RELEASE OF INFORMATION The attached document is a state required form.

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1 RELEASE OF INFORMATION The attached document is a state required form. FROM: WALNUT GROVE APARTMENTS 3100 S. WALNUT STREET PIKE BLOOMINGTON, IN Phone: Fax: The undersigned individual(s) has applied for residency at our apartment community. The property is operated under the RHTC program within Section 42 of the Internal Revenue Code, which requires that we obtain written confirmation of the income of all applicants and other household members. In order to comply with Federal regulations requesting verification of all income, assets, and allowances for residents of RHTC housing, please complete the following form in full and return it to the sender at your earliest convenience. The undersigned understands that, depending on program policies and requirements, previous or current information regarding me/us may be needed. Verifications and inquiries that may be requested include, but are not limited to: CREDIT AND CRIMINAL ACTIVITY IDENTITY AND MARITAL STATUS RESIDENCES AND RENTAL ACTIVITY EMPLOYMENT, INCOME, AND ASSETS MEDICAL ALLOWANCES STUDENT STATUS The groups or individuals that may be asked to release/verify the above information (depending on program requirements) include, but are not limited to: COURTS AND POST OFFICES PAST AND PRESENT EMPLOYERS UTILITY COMPANIES LAW ENFORCEMENT AGENCIES STATE UNEMPLOYMENT AGENCIES CREDIT PROVIDERS AND BUREAUS MEDICAL PROVIDERS VETERANS ADMINISTRATION WELFARE AGENCIES RETIREMENT SYSTEMS SOCIAL SECURITY ADMINISTRATION INTERNAL REVENUE SERVICE BANKS AND OTHER FINANCIAL INSTITUTIONS PREVIOUS LANDLORDS (INCLUDING PHA S) I/we agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file in the management office. I/we understand that I/we have a right to review my/our file and correct any information that can be proven as incorrect. The undersigned hereby authorizes the release of any information requested in order to determine my/our eligibility for the RHTC program. TO BE COMPLETED BY APPLICANT / CO-APPLICANT: Applicant/Resident Name (Printed): Social Security Number: Date: Authorizing Signature: Co-Applicant/Co-Resident Name (Printed): Social Security Number: Date: Authorizing Signature:

2 TO BE COMPLETED BY OFFICE STAFF APARTMENT NUMBER: RENT AMOUNT: INCOME LIMIT: % NEW APPLICATION HOUSEHOLD ADDITION LIVE-IN AIDE: Applicant Name: Phone #: Aliases or Maiden Names: Current Address: Marital Status (circle one): Divorced Married Separated Single Driver s License or State ID #: State: Full Name HOUSEHOLD COMPOSITION List ALL persons that will be occupying the unit at least 50% of the year. Relationship Social Security to Head of Date of Birth Employed? Number Household Full Time Student? Self RESIDENTIAL HISTORY Past Two Years (attach additional sheets, if necessary)

3 YES NO 1. Have you or any household member ever been arrested / convicted of a drug-related crime? Date of Arrest / Conviction: 2. Have you or any household member ever been convicted of a felony? Date of Conviction: 3. Have you ever been evicted? Date of Eviction: 4. Does anyone not listed in the household composition on the previous page plan to live with you in the next 12 months? Explain: 5. Are there any absent household members who, under normal circumstances, would live with you? 6. Does an adult of this household have primary physical custody of every child listed on this application? 7. Does your household have or anticipate having any pets other than those used as a service animal? 8. Does anyone in your household have special needs? Reasonable Accommodation Requested: Please tell us how you heard about Walnut Grove Apartments. ForRent.com Craigslist Phone Book Drive-by Word of Mouth Flyer Location of Flyer: Agency Referral Agency Name: Resident Referral Name of Resident: Past Resident Date & Apt. #: Other Explain:

4 EMERGENCY CONTACT NUMBER In case of emergency, notify: Home Phone: Work Phone: Applicant certifies that the information contained in this rental application is true and accurate and understands that false or inaccurate information shall be cause for denial of this application or termination of any subsequent rental agreements. I/We are the only person(s) who will reside in the apartment if this application is approved. Apartment owner or agents may verify all information given directly or through reporting agencies. Acceptance of the application is not binding on apartment owner or agent until approved in writing. You have applied to live in an apartment that is governed by the Low Income Housing Tax Credit Program. This Program requires us to certify all of your income, asset, and eligibility information as part of determining your household s eligibility. Program requirements state that we must verify each income and asset source as well as other claims of eligibility. We must determine this prior to granting your eligibility and, if such eligibility is granted, each subsequent year you remain in the unit. The undersigned is the person(s) named above and hereby authorizes Walnut Grove Apartments to conduct a search of my Criminal Record, Police Record, and Motor Vehicle Record information for the purpose of obtaining housing. Additionally, I authorize all companies and law enforcement agencies to release such information, and release them from any liability and responsibility from doing so. A faxed copy of this authorization shall be as valid as the original. If applicant cancels after two (2) days, all moneys deposited shall be forfeited to the apartment owner. If approved, all moneys deposited with this application will be applied toward security deposit and/or processing fee at owner s discretion. If an application is denied for ANY reason, a 90-day wait period is required before reapplying to this property. Applicant Signature: Co-Applicant Signature: Date: Date:

5 WALNUT GROVE APARTMENTS PET POLICY, RULES & REGULATIONS Pet Premium Fee is non-refundable and must be paid in full prior to the pet being allowed on the property. Pet owner must provide paperwork from veterinarian verifying pet has been spayed or neutered and is current all required vaccinations. Resident is allowed 1 (one) pet maximum per apartment. Pet owner must clean up after pet inside and outside apartment. Resident will hold Landlord harmless from liabilities/judgments/expenses and/or claims by third parties for injury to any person or damage to property caused by resident s pet. Resident must complete pet application and pet lease agreement. Residents may have only common household pets, such as a dog, cat, aquarium fish, or bird in a cage. Pet will be allowed outside only with human companion and on a hand-held leash or in carrier. Resident is totally responsible for the care and cleanliness of the pet. Any damage caused by pet is full responsibility of the resident. Resident understands and agrees that resident will allow Landlord to professionally fumigate the premises for fleas and ticks and clean all carpets when resident vacates the property. Resident is to provide adequate food and water and provide regular veterinary care for the pet. Resident will not leave pet unattended in apartment for extended lengths of time. Resident must maintain cleanliness of sleeping and feeding areas and litter pans by removing and properly cleaning any pet waste. We do not allow Pit Bulls, Rottweilers, Doberman Pinschers, Akitas, German Shepherds and/or Chow Chows on the property including visiting the property. Failure to comply could result in eviction. REQUIRED: Does your household have or anticipate having any pets? Yes No If yes, is your current pet or will your household s anticipated pet be considered a service animal? Yes No Please specify the type and breed of pet your household has or anticipates having (please circle one): Cat Dog Fish Bird Pet Breed: Signature Date Signature Date Management Signature Date