplete forms will not be processed. When an affordable unit becomes available, enrollees on the Interest List are matched with the unit’s criteria and notified by mail. Please submit any questions to [EMAIL REDACTED] or call 714-765- 4320 ext. 4810. NOTICE: The City of Anaheim grants a preference to persons who live or work in the incorporated area of Anaheim. If you live outside of the City of Anaheim, you may enroll, but you will not be notified of available units until all interested parties who live or work in the City of Anaheim are notified. Signature of Head of Household Date Mail to: In Person: Email/ Online: Affordable Housing Application C/O: Affordable Housing [EMAIL REDACTED] P.O. Box 3222 201 S. Anaheim Blvd., 2nd Floor www.anaheimhousingprograms.com Anaheim, CA 92803-3222 Anaheim, CA 92805