updated 12/16/2010

How Many Adults: ______ Name: ______________________ How Many Children: _____ SS#: _______________________ Birth Date: __________________

SFHA LOCAL PREFERENCE QUESTIONAIRE FOR SECTION 8 PRELIMINARY APPLICATION

Please read the following Local Preference definitions carefully and mark the box in each category which applies to you.

The information will be used to determine your status on the waiting list. At the eligibility interview, you

will be required to submit verification. Failure to submit preference verification with

this form will result in the return of your application to the Section 8 Waitlist.

CATEGORY A: WITNESS RELOCATION ______ I am participating in the Witness Relocation and Protection (WRAP) Program.

CATEGORY B: LOCAL PREFERENCE INVOLUNTARY DISPLACEMENT: You are involuntarily displaced if you have vacated or will vacate your home due to one or

more of the following reasons:

______(1) Natural Disaster: A disaster such as a fire, flood, or earthquake resulting in your home becoming uninhabitable. ______(2) Domestic Violence: Actual or threatened physical violence directed against you or one or more member of your family by a spouse or other household member or if you still live in housing with an individual who engages in violence. ______(3) Government Action: If you leave your home or will have to leave your home because of an action by government agency related to code enforcement or public improvement or development programs. ______(4) Housing Owner Action: An action by a housing owner which displaces you from your unit, where the reason for the owner’s action was beyond your ability to control or prevent, despite having met all previously imposed conditions of occupancy and the action is other than a rent increase. ______(5) Displacement to Avoid Reprisals: When you or a member of your family has provided information on criminal activities to a law enforcement agency and based on a threat assessment by the agency has recommended that the family be moved to avoid reprisals. ______(6) Displacement By Hate Crimes: Actual or threatened violence or intimidation against you or a member of your family or their property based on their race, ethnicity, color, religion, sex, sexual orientation, national origin, disability, or other physical or cultural characteristics which have either forced you to vacate your housing unit or has destroyed the peaceful enjoyment of your unit. ______(7) Displacement By Inaccessibility: When you or a member of your family has a mobility or other impairment which makes you unable to use critical elements of your housing unit and the legal owner is under no legal obligation to make the unit accessible. ______(8) Displacement Because of HUD Disposition of Multifamily Housing: An action by HUD to dispose of multifamily housing under Section 203 of the Housing and Community Development Amendments of 1978.

SUBSTANDARD HOUSING: You are living in substandard housing if you meet one or more of the following criteria under items

(1) or (2)

______(1) Homeless: If you lack a fixed, regular nighttime residence and are in a primary residence that is either:

_______(a) Supervised publicly operated shelter or is a privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for mentally ill); or

_______(b) An institution that provides temporary residence for individuals intended to be institutionalized; or _______(c) A public or private place not designed for or ordinarily used as regular sleeping accommodations for human

beings. ______(2) Non-Homeless: If you occupy a home and if your home meets any one or more of the following criteria:

_______(a) It is dilapidated and does not provide safe and adequate shelter and in its present condition endangers the health, safety or well-being of your family or it has one or more critical defects or a combination of intermediate defects in sufficient number or extent to require considerable repair or rebuilding. The defects may have resulted from original construction or from continued neglect or lack of repair or from serious damage to the structure.

updated 12/16/2010

_______(b) It does not have operable indoor plumbing.

_______(c ) It does not have a usable flush toilet for the exclusive use of your family. SROs Excluded _______(d) It does not have a usable bathtub or shower inside the unit for the exclusive use of your family. SROs Ecluded _______(e) It does not have electricity or has inadequate or unsafe electrical service. _______(f) It does not have a safe or adequate source of heat. _______(g) It should, but does not, have a kitchen. _______(h) It has been declared unfit for habitation by a government agency.

PAYING MORE THAN 50 % OF INCOME FOR RENT ______ You are paying more than 50 % of your income for rent.

CATEGORY C: RESIDENT _______ I am a resident of or am employed in the City and County of San Francisco.

CATEGORY D: VETERAN _______ I am a Veteran and/or a surviving spouse of the Unites States Armed Forces Veteran.

CATEGORY E: WELFARE TO WORK _______ I am participating in the Welfare to Work Program through the Department of Human Services

CATEGORY F: NO LOCAL PREFERENCE ______ If you are living in standard permanent replacement housing which is defined as decent safe and sanitary and is adequate for your family, you cannot claim a Local Preference. ____________________________________________________________________________________________________________ OPTIONAL INFORMATION PLEASE CHECK ANY STATEMENT(S) WHICH APPLY TO YOU: (DISABILITY INFORMATION: You are not required to answer the following questions. This information is voluntary and shall be treated as confidential medical records. This information will be used to assist the SFHA in identifying housing that meets the needs of your disability in accordance with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.) 1. _______ The head of my household is 62 years of age or older. 2. _______ I and/or member (s) of my family have a physical or mental impairment that substantially limits one or more major life

activities. Please check the following statement (s) which apply to you or a family member

_______ Mobility Impairment _______ Visual Impairment _______ Hearing Impairment _______ Other mobility or physical impairment. Please Specify ________________________________________________

ETHNICITY LANGUAGE 1. _______Samoan 7. _______Japanese 1. _______Cantonese 7. _______Cambodian 2. _______Hispanic 8. _______Laotian 2. _______Spanish 8. _______Samoan 3. _______Vietnamese 9. _______Filipino 3. _______Russian 9. _______Laotian 4. _______Cambodian 10. _______Other Asian/Pacific Islander 4. _______Vietnamese 10. _______Farsi 5. _______Chinese 11. _______Other 5. _______English 11. _______Mandarin 6. _______Korean 12. _______Russian 6. _______Korean 12. _______Tagalog RACE 1. ________White 3. _______Native American 5. _______Pacific Islander 2. ________Black 4. _______Asian ____________________________________________________________________________________________________________ SIGNATURE: TODAY’S DATE: ADDRESS: PHONE #: