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2. Report of Local Preference Change Form
4. Head of Household Name:*
6. Head of Household Social Security Number (Last 4 digits)*
8. Please “X” each preference you are eligible to claim.
10. RESIDENCY PREFERENCE: (check no more than one)*

    1. Tippecanoe County (30 points): You may claim this preference if you live or work in Tippecanoe County.
    2. Surrounding County (20 points): You may claim this preference if you live or work in Benton, Carroll, Clinton, Fountain, Montgomery, Warren or White County.
    3. State (10 points): You may claim this preference if you live or work in the state of Indiana.

    Note:  The use of the Residency Preference is not for the purpose or the effect of delaying or otherwise denying admission to the program based on the race, color, ethnic origin, gender, religion, disability, or age of any member of an applicant family.   Also once a voucher is issued the applicant must lease up in the LHA jurisdiction if they do not meet the Tippecanoe County preference.  

12. VETERANS PREFERENCE:

    1. Preference 1 (12 points): You may claim this preference if you are a Veteran, with an honorable discharge, a Surviving Spouse of a Veteran, with an honorable discharge OR if a household member is cur
    2. Preference 2 (6 points): You may claim this preference if your household composition includes a Veteran, with general discharge OR a Surviving Spouse of a Veteran with a general discharge.
14. ELDERLY / DISABLED PREFERENCE:

    1. (8 points): You may claim this preference if anyone in the household is elderly OR is a person with a disability and is currently receiving SSD or SSI.
16. WORKING PREFERENCE:

    1. (6 pts): You may claim this if any adult household member is employed and working a min. of 20 hrs/week, no less than min. wage, and has been continuously employed as such for at least 90 days.

    Note:  you may be eligible to claim this preference if you are receiving Unemployment, Short-term or Long-Term Disability or Workman’s Comp if those benefits are the result of 12 continuous months of employment at a minimum of 20 hours per week up to the start of the benefits.

18. BY SIGNING BELOW, I certify and understand the following:

    I am eligible to claim the preference(s) indicated above.  

    The LHA will verify my preference(s) at a later date and if it is discovered I am not eligible for a preference for which I’m claiming the preference will be removed and my name will be placed back on the waiting list without the preference points.

    Admission to the Housing Choice Voucher Program will be based first on preference points and then on date and time of my original Pre-Application.

    Any attempt to obtain Section 8 Housing by providing false information is a crime under federal law and is grounds for denial of assistance.

20. Signature*
21. Today's Date*
    Today's Date
23. Email*
25. Phone Number*
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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