Premier Management, LLC. Form AA-1, Rev. 6/18. Rental Application

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Cory Lee
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1 Premier anagement,. orm -1, ev. 6/18 ental pplication U P of pplication, 20 ime of pplication a.m./p.m. partment ommunity pplicant ame Phone ( ) 2 nd Phone ( ) aiden ame and/or any other names you have ever been known by ow did you hear about this property? umber of individuals who will reside in the apartment umber of bedrooms desired o-pplicant ame Phone ( ) 2 nd Phone ( ) aiden ame and/or any other names you have ever been known by ill in the information requested below for each individual who will reside in the apartment (include the applicant and/or co-applicant): elationship *ocial ecurity ity & tate ull ame to pplicant ender umber Birth of Birth *ist any household member, who was age 62 or older as of January 31, 2010, and who does not have a ocial ecurity umber, who received U rental assistance at another location on January 31, _ ist all states in which any household member has resided re any of the individuals listed above enrolled in an institution of higher education? (ollege, business, or trade school, etc. his includes full-time or part-time status). Yes o Whom? re you applying for a handicapped accessible unit only? Yes o Will you accept a unit that is not handicapped accessible? Yes o & Y PP ist 2 people (who are not related to you) as personal references list 1 person to be contacted in case of an emergency. 1 st Personal eference: ame ddress ity tate Zip ode Phone ( ) 2 nd Personal eference: ame ddress ity tate Zip ode Phone ( ) mergency ontact: ame elationship to pplicant ddress ity tate Zip ode Phone ( ) Page 1 -PP ist 2 people (who are not related to you) as personal references list 1 person to be contacted in case of an emergency. 1 st Personal eference: ame ddress ity tate Zip ode Phone ( ) 2 nd Personal eference: ame ddress ity tate Zip ode Phone ( ) mergency ontact: ame elationship to pplicant ddress ity tate Zip ode Phone ( )

2 ote: f not enough spaces are provided on this page and the next page for you to list all of your income, assets, and expenses, please use the back of this page to provide additional information. pplicant Wages $ for ours Weekly mployer ame Phone umber ( ) W or ash ssistance $_ onthly Worker s ompensation $ Unemployment Benefits $ hild upport or limony $ onthly ocial ecurity $ onthly upplemental ecurity ncome () Veteran s dministration (V) Pension ther Pension $ onthly ther ncome $ Weekly onthly Bi-weekly nnually ource have no income from any source o-pplicant Wages $ for ours Weekly mployer ame Phone umber ( ) W or ash ssistance $_ onthly Worker s ompensation $ Unemployment Benefits $ hild upport or limony $ onthly ocial ecurity $ onthly upplemental ecurity ncome () Veteran s dministration (V) Pension ther Pension $ onthly ther ncome $ Weekly onthly Bi-weekly nnually ource have no income from any source pplicant ame of Bank Phone umber ( ) hecking ccount Balance $ nterest ate avings ccount Balance $ nterest ate ertificate of eposit Balance $ nterest ate dditional ccount Balance $ ype of ccount _ nterest ate irect xpress or any card where benefits are deposited $ Whole ife nsurance ash Value $ _ ividend f you own any real estate, describe it briefly ave you sold, given away or otherwise transferred ownership of assets within the last two (2) years? f yes, list items: have no assets o-pplicant ame of Bank Phone umber ( ) hecking ccount Balance $ nterest ate avings ccount Balance $ nterest ate ertificate of eposit Balance $ nterest ate dditional ccount Balance $ ype of ccount _ nterest ate irect xpress or any card where benefits are deposited $ Whole ife nsurance ash Value $ _ ividend f you own any real estate, describe it briefly ave you sold, given away or otherwise transferred ownership of assets within the last two (2) years? f yes, list items: have no assets Page 2 orm -1, ev. 6/18

3 X P pplicant f you are employed or a student, indicate the cost of child care while you are at work or at school: $ ourly Weekly onthly ours per Week onth f you are 62 years of age or older or disabled, you are entitled to a $ deduction from your annual income, and qualify to deduct any of the following medical costs. Please indicate any medical costs paid on a recurring basis. (ndicate only amount for which you are not reimbursed from any source). heck here if you qualify for the $ deduction described above. edicare Premiums $ onthly ealth nsurance Premiums $ onthly Bi-onthly nnually octor Visits $ Per Visit umber of Visits Per Year Prescription edication $ onthly ther edical xpenses: ype $ _ onthly Quarterly nnually o-pplicant f you are employed or a student, indicate the cost of child care while you are at work or at school: $ ourly Weekly onthly ours per Week onth f you are 62 years of age or older or disabled, you are entitled to a $ deduction from your annual income, and qualify to deduct any of the following medical costs. Please indicate any medical costs paid on a recurring basis. (ndicate only amount for which you are not reimbursed from any source). heck here if you qualify for the $ deduction described above. edicare Premiums $ onthly ealth nsurance Premiums $ onthly Bi-onthly nnually octor Visits $ Per Visit umber of Visits Per Year Prescription edication $ onthly ther edical xpenses: ype $ _ onthly Quarterly nnually Page 3 orm -1, ev. 6/18

4 Y ave you ever lived in an apartment in this community or any other apartment community owned or managed by Premier anagement,? Yes o f yes, when? Where? pplicant f this information does not cover a period of at least 3 years, please use the back of this page to provide additional information. Present ddress ity tate Zip ode ength of esidency ent $ andlord s ame andlord s ddress ity tate Zip ode andlord s Phone ( ) Previous ddress ity tate Zip ode ength of esidency ent $ andlord s ame andlord s ddress ity tate Zip ode andlord s Phone ( ) ave you ever lived in an apartment in this community or any other apartment community owned or managed by Premier anagement,? Yes o f yes, when? Where? o-pplicant f this information does not cover a period of at least 3 years, please use the back of this page to provide additional information. Present ddress ity tate Zip ode ength of esidency ent $ andlord s ame andlord s ddress ity tate Zip ode andlord s Phone ( ) Previous ddress ity tate Zip ode ength of esidency ent $ andlord s ame andlord s ddress ity tate Zip ode andlord s Phone ( ) Page 4 orm -1, ev. 6/18

5 QU. Please present your driver s license or another form of identification, and W PP B PP: By my signature below, understand and agree that my credit and references will be checked and all other information provided on this application may be verified by a representative of this apartment community or Premier anagement,. certify that if am accepted for residency in this apartment community, this will be my permanent residence and will not maintain a separate residence in a different location. & U U Y PP U B Y KW U, UU PP W J PP. QU W B P U QU. s anyone in the household subject to a lifetime sex offender registration requirement? Yes o f yes, whom? as anyone in this household ever been convicted of a crime/offense (excluding minor traffic offenses) Yes o f yes, list ounty and tate n accordance with ederal civil rights law and U.. epartment of griculture (U) civil rights regulations and policies, the U, its gencies, offices, and employees, and institutions participating in or administering U programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by U (not all bases apply to all programs). emedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, merican ign anguage, etc.) should contact the responsible gency or U's enter at (202) (voice and Y) or contact U through the ederal elay ervice at (800) dditionally, program information may be made available in languages other than nglish. o file a program discrimination complaint, complete the U Program iscrimination omplaint orm, -3027, found online at and at any U office or write a letter addressed to U and provide in the letter all of the information requested in the form. o request a copy of the complaint form, call (866) ubmit your completed form or letter to U by: (1) mail: U.. epartment of griculture, ffice of the ssistant ecretary for ivil ights,1400 ndependence venue, W Washington, ; (2) fax: (202) ; or (3) program.intake@usda.gov his institution is an equal opportunity provider. pplicant o-pplicant _ pplicant s ignature _ anager s ignature _ o-pplicant s ignature _ anager s ignature dentification Viewed: river s icense umber ther.. icense umber & ake of utomobile (s): 1st uto 2nd uto dentification Viewed: river s icense umber ther.. icense umber & ake of utomobile (s): 1st uto 2nd uto he information regarding race, ethnicity and gender designation solicited on the application is requested in order to assure the ederal overnment, acting through the ural ousing ervice that the ederal law prohibiting discrimination against tenant applications on the basis of race, color, national origin, sex, age, disability, religion and familial status are complied with. You are not required to furnish this information, but are encouraged to do so. his information will not be used in evaluating your application or to discriminate against you in any way. owever, if you choose not to furnish it, the owner is required to note the race, ethnicity and gender of the individual applicants on the basis of visual observation or surname. thnicity: ispanic or atino ot ispanic or atino ace: (ark one or more) merican ndian/laskan ative sian Black/frican merican ative awaiian or ther Pacific White ender: ale emale arital tatus of pplicant: ingle arried eparated Page 5 orm -1, ev. 6/18

Gan-Aden of Colchester 385 South Main Street, Colchester

Gan-Aden of Colchester 385 South Main Street, Colchester Paradise Agency, LLC Property Development & Management 151 Broadway P.O. Box 175 Colchester, Connecticut 06415 Phone: (860) 537-7044 Fax: (860) 537-1142 TDD/TT: 1-800-842-9710 Visit us at www.paradiseagency.com