Date:______

Name of Applicant: Are you 18 years of age or older?_____

Address Phone

Referred By: ______Do you see someone at Vera French? ______

If yes please list who______

NAMESand RELATIONSHIPS of EVERYONE who will occupy unit:

1. 2.

3. 4.

Social Security # Driver’s License #

Present Address:

Present Landlord: Phone

How long at present address? Reason for Moving?

Have you ever been evicted? If “yes” explain:

List names and addresses of landlords for past three years:

NameAddressPhoneHow Long?

Do you have or expect to have any PETS? If “yes” explain:

Do you have or expect to have a waterbed? If “yes” explain:

EMPLOYER & ADDRESS:

Phone: How Long? Your Position:

Supervisor: Are you subject to transfer?

PREVIOUS EMPLOYER & ADDRESS:

(If less than one year with current employer)

Current Monthly Income: / Current Housing Expenses:
Source(s) of Income: / Rent/Own - Monthly Amount / $
Social Security (SSI) / $ / Utilities*-Average Monthly Amount / $
Social Security Disability (SSDI) / $ / I am responsible for: / Gas (cooking)
Employment / $ / Water / Gas (heat)
Other: ______/ $ / Sewer / Electric
TOTAL MONTHLY INCOME: / $ / TOTAL MONTHLY EXPENSES: / $
Savings Account / $
Checking Account / $

Current Bank/Address______

Do you receive Medicaid- Title 19 Yes No Title 19 #______

Date of Birth______Do you or have you ever gone to Vera French? Yes No

Do you pay your own bills? Yes No If no, do you have someone who can help you? Yes No

Name

Relationship Address Phone

Have you applied for or participated in a rental assistance program? Yes No

If yes, give name & location: Date:

Are you presently an illegal abuser of any controlled substance? Yes No

Do you have a criminal record? Yes No If “yes” explain:

______

VEHICLE INFORMATION:

Car #1: Make Model Year License #

Car #2: Make Model Year License #

NON-RELATIVE REFERENCE

Name: Relationship:

Address: Phone:

EMERGENCY CONTACT

Name: Relationship:

Address: Phone:

No persons other than those specifically named will be permitted to occupy the dwelling without the written permission of the landlord. Acceptance of this application by the Landlord shall not constitute a completed agreement to rent the premises. Both parties must also sign a formal written RENTAL AGREEMENT. In the event the applicant refuses to sign an agreement promptly, for any reason whatsoever, it is understood and agreed that any deposit required for processing this application or any deposit to hold the unit shall be forfeited to the Landlord.

I certify that the above information is true and correct to the best of my knowledge. I understand this application will be checked for accuracy. I authorize verification of references given and a credit check.

SIGNATURE DATE

SIGNATURE DATE

CLIENT INFORMED CONSENT &

RELEASE OF INORMATION AUTHORIZATION

For The Iowa Homeless Information Management Network

VERA FRENCH HOUSING COPRORATIONis a Participating Agency in the ServicePoint system. ServicePoint is a shared homeless and housing management information system administered by the Iowa Institute for Community Alliances (IICA). ServicePoint can improve the services and programs for homeless and low-income households by allowing only authorized personnel at Participating Agencies to collect demographic information and share relevant Client information needed for service delivery and to use an on-line directory of services available statewide. The ServicePoint system operates over the Internet and uses many security protections to help ensure confidentiality.

Please read the following statements (or ask to have them read to you), and make sure you have had an opportunity to have your questions answered.

  • Information you provide will help to improve services this agency or your community can offer you.
  • Your name and other identifying information will not be reported to offices and organizations that plan and fund homeless services.
  • IICA will not report or disclose your name and other identifying information.
  • Information about the: diagnosis or treatment of a mental health disorder, drug or alcohol disorder, HIV, AIDS, or domestic violence concerns, will not be disclosed without your written, informed consent.
  • You are not legally required to provide any information.

As you receive services, demographic information will be collected about you and information may be collected about the services provided to you, and the outcomes these services help you to achieve. This information will be collected so that the agency and community can:

  1. Share your information, if appropriate, with other ServicePoint Participating Agencies.
  2. Monitor the outcomes of services that are provided to you,
  3. Improve the quality of care and services for homeless individuals and families.

This agency is asking your permission to share information with other agencies in the planning and delivery of services to you. If not restricted by you, your name and other basic identifying information will be available to Participating Agencies for three (3) years. Unless specified below, you authorize the release and exchange of ALL information collected with all Partner Agencies:

Medical information Employment, skills & income information

Services provided/service history Residential/housing information

Basic identifying information

(intake date, name, SSN, citizen/immigration status, address, phone numbers, emergency contact, DOB, gender, race, marital status, household relationships)

My information should not be shared with

My information should only be shared with

I understand that I may cancel this authorization at any time by written request, but the cancellation will not be retroactive. I understand that this release is valid for three (3) years from the date of this document.

Date:Date:

SIGNATURE OF CLIENT OR GUARDIANSIGNATURE OF WITNESS

DAVENPORT POLICE DEPARTMENT LANDLORD BACKGROUND CHECK

Name: ______

Last First Middle Initial

Social Security #:______-______-______D.O.B._____/____/_____

Phone: ______Alternate Phone: ______

Current Address: ______

Street # City State Zip code

Rent: [ ] Own: [ ] Living with Family Member: [ ]

If Renting, Name of Current Landlord: ______Phone: ______

List all aliases: ______

List any co-applicants: ______

List any children who will be living in the household.

Child 1: ______Child 2: ______Child 3: ______

D.O.B.: ______D.O.B.: ______D.O.B.: ______

Child 4: ______Child 5: ______Child 6: ______

D.O.B.: ______D.O.B.: ______D.O.B.: ______

Current Employer: ______

Address: ______Phone: ______

Street # City State Zip code

Please list any additional information you feel is relevant: ______

______

I authorize the release and verification of all information needed to complete a full background

report including criminal and consumer credit report.

______

Applicant (Print Name) Date

Applicant (Signature) Date.

NOTE: ***All fields must be completed in full or request will not be processed.***

This information is being provided at the request of Landlord and Landlord agrees that the decision to rent

is the Landlord’s SOLE decision. The city of Davenport is not an agent of Landlord nor does it guarantee or

warrant the character or suitability of a tenant. The city is simply providing information requested.

______

Property Agent Date

Vera French Housing______

Name of Property

______

Property Address

563-445-7977______563-445-7995

Phone Fax

Please return to the Crime Prevention Unit, Davenport Police Department Fax# 563-888-2081.Fax

HOMELESS QUALIFICATION CHECKLIST

In order to be eligible for HUD funded activities and/or other state and federal funded housing programs; each participant must meet the homeless definition. This form needs to be completed for each participant and placed in the participant file to serve as documentation that the participant qualifies as homeless.

A homeless person is defined as an individual or family who lacks a fixed, regular, and adequate nighttime residence. Please check the living situation below that provides documentation that the participant qualifies as being homeless.

NOTE:If there are multiple requirements listed with the item, all requirements must be met.

NOTE:For individuals in transitional housing programs, indicate the participant’s living situation prior to entering the program.

Staying in a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill).

Staying in an institution that provides a temporary (30 days or less) residence for individuals intended to be institutionalized, or has been a resident in an institution for more than 30 days, and being discharged within the week, and having no subsequent residence identified, and lacking the resources and support networks needed to obtain access to housing.

Name & location of institution:

Staying in a public or private place not designed for, or ordinarily used as regular sleeping accommodation for human beings.

Living on the streets

Living in a dwelling place, and being evicted within the week, and having no subsequent residence, and lacking the resources and support network needed to obtain access to housing.

Living doubled up, and being evicted/forced out due to circumstances beyond their control, and having no subsequent residence, and lacking the resources and support network needed to obtain access to housing.

Living in substandard housing that has been condemned as unfit for human habitation.

Participant SignatureDate

Staff SignatureDate

VERA FRENCH HOUSING CORPORATION

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by Local, State and Federal Governmental agencies for monitoring purposes in order to monitor Vera French Housing Corporation’s compliance with equal housing opportunity and fair housing laws. You are not required to furnish this information, but are encouraged to do so. The law provides that Vera French Housing Corporation may neither discriminate on the basis of this information, not on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations Vera French Housing Corporation is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish the above information, please check the box below.

ApplicantI do not wish to furnish this information

Ethnicity (select only one)

Hispanic or Latino Not Hispanic or Latino

Race/National Origin (select all that apply)

American Indian/Alaskan Native & Black American Indian/Alaskan Native & White

Black/African American & White Asian & White

Alaskan Native American Indian

Asian Black

Native Hawaiian Pacific Islander

White Other

Other Multi-Racial

Gender

Female Male Transgender Unknown

Information obtained by:

Face-to-face interview mail telephone applicant

Interviewer’s Name (print or type)Interviewer’s Signature

Date

Please circle the income amount that is at or below your family’s income and size:

AUTHORIZATION FOR RELEASE OF INFORMATION

CONSENT

I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to and verify my application for an apartment managed by Vera French Housing Corporation. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Management of Vera French Housing Corporation in administering and enforcing program rules and policies. I also consent for the Management of Vera French Housing Corporation to release information from my file about my rental history to credit bureaus, collection agencies, or future landlords. This includes records on my payment history, and any violations of my lease.

INFORMATION COVERED

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

Identity and Marital Status / Employment, Income, and Assets
Medical or Child Care Allowances / Credit and Criminal Activity
Residences and Rental Activity

GROUP OR INDIVIDUAL THAT MAY BE ASKED

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

Previous Landlords (including Public / Past & Present Employers / Welfare Agencies
Housing Agencies) / Courts and Post Offices / Schools and Colleges
State Unemployment Agencies / Social Security Administration / Retirement Systems
Law Enforcement Agencies / Support & Alimony Providers / Utility Companies
Medical & Child Care Providers / Banks & Other Financial Institutions / Veterans Administration
Credit Providers & Credit Bureaus

COMPUTER MATCHING NOTICE AND CONSENT

I understand and agree that the Management of Vera French Housing Corporation 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 incorrect information. The Management of Vera French Housing Corporation 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 U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies.

CONDITIONS

I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is in the tenant file and will stay in effect for a year and one month from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect.

SIGNATURES:

Head of Household (Print Name) Date

Spouse (Print Name) Date

Adult Member (Print Name) Date

Adult Member (Print Name) Date