Instructions: Please follow all instructions carefully and completely
1.
2.
3.
4.
Use only black ballpoint pen to complete application.
Complete all information requested. Incomplete or unreadable forms will be rejected.
Print clearly and write “N/A” for any questions that do not apply to you. See sample below.
Only one application form is necessary for one or any combination of sites. Check off the
properties that you are interested in applying. Do not submit duplicate applications.
5. List Head of Household as member 1, spouse or co-head as member 2. Write “N/A” if there is no
spouse or co-head. See sample below
6. List all other family members in the order of their age, from oldest to the youngest. See sample
below.
7. If any member does not have a SSN, write “999-99-9999”. See sample below.
8. Sign and date your application.
9. Mail the application to: Housing Authority, c/o UPS Store, 951-2 Old County Road #403,
Belmont, CA 94002. This is the only address an application may be received.
10. Keep a copy of the application with a receipt of mailing for your own records.
11. The application, when submitted, becomes the property of the Housing Authority of the County of
San Mateo.
SAMPLE
Social Security
Number
123-45-6789
Birthdate
(MM/DD/YY)
1/1/1970
Relationship to Head of
Household
Head of Household
Last Name
First Name
1
Doe
Jane
2
N/A
3
Jones
Sarah
F
321-54-9876
1/1/1948
Mother
4
Doe
John
M
987-65-4321
1/1/1998
Son
5
Doe
Mary
F
999-99-9999
1/1/2005
daughter
Gender
F
Spouse or Co-Head
6
(see other side for application)
Rev. 12/10/13