Thank you for your interest in ACCT s Mobile Home Parks. We look forward to reviewing your application. INSTRUCTIONS

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1 Thank you for your interest in ACCT s Mobile Home Parks. We look forward to reviewing your application. INSTRUCTIONS Read the application carefully and fill out each section that applies to you or any additional household members Provide as much information as possible, this will help our application processor complete the application in a timely manner Be sure to sign the Consent for Release of Information PRIVACY ACT STATEMENT Addison County Community Trust will comply with the Federal Privacy Act Statement. Any information you provide us will not be disclosed to an outside agency except as required and permitted by law. Once your application is complete please mail to: Addison County Community Trust PO Box 311 Vergennes, VT Or stop by our office located at: 272 Main Street Vergennes, VT Any questions please contact Mary at

2 PART 1-APPLICANT INFORMATION APPLICANT NAME: First Last Middle Initial MAILING ADDRESS: PO Box/Street City/Town State/Zip Code PHYSICAL ADDRESS: Street Address City/Town State/Zip Code TELEPHONE: Home Cell Work CO APPLICANT: First Last Middle Initial MAILING ADDRESS: PO Box/Street City/Town State/Zip Code PHYSICAL ADDRESS: Street Address City/Town State/Zip Code TELEPHONE: Home Cell Work PART 2-OTHER FAMILY MEMBERS-LIST ALL PERSONS WHO WILL BE LIVING IN HOUSEHOLD Names of Household Members Name HEAD Relationship to Head Of Household Date of Birth

3 PART 3-GENERAL INFORMATION 1. Will this be your primary residence? Yes No 2. Which Park do you wish to live in? Circle all that apply. Brookside Hillside KTP Lazy Brook Lauritsen Lindale Maple Ridge Otter Creek Vaughn Starksboro Parks-Brookside, Hillside & Lazy Brook Bristol Parks-KTP, Lauritsen & Maple Ridge Middlebury Park-Lindale Vergennes Park-Otter Creek Monkton Park-Vaughn 3. Your Home Purchasing Existing home on lot New Home to be placed on vacant lot Used home to be placed on vacant lot Year of mobile home Make Model Paying cash for the home OR I am financing the home Financial Lender Contact Name Telephone # Loan Amount $ Monthly Payment (including taxes & Insurance) $ Renting w/ Option to Purchase $ Amount of monthly rent you will be paying. Amount includes lot rent? Yes No PETS Some of our parks do not allow dogs. Only ONE pet/ household. Dog Cat Breed Age Up to date on shots? If you have a pet, before you can reside in the park, please provide us with your animals vet papers.

4 PART 4-INCOME EMPLOYMENT INFORMATION: List all full and/or part-time employment for all members of the household. Family Member Employer Name & Address Employer Phone # Rate/Hour Or Salary Hours/ Week OTHER INCOME: List income from: Welfare, Reach Up, General Assistance, SSI, Social Security, Workers Comp, Unemployment Comp, Pensions, Child Support or Alimony. Family Member Source Name & Address ID/Claim # Amount Per Week, Month or Year COMMENTS:

5 PART 5-REFERENCES CREDIT REFERENCES: Please provide the names, addresses, account numbers, phone and/or fax numbers for THREE (3) credit references. Acceptable credit references include insurance companies, utility companies, or an individual who you ve owed money to. Credit Card companies ARE NOT acceptable credit references. Name Address Account # Phone and/or fax # LANDLORD REFERENCES: Please list three (3) landlords. If you have not had three landlords, provide a written statement as to where you have been living the last five (5) years. Name Complete Address Telephone # Dates lived there From: To: Written Statement: PERSONAL REFERENCES: Please list three (3) non-relative personal references. references include: co workers, neighbors, and friends. Acceptable Name Complete Address Telephone #

6 PART 6-CRIMINAL BACKGROUND Have you or any member of your household been convicted of a crime? Yes No If so, explain nature of crime: How was this matter resolved: Do you, or any member of your household, have a warrant in any state for arrest? Yes No If yes, explain. PART 7-CERTIFICATION OF COMPLETION If any of the above information is found to be incorrect, I understand that ACCT may immediately deny my application and/or terminate any lease agreement between ACCT and myself. By signing below I verify the above information is complete and true to the best of my knowledge. Applicant Signature: Date: Co Applicant Signature: Date: Other Adult Signature: Date: PLEASE NOTE: Closing on a mobile home purchase in any ACCT Park cannot occur until ACCT approves the buyer as a Park Resident. ACCT will begin credit, personal and landlord reference checks for this approval when this application is received in ACCT s office.