Interest Form – Hale O Pi’ikea Phase 3

Head(s) of Household

Head of Household *

First Name

Middle Initial

Last Name

Head of Household Email Address *

Head of Household Phone Number *

Would you like to add a Co-head of Household? *

Co-head of Household *

First Name

Middle Initial

Last Name

Co-head of Household Email Address *

Co-head of Household Phone Number *

Residence Address *

Address Line 1

City

State

Zip Code

Household Composition

Total number of household members including Head of Household *

More than nine (9) household members? Please contact us.

Total number of household members including Head and Co-Head of Household *

More than ten (10) household members? Please contact us.

Head of Household Age *

U.S. Citizen? *

Full-Time Student? *

4 U.S. 3

Income & Assets

Estimated Annual Household Income: *

Income Sources *

Check all that apply

If other, please describe *

Verification

Checkboxes *

I confirm that the information provided is accurate and may be verified as part of the application process and that my total household income meets the area eligibility requirement. *

Submission of this pre-application does not guarantee housing. All information provided is subject to verification. Inaccurate, incomplete, or false information may result in disqualification. Additional documentation may be required during the full application process.

Online Interest Form

Hale O Pi’ikea Phase III

Head(s) of Household

Household Composition

Income & Assets

Verification

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