APPLICATION INFORMATION: (Rev. 09/15)

APPLICATION INFORMATION: (rev. 09/15)

HEAD OF HOUSEHOLD NAME:______

ADDRESS:______

CITY:______STATE:______ZIP CODE:______

PHONE #: ______MESSAGE PHONE: ______

TO KEEP APPLICATION UPDATED, YOU MUST ADVISE WHEN AND IF THE FOLLOWING INFORMATION CHANGES:

FAMILY COMPOSITION: List all of the people who will be residing with you

NAME / RELATIONSHIP / BIRTHDATE / SOCIAL SECURITY #
HEAD OF HOUSEHOLD

Will you require a Live-in Aide? ______

Will you need an accessible unit? ______

HOUSING INFORMATION:

How many persons reside in your present home ____ Rent Rate $ ______Number of Bedrooms ______

Do you pay utilities? ______Average Cost per month $ ______

Why do you wish to move?

Are you being evicted? ______Have you ever been evicted? ______If so, from where and why?

Have you ever applied for or been refused housing here, or in any other subsidized housing community? ____

Current Landlord’s Name:

Current Landlord’s Address:

Current Landlord Phone Number: ( ) - Date of Residency to

Previous Landlord’s Name:
Previous Landlord’s Address:

Previous Landlord’s Phone Number: ( ) - Date of Residency to

NOTE: If you do not provide landlord information, your application will not be considered.

INCOME: List income from all sources for ALL HOUSEHOLD MEMBERS. Use another sheet of paper if necessary.

Family Member Name / Source of Income / Gross Monthly Amount
Social Security
Pension
Source:
Address:
Claim No:
VA Benefits
Claim No:
SSI Benefits
State SSI
TANF
Unemployment Compensation
Wages
Employer:
Address:
Alimony
Child Support
Other Income

ASSETS: List all assets held by all household members.

Name of Institution / Account Information / Balance
Bank:
Address: / Type:
Account #:
Bank:
Address: / Type:
Account #:
Bank:
Address: / Type:
Account #:
Bank:
Address: / Type:
Account #:

Do you own property (house, land, mobile home, etc.)? Yes ___ No ___

If yes, Market Value $ ______Mortgage or outstanding loan due $ ______

Do you own a Car? Yes No Make Model Year

License Plate Number Driver’s LicenseNumber:

Have you sold or disposed of any assets valued over $1000 in the last two years? Yes ___ No ___

If yes, type of asset (money, land, house, etc.)

Market Value when sold/disposed $ ______Amount sold/disposed for $ _____ Date of transaction ______

CHILD CARE EXPENSES:for children 12 and younger

Weekly Cost: $ _____ Care Agency/Providers Name:

Address: Phone number:

Does Department of Human Services (DHS) help pay for your child care? Yes ____ No ____

If yes, full ____ or partial ____

MEDICAL EXPENSES:

Do you have Medicare? Yes ___ No ___ Do you have Medicaid? Yes ___ No ___

Any other Medical Insurance provider? Yes ___ No ___ If so, who?

Do you pay for prescription drugs? Yes ___ No ___ Reimbursed by your medical coverage? Yes ___ No ___

Do you have special needs that we should be aware of? Yes___ No ___If so, please provide more information about the accommodations you might need:

GENERAL INFORMATION:

Are all household membersU.S. Citizens? Yes___ No ___

Has any household member ever been convicted or pled guilty to a violent crime? Yes___ No___

Has any household member ever been convicted or pled guilty to a drug related crime? Yes___ No ___

Has any household member ever been convicted or pled guilty to a sex related crime? Yes___ No___

Are you the applicant or any member of the household subject to a lifetime state sex offender registration program in any state? Yes___ No ___

If yes, please explain:

Are you currently receiving Section 8 or Housing Choice Voucher? Yes ___ No ___

List all the states you the applicant and any member of the household have resided in:

Is anyone in the household a student of higher learning? Yes___ No ___

If yes to the question above, please answer the following questions:
Answer the following as it pertains to the student:
Is the student applying for housing with a parent or guardian? Yes___ No ___
Is the student of higher learning over 23? Yes___ No ___
Is the student of higher learning married? Yes ___ No ___
Does the student of higher learning have a dependent child? Yes ___ No ___
Is the student of higher learning a veteran of the US armed forces? Yes ___ No ___
If the student of higher learning has answered no to all of the questions above, the household is ineligible unless the student can demonstrate that he/she is independent from the parents, and is of legal contract age under state law.
Has the student established a separate household from the parents/guardians for at least one year prior to occupancy? Yes___ No ___
Was the student an orphan or a ward of the court through the age of 18? Yes ___ No ___
Will be student be at least 24 years old by December 31st of the award year for which aid is sought?
Yes ___ No ___
Is the student a graduate student or professional student? Yes ___ No ___
Was the student disabled and receiving Section 8 assistance as of Nov. 30, 2005? Yes ___ No ___
If the student has answered yes to any of the questions above, the household may be eligible provided the student is NOT claimed as a dependent on someone else's tax return.
Is the student of higher learning able to be claimed as a dependent by parents or legal guardians pursuant to IRS regulations? Yes___ No ___

PLEASE READ BEFORE SIGNING:

I agree to give the Management Agent, ______, the authority to investigate my credit rating, criminal background and past and current rental records. I understand that good credit and references is required. The information obtained will be used for purposes of determining eligibility only and will be held in strict confidence.

This is a preliminary application only and does not guarantee the availability of a rental unit. There may be a long delay for an available unit. Please contact us every 60 days to keep your name on the waiting list. If more than 3 months passes with no correspondence we may remove your name from the list and you will be required to apply again.

Should your application be rejected for credit purposes, we will be unable to discuss your credit rating with you.

Should the applicant be rejected due to criminal background, the applicant will be provided with a copy of the information the action was based upon, The applicant will have an opportunity to dispute the accuracy and relevance of the information obtained from any or all law enforcement agencies within 10 days of receipt.

Applications are processed in order of the date and time received.

MISREPRESENTATION ON THIS APPLICATION WILL AUTOMATICALLY BE GROUNDS FOR DENIAL OF ADMISSION AND/OR EVICTION

All adult household members must sign this application

SIGNATURE: ______DATE: ______

SIGNATURE: ______DATE: ______

SIGNATURE: ______DATE: ______

ALTMAN MANAGEMENT DOES NOT DISCRIMINATE ON THE BASIS OF RACE, SEX, AGE, RELIGION, NATIONAL ORIGIN, FAMILIAL STATUS OR HANDICAPPED IN THE ADMISSION OR ACCESS TO OR TREATMENT OR EMPLOYMENT IN ITS FEDERALLY ASSISTED PROGRAM AND ACTIVITIES.

THE PERSON NAMED BELOW HAS BEEN DESIGNATED TO COORDINATE COMPLIANCE IN THE DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT'S REGULATIONS IMPLEMENTING SECTION 504 (24 CFR Part 8 Dated 6/2/88)

Carol Loveless

PENALTIES FOR MISUSING THIS CONSENT: TITLE 18. SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY OR WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT. HUD AND ANY OWNER (OR ANY EMPLOYEE OF HUD OR THE OWNER) MAY BE SUBJECT TO PENALTIES FOR UNAUTHORIZED DISCLOSURE OR IMPROPER USES OF INFORMATION COLLECTED BASED ON THE CONSENT FORM. USE OF THE INFORMATION COLLECTED BASED ON THIS VERIFICATION FORM IS RESTRICTED TO THE PURPOSES CITED ABOVE. ANY PERSON WHO KNOWINGLY OR WILLINGLY REQUESTS, OBTAINS, OR DISCLOSES ANY INFORMATION UNDER FALSE PRETENSES CONCERNING AN APPLICANT OR PARTICIPANT MAY BE SUBJECT TO A MISDEMEANOR AND FINED NOT MORE THAN $5,000. ANY APPLICANT OR PARTICIPANT AFFECTED BY NEGLIGENT DISCLOSURE OF INFORMATION MAY BRING CIVIL ACTION FROM DAMAGES AND SEEK OTHER RELIEF, AS MAYBE APPROPRIATE, AGAINST THE OFFICER OR EMPLOYEE OF HUD OR THE OWNER RESPONSIBLE FOR THE UNAUTHORIZED DISCLOSURE OR IMPROPER USE. PENALTY PROVISIONS FOR MISUSING THE SOCIAL SECURITY NUMBER ARE CONTAINED IN THE SOCIAL SECURITY ACT **208(A)(6), (7) AND (8).** VIOLATIONS OF THESE PROVISIONS ARE CITED AS VIOLATIONS OF 42USC**408(A)(6), (7), AND (8).**