Property interested in: (location, how many bedrooms)
Full Name (including middle initial)
Have you lived in Scioto County for the past 3 years? Yes
No
If no, where did you live? (City, State, and County) or NA if this does not apply
Birthdate
SSN (can call to give this instead)
Current employer or source of income if not employed
Full name of other adult in household
Has this person resided in Scioto County for the past 3 years? Yes
No
If no, where did they live? (City, State, and County)
Birthdate
SSN (can call to give this instead)
Current employer or source of income if not employed
Please give same information for any other adults living in the household.
Total number of persons to reside here (adults and children)
Any pets? Yes, indoor
Yes, outdoor
No
If yes, type and number of pets: (NA if none)
Phone (cell or main)
Phone (home or alternate)
Are you currently on HUD? Yes
No
Email Address:
Please add any comments here. Thank you.

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