APPENDIX 3

GUAM HOUSING CORPORATION

RENTAL DIVISION

PRELIMINARY APPLICATION FOR RENTAL HOUSING

***Please fill out completely and submit with Verification of Employment for all workinghousehold members.

For assistance contact John Potter at 632-5660

Name:

DEMOGRAPHIC INFORMATION
  1. Ethnic background of head of household: CHAMORRO CAUCASIAN

______FILIPINOPALAUAN

OTHER:

Ethnic background of spouse:

  1. Is head of household or spouse a U.S. Citizen?( ) YES( ) NO
  2. Is any member of your immediate family a U.S. Citizen?( ) YES( ) NO

If YES, who:

  1. If an alien or U.S. Permanent Resident, who sponsored you for entrance into the U.S.?

NAME: PHONE NO.:

ADDRESS:

OTHER INFORMATION

Home:

  1. MAILING ADDRESS:2. TELEPHONE NO.:

______Work:

  1. PRESENT ADDRESS: Name of Landlord:

Present Monthly Rent: $Landlords Contact No.:

  1. REFERENCES: (Past Landlord or Employer)5. CREDIT REFERENCES:

Name: (a)

Phone:

Name: (b)

Phone:

  1. ASSETS: (Cash, Land, Car, Furniture, etc.)
  1. REASON FOR APPLICATION:

PLEASE NOTE THAT THIS IS A PRELIMINARY APPLICATION AND GIVES NO LEASE OR RENT RIGHTS. MORE INFORMATION MAY BE REQUESTED AT A LATER DATE PRIOR TO HOUSING ASSIGNMENT.

APPLICANT CERTIFIES THAT THE AFOREGOING INFORMATION IS TRUE AND CORRECT, AND INQUIRIES MAY BE MADE TO VERIFY ANY STATEMENTS MADE HEREIN. IN ADDITION, THE APPLICANT ACKNOWLEDGES HE/SHE HAS BEEN APPRAISED OF THE REQUIRED DATES FOR CHECKING WITH THE OFFICE TO INSURE CONTINUACY ON THE WAITING LIST.

APPLICANT’S SIGNATUREDATE

TO BE ATTACHED TO FORM 50059

CERTIFICATION/RECERTIFICATION

OF TENANT ELIGIBILITY

FORM 50059

PART I – GENERAL AND TENANT INFORMATION
Report Type (Enter one Code)
1 = Initial Certification
2 = Scheduled Recertification 3 = Interim Recertification / Project Name (Enter one Code)
1 = Lada Gardens
2 = Guma As Atdas 3 = Sagan Linahyan
Previous Housing Initial Certification Only
(Enter one Code)
1 = Substandard
2 = With or About to be Without Housing
3 = Standard / Displacement Status (If Applicable)
(Enter one Code)
1 = Government Action
2 = Natural Disaster
3 = Private Action / Minority (Enter one Code)
1 = White
2 = Black
3 = American Indian or Alaskan Native
4 = Asian or Pacific Islander
Household Status (Check all that applies): Head/Spouse is: a. Age 62 or over b. Disabled
PART II – HOUSEHOLD COMPOSITION
No. / Last Name / First Name / M.I. / Relationship / Sex / Nationality
Head / Head
2
3
4
5
6
7
8
9
No. / Place of Birth / Date of Birth / Occupation / Social Security No.
U.S. City or Foreign Country / U.S. State / MM / DD / YY
Head
2
3
4
5
6
7
8
9
Total No. In Household No. of Minors
PART III – INCOME / PART IV – NET FAMILY ASSETS
Wages, Salaries, Etc. / Social Sec., Pensions, Etc. / Public Assistance / Income From Assets / Other / Type / Amount
Head
TOTAL NET ASSETS:
TOTAL / PART V - ELIGIBILITY
ANNUAL INCOME / $
ELIGIBILITY INCOME / $
ADJUSTED INCOME / $
PART VI – UNIT ASSIGNMENT (for official use only)
MM DD YY
Original Move-In Date / / / MM DD YY
Effective Date Of this Cert/Recertification / / / MM YY
Date for Next Recertification /
No. of Bedrooms / Unit No. / Street Name / Contract Rent / $
PART VII – TENANT(S)/OWNER OFFICIAL CERTIFICATION
PRIVACY ACT STATEMENT – The Information on this form is being collected to determine eligibility, proper unit size, and the amount of tenant(s) rent. It will be used to provide the basis for managing the rental program, for protecting the Government’s financial interest, and for verifying the accuracy of the information furnished. It may be released to appropriate Federal, State, and local agencies, and when relevant to civil, criminal or regulatory investigators or prosecutors.
TENANT(S) STATEMENT – I/We certify that the statement in Parts II, III, IV and V above are true and complete to the best of my/our knowledge.
______
Signature of Head of Household Date Signature of Spouse Date
______
Signature of Authorized Representative Date