If there is not a secondary applicant, please go to the NEXT STEP.
If yes, please list their relationship and monthly income.
Current employer information (please provide at least a 2 year history)
Secondary employer information (If applicable)
Previous employer information (if not at current employer for 2 years)
Previous employer information (if not at above employer for 2 years)
If yes complete below
Other Gross Monthly Income
Please provide monthly amounts. You must complete the first line of each column. If you do not have that type of income type 0
The purpose of collecting this information is to help ensure that all applicants are treated fairly and that the housing needs of communities and neighborhoods are being fulfilled. You are not required to answer the questions below. Responses to these questions are voluntary - you may check "Decline to State." There will be no impact on your application based on your selection of these answers. The information provided below will be kept confidential.
Affidavit and Authorizations
I hereby consent to release of information to third parties and/or my information to be released to PHDC as it relates to and is necessary to the counseling services received by PHDC or an affiliate.
- So long as you have not opted-out, we may disclose some or all of the information that we collect, as described above, to your creditors or third parties where we have determined that it would be helpful to you, would aid us in counseling you, or is a requirement of grant awards which make our services possible.
- We may also disclose any nonpublic personal information about you or former customers to anyone as permitted by law (e.g., if we are compelled by legal process).
- Within the organization, we restrict access to nonpublic personal information about you to those employees who need to know that information to provide services to you. We maintain physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
Please upload the followwing supporting documents. Please ensure that none of your files are larger than 8MB. Missing documents or an incomplete form may result in a delay to your process.
Supply in jpg or png format
Upload all of the following that apply: Paystubs, Federal Tax returns for the last 2 years, W2s for the last 2 years, Bank Statements for the last 2 months, Other income such as Alimony, Social Security, Pensions, etc.
This could be alimony, social security, pensions, retirement, child support, etc.
To be completed by each Household Member 18 or older with zero income. Please download the form from this link: Zero Intake Form
Next have each member of the household with Zero Income complete that form (one form per person with Zero Income). Then upload the completed and signed form(s) below.
Please upload all forms completed for members of the household 18+ with Zero Income.