HOUSING AUTHORITY OF JEFFERSON COUNTY (HAJC)
Mailing Address: Post Office Box 2109  Physical Address: 5210 Kuhn Street
Port Townsend, WA 98368
Phone (360) 379-2565  Fax (360) 379-2561

HAJC APPLICATION PROCEDURES

1) Applications will be accepted via mail or over the counter ONLY. Submit original
application along with:

 Declaration of citizenship form, enclosed, for each adult in the household.

A copy of each person’s social security card, (over the age of six) must
also accompany each application.

Applications must be signed by each person over the age of 18.

2) Application is processed and you are placed on the waiting list.

3) A letter will be sent to applicant to inform them that placement on the waiting list has
occurred.

4) Placement on the waiting list may be reviewed on our website at
www.jeffersonhousing.org
. Allow 4 weeks for this information to appear on the webpage.

5) When applicant’s name comes up on the waiting list, applicant will be notified by MAIL.

6) APPLICANT IS RESPONSIBLE TO NOTIFY HAJC IN WRITING OF ANY
CHANGES OF ADDRESS, within 10 days.
Legal Name
Last, First, Middle Initial

Sex
M/F
Relationship
to Head
Social Security
Number
Date of Birth
Month/date/year
Place of Birth
City/State
1
Head

2
3
4
5
6
7 Optional Information for Statistical Purposes Only (Please check all that apply):

¾ Wages, Tips, Salary
¾ TANF
¾ VA Benefits
¾ Social Security, SSI, SSDI
¾ Unemployment
¾ Pension or retirement
¾ Worker’s Compensation
¾ Child Support
¾ Per Capita payments
¾ Interest income from bank accounts, investments etc.
¾ Income from real estate
¾ Contributions from family members (this includes regular payments of bills, purchase of products such as
diapers, food etc.) INCOME INFORMATION: Please list the source and amount of all current income received by all
household members, including your children and yourself. Household Member
Name
Income Source
Monthly
Amount
Hourly Wage # of Hours per week
$
$
$
$
$
Are you or any other members of your household disabled? Yes _____ No _____
If yes, which member(s) are disabled?
__________________________________ __________________________________
__________________________________ __________________________________

Do you or any member of your family require any of the following accommodations or unit
modifications?

• Wheelchair accessible unit
• Sensory impaired accessible unit
• Ground floor unit (no stairs)
• Other physical adaptations (grab bars etc.)
• Service/Companion Animal
• Copy mail to Case Manager
• Large type documents
• Live-in aide/caregiver
• Payee (please list name) ___________________________
• Other _______________________________________________________

The Housing Authority of Jefferson County complies with the Fair Housing Act and provides
reasonable accommodations and modifications to persons with disabilities. Special Assistance

If you want the Housing Authority of Jefferson County to speak with your case manager,
friend or relative about your housing status, you must first complete and sign the
following release. Remember to write in the name of the person that you are allowing us
to speak with and sign the bottom of the release.

RELEASE OF INFORMATION I, ______________________, give the Housing Authority of Jefferson County permission to

CLIENT NAME (print)

speak with
_______________________________________________
regarding my housing application.
(Name of Person or Organization)

I voluntarily allow the above named parties to obtain and/or release information regarding my
housing application. I understand that this information will not be forwarded to anyone other
than the parties listed above, without my written permission. I understand that I can revoke this
release at any time. This consent form expires 15 months after signing. _________________________________ _______________ _____________________
Applicant’s Signature Date of Birth Social Security Number

It is the responsibility of all clients to provide accurate and complete information to HAJC. If you
do not provide all required information or if you submit false information to HAJC you may be