Application for Occupancy

APPLICATION FOR OCCUPANCY

(Name of Project) Paul Boe Manor Return Application to:

Impact Seven, Inc. Impact Seven

IRS Section 42 Program 147 Lake Almena Dr.

Almena, WI 54805

TO THE APPLICANT FROM THE PROPERTY MANAGER:

You have applied to rent a unit, which Impact Seven, Inc. as Management Agent for the Owner, has agreed with the government to rent only to qualified lower-income persons. To see if you qualify, you must provide the following information in a sworn certificate. The information will be kept confidential by the Owner, and the Owner's employees, except as necessary to prove to government officials that you qualify. Each resident of the unit who is not related by blood, marriage, or adoption must complete a separate Income Certification Form. All residents related by blood, marriage, or adoption may complete a single Income Certification showing total family income and assets. You should read each item carefully, and provide the information requested truthfully and fully, because making a false statement under oath might subject you to criminal penalties.

A NON-REFUNDABLE application fee of $15 per applicant 18-years and older MUST accompany this application. Any applications submitted without fee will not be processed. PLEASE DO NOT SEND CASH…Any returned checks will result in application becoming ineligible.

Where did you hear of the housing program? Newspaper Radio Poster Word of Mouth

Preferred Moving Date:

1. Provide the following information:

NAMES OF ALL HOUSEHOLD MEMBERS DATE SEX SOCIAL SECURITY NUMBER

(Last, First, and Middle Initial) OF BIRTH OR ALIEN REGISTRATION

(List Maiden Name) (If you have one)

_______________________________________ ______________ __________ __________________________

CURRENT ADDRESS: ______________________________________________________________________

(Mailing Address)

(CITY, STATE, ZIP): ______________________________________________________________________

PREVIOUS ADDRESS: ______________________________________________________________________

(If less than 3 years

at current address) ______________________________________________________________________

TELEPHONE NUMBER: Home: _________________________ Work: ____________________________

Do you have a pet? Yes No If yes, what type and how many? (Cat, dog, etc.?) ____________________________

Breed: ______________________________________ Approximate Weight: __________________________________

2. Are you considered a full-time student, for five months or more per year, by a school or schools (other than a correspondence school) with a regular faculty, curriculum, and students?

Yes No

If you answer "yes" to question 2 above, you are required to fill a student certification to see whether you qualify (will be supplied from our Management Office).

INCOME CERTIFICATION

3. Provide on Exhibit A the total "VALUE" of equity in real property, savings, stocks, bonds, and other forms of capital investment. The value of your assets is the amount a third party would pay for them. You do not have to value interests in Indian trust land or necessary items of personal property such as furniture and automobiles. Use the following special rules in determining the value of your assets:

a. In cases where a trust fund has been established and the trust is not revocable by you, under your control or the control of any member of the Family or household, you can exclude the value of the trust fund so long as the fund continues to be held in trust, but you must include any income distributed from the trust fund when determining income below.

b. Include the value of any assets you sold or gave away for less than their value during the last two years, less any amount you were paid for such assets.

(i) Type of Asset: _________________________

(ii) Total Asset Value: $________________________

(iii) Name and address of person or business who can verify

this asset: _________________________________________________

_________________________________________________________

EXHIBIT A

Short Term Name & Address (Rep payee accounts must be reported)

Account # As of:

Assets: Institution Telephone # (if applicable) Balance (date)

Checking: ____________________ __________ _____________ _________ _____

_______________________

Savings: ____________________ __________ _____________ _________ _____

_______________________

Certificates ____________________ __________ _____________ __________ _____

of Deposit: _______________________

_______________________

Long-Term Assets:

Real Estate:

In the Name of: _______________________________________________

Address: _______________________________________________

Mortgage Balance: $____________________

Mortgage With: _______________________________________________

Name and Address: _______________________________________________

Stocks:

Company: __________________________________________________________

Address: __________________________________________________________

Number of Shares: _______________

Market Price @: _______________ (Insert Date) Held @:_______________

Bonds: Face Value Interest Rate Maturity Date Date of Issue

U.S. Gov’t

Bonds: __________ __________ __________ __________

Series E,

EE Bonds: __________ __________ __________ __________

Corporate Bonds:

Company Name: _____________________________________________________

Address: _____________________________________________________

Face Value: __________ Market Value @: __________ (Insert Date)

Held @: __________ Account Number: __________

Other: ___________________________________________________________

______________________________________________________________________

4. Provide the total amounts of projected income from the following sources for you and all family members (including the income of any family member who is temporarily absent) for the 12-month period beginning on the date of this certification:

(a) The full amount of wages and salaries, overtime pay, commissions, fees, tips and bonuses, and other compensation for personal services, BEFORE ANY PAYROLL DEDUCTIONS:

Name and address of employer(s):

_______________________ ______________________ _______________________

Gross Wages: $_____________

(b) The net income from operation of a business or profession, including cash withdrawals from the business for use by you or any family member. In determining net income of a business or profession, do not deduct depreciation, payments made to expand the business, or principal payments on debt: (Income tax report must be made available for verification)

Net Income: $_____________

(c) Interest, dividends, and other net income of any kind from real or personal property. Do not deduct depreciation or principal payments on debt when you determine the net income from real or personal property. If your answer to Question 3 above is in excess of $5,000, include the greater of the actual income derived from all such assets or a percentage of the value of such assets based on the current passbook savings rate determined by the Secretary of Housing and Urban Development.

Name and address of party who could verify this income: _______________________

_____________________________________________________________________

Net Income: $______________

(d) The full amount of periodic payments received from social security, annuities, insurance policies, retirement funds, pensions, disability, or death benefits, and other similar types of periodic receipts, including a lump-sum payment for the delayed start of a periodic payment: (Provide names and address of all sources where this income can be verified)

_____________________ _____________________ ______________________

Gross Amount: $______________

(e) Payments in lieu of earnings, such as unemployment and disability compensation, worker's compensation, and severance pay: (Provide names and addresses where this income can be verified)

_____________________ _____________________ ______________________

Gross Amount: $______________

(f) All welfare or other payments to you based on need that are made under programs funded, separately or jointly, by federal, state, or local governments. If your welfare assistance payments include an amount specifically designated for shelter and utilities that is subject to adjustment by the welfare assistance agency depending on the actual cost of shelter and utilities, then you should include:

(i) the amount of the allowance or grant, reduced by the amount specifically designated for shelter or utilities, plus

(ii) the maximum amount that the welfare assistance agency could in fact allow you for shelter and utilities:

Name and Address of County Department of Human Services receiving payment from:

_________________________________ ________________________________

Total Grant: $_______________

(g) Periodic and determinable allowances, such as alimony and child support payments, and regular contributions or gifts received from persons not residing in the apartment. A copy of the court order MUST be attached to this application. Further documentation may be requested.

Name and address of party who could verify this income: ____________________________

__________________________________________________________________________

Total: $______________

(h) All regular pay, special pay, and allowances of a member of the armed forces (whether or not living in the unit) who is your spouse or whose dependents are residing in the unit (but see subparagraph 4(e) above):

Name and address of party who could verify this income: ____________________________

___________________________________________________________________________

Total: $______________

(i) Any earned income tax credit to the extent it exceeds your income tax liability:

Total: $______________

(j) Any other anticipated income from any other source:

Name and address of person making payments to applicant: ____________________

_____________________________________________________________________

Total: $______________

(k) Total Current Income (add 4(a) through 4(j): $______________

I certify that the information and statements provided above are true and complete to the best of my knowledge and belief, and I consent to release of such information for the purposes described above. I understand that providing false information or making false statements under oath may subject me to criminal penalties. I agree to provide such verification of any income of assets as may be required by the Owner. I further authorize disclosure to the Owner of any and all information which will verify my income or assets, including, but not limited to, verification of: wages and salary, welfare, unemployment or social security benefits, and bank account or other investment account balances.

I further authorize the release of information in regard to police records, court records, former tenant records, and related information necessary to meet the eligibility and continued occupancy policies of Impact Seven, Inc.

Date: ______________________ ______________________________________

(Signature)

______________________________________

(Printed Name)

Date: ______________________ ______________________________________

(Signature)

______________________________________

(Printed Name)

REFERENCES

Please list your present landlord and other landlords for past five years.

Landlord Address Phone

__________________________________________________________________________

Rented From: ____________________, 20___ to ____________________, 20___

Landlord Address Phone

__________________________________________________________________________

Rented From: ____________________, 20___ to ____________________, 20___

__________________________________________________________________________

Landlord Address Phone

Rented From: ____________________, 20___ to ____________________, 20___

Have you ever broken a lease or been evicted from any type of housing?

If yes, please explain: (You may use a separate paper if necessary)

Please list two- (2) personal references; include addresses and daytime & evening telephone numbers:

___________________________________________________________________________

Name Address Phone

___________________________________________________________________________

Name Address Phone

Who should we contact in case of an emergency?

Name

Address Phone

Applicant Co-Tenant/Spouse

Race/National Origin Race/National Origin

White Black White Black

Hispanic Asian or Pacific Islander Hispanic Asian or Pacific Islander

American Native/Alaskan Native American Native/Alaskan Native

Other (Specify) _________________ Other (Specify)

Sex Sex

Male Male

Female Female

ILLEGAL ACTIVITY

Is any member of the applicant's household engaged in the current illegal use of a controlled substance? Yes No

Has any member of the applicant's household been convicted of illegal manufacturer or distribution of a controlled substance? Yes No

G:\...\HOUSING\APPLICAT\LIHTC.DOC 08/2012

IMPACT SEVEN, INC. – 147 LAKE ALMENA DR. - ALMENA, WI 54805

715-357-3334

Authorization for Release of Information

Consent:

I authorize and direct any Federal, State, or Local Agency, organization, business, or individual to release to Impact Seven, Inc. any information or materials needed to complete and verify any application for participation, and/or maintain my continued assistance under Section 8, Section 202, Section 811, FHA 515, or IRS Section 42, housing programs. I understand and agree that this authorization of the information obtained with its use may be given to and used by the Wisconsin Housing Economic Development Association (WHEDA), Rural Development (RD), and/or The Office of Housing and Urban Development (HUD) in administering and enforcing program rules and policies.

Information Covered:

I understand that depending on program policies and requirements, previous or current information regarding my household or me may be needed. Verifications and inquiries that may be requested, include but are not limited to:

Identity & Marital Status Credit and Criminal Activity

Medical or Child Care Expenses Residence & Rental Activity

Employment, Income & Assets

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in the housing assistance program.

Group or Individuals that may be asked:

The groups or individuals that may be asked to release the information (depending on program requirements) include but are not limited to:

Previous Landlords (including State Unemployment Agencies

Public Housing Agencies) Social Security Administration

Courts & Post Offices Wisconsin State SSI Office

Schools & Colleges Medical & Child Care Expenses

Law Enforcement Agencies Veterans Administration

Past & Present Employers Retirement Systems

Welfare Agencies Banks & Other Financial Institutions

Child Support & Alimony Providers Credit Providers & Credit Bureaus

Utility Companies Doctors or Counselors (to determine

disability eligibility)

Computer Matching Notice and Consent:

I understand and agree that WHEDA, RD, or HUD may conduct computer-matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. WHEDA, RD, or HUD may in the course of its duties exchange such automated information with other Federal, State, or Local Agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the US Postal Service; the Social Security Administration; and State welfare and food stamp agencies.

Conditions:

I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in effect for one year from the date signed.

Head of Household:

Print Name Signature Date

Spouse or Co-Tenant:

Print Name Signature Date