Cedar Park Senior Housing
474 N Cedar St Schoolcraft, MI 49087 269-679-5469 ph 269-679-5158 fax
Tenant Application
(Please complete 1 Tenant Application for each person who is 18 or older)
If there is information requested that does not apply to your circumstances, please write “n/a” (for not applicable) in the requested space. If there is information you do not know, you may leave it blank; however, this may delay the processing of your application. If your information does not fit within the spaces provided, you may attach additional pages, as necessary.
Full Name of Applicant:______
Former Last Name:______
Social Security Number:______
Applicant’s Gender: Male Female
Applicant’s Date ofBirth:______
Head of Household:______
Relationship to Head of
Household:______
(Self, spouse, adult co-head, other adult, dependent foster child, foster adult, minor, etc.)
Name of additional occupant (if applicable):______
Is the additional occupant at least 18 years of age? Yes No
(If yes, the additional occupant must complete a separate Tenant Application.)
Home Phone#:______
Cell Phone#:______
Work Phone#:______
Email:______
Race:______
Ethnicity: Hispanic or Latino Not Hispanic or Latino
Do you consider yourself:Mobility Impaired? Yes No
Vision Impaired? Yes No
Hearing Impaired? Yes No
Other Impaired? Yes No
Please indicate your accessibility needs for an apartment: Mobility accessible: Yes No
Vision accessible: Yes No
Hearing accessible: Yes No
Other: ______
Date apartment is needed:______
Are you at least 62 years of age and/or disabled? Yes No
Do you have any pets? Yes:______ No
Marital status: Single Married Separated Divorced Widow/Widower
Do you consider yourself frail elderly? Yes No
Are you a student? Yes No
Citizenship status: Eligible citizen Eligible non-citizen Other: ______
Have you ever:
Been evicted? Yes No
Broken a lease? Yes No
Been sued for rent? Yes No
Been sued for property damage? Yes No
Been convicted, plead guilty, received probation, deferred adjudication, court-ordered supervision, or pre-trial diversion for a felony, sex-related crime, or misdemeanor assault against another person? Yes No
I would like to request a copy of the Tenant Selection Criteria: Yes No
WARNING: Section 1001 of Title 18 of the US Code makes it a criminal offense to make willful false statements of misrepresentation to any Department or Agency of the US as to any matter within its jurisdiction.
All the information contained within this application packet is true and complete, to the best of my knowledge:
______
SignatureDate
1
Housing Information
Current Address:Street Address: / City, State & Zip: / Move-In Date: / Landlord’s Name:
Landlord’s Street Address: / Landlord’s City, State & Zip: / Monthly Payment: / Landlord’s Phone Number:
Previous Address:
(Please provide addresses for the previous 5 yrs. If necessary, you may attach additional pages)
Street Address: / City, State & Zip: / Move-In Date: / Landlord’s Name:
Landlord’s Street Address: / Landlord’s City, State & Zip: / Monthly Payment: / Landlord’s Phone Number:
Income Information
Employer InformationName of Employer: / Street Address: / City, State & Zip / Phone Number: / Fax Number: / Monthly Income:
$
Government & Other Income
(Social Security, Disability, Public Assistance, VA Income, Pension, Rental Income, etc.)
Type of Income: / Monthly Award: / Will this continue for the next year? / Contact person, if applicable: (Ex: DHS Worker) / Contact Person’s Phone Number:
$ / Yes
No
$ / Yes
No
$ / Yes
No
$ / Yes
No
Assets
Checking, Savings, CDs, Stocks, Bonds, etc.Name of Institution: / Address: / Phone Number: / Approximate Balance: / Interest Rate: / Account Type & Account Number:
Acct Type:
Acct #:
Acct Type:
Acct #:
Acct Type:
Acct #:
Acct Type:
Acct #:
Acct Type:
Acct #:
Other Assets (Real Estate, Money Held in a Safety Deposit Box, Savings Bonds, Revocable Trusts, IRAs, etc.)
Description: / Cash Value:
$
$
$
Medical Insurance, Prescription, Primary Care Physician, Eye Doctor, Dentist, OB/GYN, Surgeon, Chiropractor, etc.
NOTE: If you see different doctors at the SAME office, please do not list the office more than once.
Provider: / Street Address: / City, State & Zip / Phone Number: / Fax Number: / Monthly Cost:
$
$
$
$
$
$
Medical and/or Disability Deductions
(If you do not pay out-out-pocket medical/disability expenses, you do not need to complete this portion of the application)
1
Cedar Park Senior Housing
474 N Cedar St
Schoolcraft, MI 49087
269-679-5469 phone 269-679-5158 fax
Authorization for Release of Information
Applicant:
Full Name:______
Current Address:______
______
Date of Birth:______Social Security #: ______
I hereby authorize Cedar Park Senior Housing to obtain a complete credit and criminal history report. I further authorize Cedar Park Senior Housing to contact previous landlords, obtain rental history information, contact employers, and verify additional information contained in the application including, but not limited to residence history, employment information, salary verification, asset verification, banking records, and credit references. I release third parties from liability associated with information provided during the verification. I understand that this information will be used to determine my eligibility for residency at Cedar Park Senior Housing.
______
SignatureDate
Revised: 9/18/09
1