ENOLA COMMONS SENIOR APARTMENTS

16 S. Enola Dr., Enola, PA 17025

Phone: (717) 732-2811

INITIAL APPLICATION

(The following information is confidential and will not be disclosed without your consent.)

Please complete each question in full. You must provide copies of birth certificates and social security cards for each family member at time of application. Failure to do so may delay the application process.

HOUSEHOLD COMPOSITION: List the head of your household and all members who will live in your home. Give the relationship of each family member to the Head of Household.

Full Name / Relationship / Birth Date / Age / Sex / Social Security Number / Full Time Student
(Yes or No)
Head
of Household

Please indicate if you want a 1 bedroom or 2 bedroom unit [ ] 1 Bedroom [ ] 2 Bedroom

CONTACT INFORMATION:

Home Phone: ______Cell Phone: ______

Other contact information: ______

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RENTAL HISTORY: Current Address: ______

(Street, City, State, Zip)

Current Rent: $______Number of Years at Present Address:______

Landlord’s Name: ______Landlord Phone #: ______

Landlord’s Address: ______

If you have lived at this address less than 2 years, please provide previous address:

______

Landlord’s Name: ______Landlord Phone #: ______

Landlord’s Address: ______

Number of Years at previous address: ______

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Have eviction charges ever been filed against you for nonpayment and/or late payment of rent to your landlord or for any other reason? [ ] Yes [ ] No

Are there any special housing needs or reasonable accommodations that the household will require? For example, a unit for mobility impaired, visually impaired, hearing impaired, etc. [ ] Yes [ ] No Please list:______

Do you currently own your home? [ ] Yes [ ] No

Do you currently live or work in Cumberland County? [ ] Live [ ] Work

Do you now or have you ever lived in subsidized housing (rental assistance)? [ ] Yes [ ] No

Is any household member a full-time student? [ ] Yes [ ] No

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ANNUAL INCOME: For each type of income that your household receives, give the amount of income (before any deductions) that can be anticipated from that source during the next 12 months.

SOURCE / APPLICANT / CO-APPLICANT / TOTAL
Gross Wages including any Overtime Pay / $ / $ / $
Commissions/Tips/Bonuses/
Fees / $ / $ / $
Alimony/Child Support / $ / $ / $
TANF/
Public Assistance / $ / $ / $
SSP / $ / $ / $
Social Security / $ / $ / $
SSI / $ / $ / $
Pensions/Retirement Funds/Etc. / $ / $ / $
Unemployment
Benefits / $ / $ / $
Worker’s Compensation/
Disability / $ / $ / $
Income from
Business / $ / $ / $
Recurring Income or
Gifts / $ / $ / $
Other
Explain: ______ / $ / $ / $

Does any member of your household who is not now working, expect to work for any period during the next 12 months? [ ] Yes [ ] No

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ASSETS: Assets include, equity in real estate or capital investments, notes receivable, stocks, bonds, money market accounts, certificates of deposits (CDs), IRA’s, retirement and pension funds, 401K’s, 403B’s, luxury personal property (gems, jewelry, art, coin collections, etc.), etc. You must also include cash value of whole or universal life insurance policies.

[ ] I/We have NO assets at this time.

I ______have/______have not disposed of any assets valued at $1,000 or more in the past two years for less than fair market value of the item. If yes, please list the asset value under the “other” column in the below listing of assets.

ASSETS / CASH VALUE / INCOME FROM
ASSETS / NAME OF FINANCIAL INSTITUTION
CHECKING ACCOUNT / $ / $
SAVINGS ACCOUNT / $ / $
CERTIFICATES OF DEPOSIT / $ / $
MUTUAL FUNDS/
STOCKS/BONDS / $ / $
ANNUITY/401K/IRA/
OTHER RETIREMENT / $ / $
REAL ESTATE / $ / $
LIFE INSURANCE / $ / $
SAVINGS BONDS / $ / $
TRUSTS / $ / $
OTHER / $ / $

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PLEASE NOTE: Failure to truthfully respond to these questions may jeopardize approval of the application or result in lease termination/eviction.

List all other names you or any other member of your household has ever used or been known by (maiden, married, etc.) ______

Have your or any member of your household ever been convicted of a crime? [ ] Yes [ ] No

Are you or any member of your household currently charged with any crime? [ ] Yes [ ] No

Are you or any member of your household subject to a lifetime sex offender registration in

any state? [ ] Yes [ ] No

If yes, to any question above, list the nature of crime, approximate date of conviction/charge, and place of conviction/charge.

______

______

Are you or any member of your household a current illegal abuser or addict of a controlled substance? [ ] Yes [ ] No

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In accordance with the data collection information requested by the Department of Housing and Urban Development (HUD), please provide the following information for the head of household. (This information is optional and used for statistical purposes only.)

RACE

 American Indian or Alaska Native  Asian

 Black or African American  Native Hawaiian or Other Pacific Islander

 White

ETHNICITY GENDER

Hispanic or Latino Male

Not Hispanic or Latino Female

 I decline to provide this information.

I/We certify that the information on this application is true and correct to the best of my/our knowledge. I/we certify that if selected, the unit I/we occupy will be my/our only residence. I/We authorize the owner/manager to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information, which, may be released to appropriate federal, state, or local agencies. I/We certify that the statements made in this application are true and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under federal law.

ALL HOUSEHOLD MEMBERS MUST SIGN BELOW:

______

Signature of Applicant Date

______

Signature of Co-Applicant Date

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense for any person to make false or fraudulent statements to any department or agency of the United States Government or public housing authority as to any matter within its jurisdiction or to make unauthorized disclosures or improper use of the information collected hereunder.

FOR MANAGEMENT USE ONLY: DATE APP REC’D: ______

ð Received Social Security Cards ð Passed Criminal TIME APP REC’D: ______

ð Received Birth Certificates ð Passed Credit REQ ACCESS UNIT: ______

ð Received Landlord Verification ð Income Eligible SET ASIDE: ______

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