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2. I certify that all information provided to the City of Dubuque is true and correct. I further understand that the Housing Agency may make inquiries regarding criminal activity of all family members including juvenile records from Law Enforcement Agencies/Dept. of Correctional Services/juvenile court services/County/District attorney or any other means to verify this certification. Under Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any department or agency of the United States as to any matter within its jurisdiction. Please intial that you understand and agree to this statement.*
4. Full Name:*
6. Caseworker:*
   -- Select One --Dawn DeMaioRyan FellerHollie OhnesorgeTonya EnglandTracy DoyleCrystal KilgoreRaneisha Ross
7. Date Completed: *
   Date Completed:
9. Please select the true and correct statement: *

   1. No, criminal record in Illinois, Iowa or Wisconsin
   2. Yes, I have a criminal record in Illinois, Iowa or Wisconsin
10. Please list city & states you've lived in the past 7 years:*
12. Please select the true and correct statement: *

    1. No, criminal record in any other state
    2. Yes, I have a criminal record in another state
13. Please list the city, county, state(s) of the crimes:
15. If you answered yes to the above question, please list the city, county, state(s) of the criminal record. Please indicate n/a if this does not apply. *
17. If yes, please explain when the activity occured and the nature of the crime:
19. Date of Crime:
    Date of Crime:
20. Crime:
22. Date of Crime:
    Date of Crime:
23. Crime:
25. Date of Crime:
    Date of Crime:
26. Crime:
28. Date of Crime:
    Date of Crime:
29. Crime:
31. Failure to disclose true and complete information may result in termination from the program and repayment all benefits paid on your behalf. Use the box below to provide addtional information if needed.
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field