Complete the following information for each household member that will occupy the unit at time of move-in.
Is there anyone other than those listed on this application whose credit may impact on yours?
1. Do you have a pet? 35 pound weight limit- 2 pets allowed
Answer either Yes or No to each question.
2. Do you expect any additions to the household within the next twelve months?
3. Do you have full custody of your child(ren)?
4. Have you or anyone else named on this application ever filed bankruptcy?
5. Have you or anyone else named on this application ever been convicted of a felony?
Residence History:
List the past THREE years of housing references. (If additional space is required use the back of this page.)
Have you or anyone else named on this application ever been evicted for any reason?
Personal References :
List a personal reference other than a relative.
Vehicle Identification:
1
2
Emergency Contact:
Income Information:
Include all income anticipated for the next 12 months. Include all dollar amounts in the space provided.
Check Yes or No to each question.
Do you or anyone in your household receive or expect to receive income from:
1. Employment wages or salaries? (Include overtime, tips, bonuses, commissions, and payments received in cash)
2. Self-Employment?
3. Regular pay as a member of the Armed Forces?
4. Unemployment benefits or workman’s compensation?
5. Public Assistance, General Relief or Aid to Families with Dependent Children?
6. Child support or alimony?
7. Social Security, SSI, or any other payments from the Social Security?
8. Veteran’s benefits, pensions, retirement benefits, or annuities?
9. Severance Payments?
10. Settlements? (Such as insurance settlements)
11. Disability, death benefits, or life insurance dividends?
12. Regular gifts or payments from anyone outside of the household.
(This includes anyone supplementing your income or paying any of your bills)
13. Educational grants, scholarships, or other student benefits?
14. Lottery winnings or inheritances?
15. Payments from rental property, land contracts, or other forms of real estate?
16. Any other income sources or types not listed?
Asset Information:
Include all assets held and the corresponding annual interest rate, dividends, or any other income derived from the asset. An asset is defined as any lump sum amount that you hold and currently have access to. Include the value of the asset and corresponding income from the asset in the space provided.
Include all assets held by ALL household members including minors.
Do you or anyone in your household hold:
1. Checking, savings account or prepaid debit card?
2. CD’s, money market accounts, or treasury bills?
3. Stocks, bonds, or securities?
4. Trust funds?
5. Pensions, IRAs, KEOGH, or other retirement accounts?
6. Cash on hand over $500.000?
7. Real estate, rental property, land contracts/contract for deeds or other real estate holdings? (This includes your personal residence, mobile homes, vacant land, farms, vacation homes, or commercial property?)
8. Personal property as an investment? (this includes paintings, coin, or stamp
collections, artwork, collector, or show cars, and antiques)
9. A safe deposit box?
10. Have you or any household member disposed of or given away any asset(s) for LESS than fair market value within the past 2 years?
Asset Information:
Are you or is any other adult member of your household claiming zero income?
Student Information:
Are you or is anyone in your household currently a full-time student, or planning to be one within the next 12 months?
IF YES student must continue on with the following questions:
You will need to provide verification of all items to which you answered yes.
a. Are you married and currently filing a joint tax return?
b. Are you receiving AFDC (Aid to Families with Dependent Children?)
c. Are you enrolled in the Job Training Partnership Act (JTPA) or another similar local, county, or state program?
d. Are you a single parent with child (ren) and neither you nor the child(ren) are dependents on anyone else’s tax return?
e. Will you be living with someone who is not a full time student?
Live in Care Attendant:
Will you or anyone in your household require a live in care attendant?
Section 8 Rental Assistance:
1. Will your household be receiving Section 8 rental assistance at the time of move-in?
2. Will your household be eligible or are you applying to receive Section 8 rental assistance in the next 12 months?
All questions that were answered Yes will be verified through the appropriate third-party source. It will be your responsibility to provide management with all necessary information to properly process your application and verify your eligibility. This will include names, addressed, phone and fax numbers, account numbers where applicable and any other information required to expedite this process.
Signature Clause:
I understand that management is relying on this information to prove my household’s eligibility for the Low Income Housing Tax Credit Program. I certify that all information and answers to the above questions are true and complete to the best of my knowledge. I consent to release the necessary information to determine my eligibility. I understand that providing false information or making false statements may be grounds for denial of my application. I also understand that such action may result in criminal penalties. I authorize my consent to have management verify the information contained in this application for purposes of proving my eligibility for occupancy. I will provide all necessary information and expedite this process in anyway possible. I understand that my occupancy is contingent on meeting management’s resident selection criteria and the Low Income Housing Tax Credit Program requirements.
All ADULT household members must sign below:
