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The Housing Authority of the County of Contra Costa (HACCC) is accepting applications for Project-Based
Voucher (PBV) site-based wait lists. PBV units provide families with a housing opportunity where the
assistance is tied to the unit you live in. After twelve months of consecutive residency in a PBV unit, you may
be eligible for continued tenant-based rental assistance subject to availability and your lease agreement. If you
are on the tenant-based Housing Choice Voucher wait list, placement on the PBV site-based wait lists DOES
NOT CHANGE YOUR PLACE ON THE HCVP WAIT LIST FOR A VOUCHER. If you are interested in this
opportunity, please complete the questions below and indicate what properties you are interested in on the
next page. NOTE: Some properties have resident restrictions as indicated. Check only the properties
you are interested in AND you qualify for.
1. I am interested in being on a PBV site-based wait list Yes No
3. Current Address:
Address City State Zip
4. Telephone #: Secondary/Mobile
5. Email Address:
6. Do you or any household member live, work or have you been hired to work in Contra Costa County?
Yes No
7. Race: White African American Asian Native American Pacific Islander Other
9. Please list all household members who will live in the assisted unit including yourself:
11. How much is your estimated combined household annual income before taxes? $
If yes, check one of the following boxes: - Physical Mental Developmental HIV/AIDS
Vision Hearing
13. Do you qualify for the State’s Multifamily Housing Program (MHP) Supportive Housing or Special Needs programs?
Yes No
These Programs are State Programs to assist Special Needs Populations, including but not limited to individuals with:
• Long-term chronic health conditions that qualify for programs such as MSSP, IHSS, or PACE
• HIV/AIDS
• Mental Illness
• Physical or orthopedic disability
14. Have you been involuntarily displaced from housing due to a Federal or State declared disaster or government action
(e.g., code enforcement, public improvement or development, witness protection program)? Yes No
15. Have you graduated from an approved transitional housing program that partner’s with the Housing Authority
of Contra Costa County (HACCC), such as Shelter Plus Care? Yes No
16. If you are employed, what City do you work or were recently hired to work in: ___________________________
(CONTINUED)
2870 Howe Rd., Martinez, CA94553 Phone (925) 957-7001Fax (925) 957-1280 TDD (925) 957-1685
contracostahousing.org
17. Have you previously been terminated from the Housing Authority of the County of Contra Costa HCV Program due to
insufficient program funds? Yes No
20. If you are not interested in any of the sites listed below, would you be interested in being placed on project-based
voucher site-based wait lists in the future for a new property? Yes No
Place an " X" in the far right column next to the properties you
want to live in AND meet the property restrictions.
Housing Authority of the County of Contra Costa Project-Based Voucher Unit Inventory
Yes,
Add Me
PROPERTY 0 1 2 3 TOTAL To This
ADDRESS PROPERTY RESTRICTIONS Wait
NAME BR BR BR BR UNITS
List -
"X"
Brentwood
Senior 750 Larkspur Lane,
Apartments Brentwood, CA X 79 Over 62 Yrs Old
Lafayette
Senior/Belle 3428 Mt. Diablo Blvd, Over 62 Yrs. Old, 17 Verifiably
Terre Apartments Lafayette, CA X 45 Disabled Units
Riley Court 2050-2060 Riley Ct., Family Housing, Some units for
Apartments Concord, CA X X 15 disabled with HIV/AIDS
Third Avenue 3rd Ave. & Baldwin St., Family Housing, Some for
Apartments Walnut Creek, CA X X X 29 developmentally disabled
Robin Lane 2050-2060 Riley Ct., Family Housing, Some units for
Apartments Concord, CA X X 8 disabled with HIV/AIDS
(CONTINUED)
2870 Howe Rd., Martinez, CA94553 Phone (925) 957-7001Fax (925) 957-1280 TDD (925) 957-1685
contracostahousing.org
Yes,
Add Me
PROPERTY 0 1 2 3 TOTAL To This
ADDRESS PROPERTY RESTRICTIONS Wait
NAME BR BR BR BR UNITS
List -
"X"
Elaine Null 3rd Ave. & Baldwin St., Family Housing, Some for N/A
Apartments Walnut Creek, CA X 4 developmentally disabled
2870 Howe Rd., Martinez, CA94553 Phone (925) 957-7001Fax (925) 957-1280 TDD (925) 957-1685
contracostahousing.org