RENTAL APPLICATION. P a g e 1 4 FOR INTERNAL USE ONLY HOUSEHOLD COMPOSITION

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1 RENTAL APPLICATION FOR INTERNAL USE ONLY Community Name: Community Phone: Community Fax: HOUSEHOLD COMPOSITION Applicant Name: Phone: ( ) Address: Driver s License # and State: Or Government ID: Are you a U.S Citizen? Yes No DOB: SSN: Student Status: FT PT NA Marital Status: Single Married Divorced Widowed Separated Received Date: Time Received: Wait List Number: Spouse Name: Phone: ( ) Address: Driver s License # and State: Or Government ID: Are you a U.S Citizen? Yes No DOB: SSN: Student Status: FT PT NA Other Occupants Name Relationship DOB Student Status SSN/Alien Registration Gender FT PT NA FT PT NA FT PT NA FT PT NA FT PT NA FT PT NA ADDITIONAL HOUSEHOLD INFORMATION Do all above household members reside in the household 100% of the time? YES / NO If no: Are there any anticipated change in household size within the next 12 months? YES / NO If yes: Are there any anticipated change in the number of students within the next 12 months? YES / NO If yes: Are any of the household members listed above Foster Children? YES / NO If yes: Is any adult household member subject to state or federal lifetime sex offender registry? YES / NO If yes: RENTAL HISTORY (3 Years rental history required) Current Residence Address: City/St/Zip: Current Rent: $ Current Owner/Landlord: Landlord Phone #: Date Moved In: Reason For Moving: Previous Residence Address: City/St/Zip: Current Rent: $ Current Owner/Landlord: Landlord Phone #: Date Moved In: Date Moved Out: Reason For Moving: ADDITIONALINFORMATION Have you, your spouse or any occupant listed in this application ever: Y N Been evicted or asked to move out? Y N Moved out of a dwelling before the end of the lease term without the owner s consent? Y N Been sued for rent? Y N Been sued for property damage? Y N Been charged, detained or arrested for a felony or sex crime that was resolved by conviction, probation, deferred adjudication, court ordered community supervision or pretrial diversion? Y N Been charged, detained or arrested for a felony or sex related crime that has not been resolved by any method? Please indicate the year, location and type of each felony or sex related crime other than those resolved by dismissal or acquittal: P a g e 1 4

2 RENTAL APPLICATION EMPLOYMENT INFORMATION Applicant Current Employer: Address: City/St/Zip: Employer Phone: Supervisor Name: Date you Began this Job: Position: Gross Monthly Income: Spouse Current Employer: Address: City/St/Zip: Employer Phone: Supervisor Name: Date you Began this Job: Position: Gross Monthly Income: Previous Employer: Address: City/St/Zip: Employer Phone: Supervisor Name: Date you Began this Job: Date you Ended this Job: Position: Gross Monthly Income: Previous Employer: Address: City/St/Zip: Employer Phone: Supervisor Name: Date you Began this Job: Date you Ended this Job: Position: Gross Monthly Income: ANNUAL INCOME SOURCES Income Source Yes / No Applicant Spouse or Other Adult Child and/or Co-Head Members Dependent Totals Salary Yes No $ Overtime Pay Yes No $ Commissions and Fess Yes No $ Tips and Bonuses Yes No $ Interest/Dividends Yes No $ Net Business Income Yes No $ Social Security Yes No $ Supplement Security Income Yes No $ Disability Death Benefit Yes No $ Pension Retirement Income Yes No $ Annuities Income Yes No $ Income from Rental Property Yes No $ Recurring Monetary Gifts Yes No $ Short/Long Term Care Payments Yes No $ Alimony Yes No $ Child Support: Anticipated Yes No $ Voluntary Yes No $ Court Ordered Yes No $ TANF / Cash Aid / Welfare Yes No $ Periodic Lottery Payments Yes No $ Unemployment Benefits Yes No $ Workman s Compensation Yes No $ Educational Scholarships/Grants Yes No $ Other Income Yes No $ If other income, please explain: TOTAL: $ P a g e 2 4

3 RENTAL APPLICATION ASSETS Asset Type Yes / No Value of Asset Asset Income Bank Name Checking Account Yes No Savings Account Yes No Direct Express Card Yes No Certificate of Deposits* Yes No Mutual Funds/Stocks/Bonds* Yes No Money Market Funds Yes No Treasury Bills Yes No IRA/401K/Keogh* Yes No Retirement/Pension Funds* Yes No Annuities* Yes No Whole Life Insurance (cash value)* Yes No Personal Property Held for Investment Yes No Cash Held in Safe Deposit Boxes, etc. Yes No Mortgage or Deed of Trust Yes No Land/Real Estate* Yes No Trust Fund (revocable)* Yes No *When listing the cash value of any of the items that have an asterisk, please keep in mind penalties for withdrawal, or any fees deducted to convert the assets to cash. For example, if you owned a home, and sold it, how much cash would you have after you paid off the mortgage, the realtor, etc.? That s the amount you should list in the value column.* LUMP SUM PAYMENTS Lump Sums Yes/No Value of Asset Asset Income Lump Sum Source Inheritances Yes No Lottery or Other Winnings Yes No Workers Compensation Settlements Yes No Social Security Disability Settlements Yes No VA Disability Settlements Yes No Capital Gains Yes No Other Yes No If other assets, please explain: ADDITIONAL ASSET INFORMATION Y N Other than Foreclose or Bankruptcy, have you disposed of any assets for less than its worth in the last 2 years? If yes, please explain: Y N Has anyone in your household owned real estate or land in the last 2 years? HOUSING ASSISTANCE Assistance Type YES / NO Amount Date Received Federal Emergency Management Agency (FEMA) Yes No Small Business Administration (SBA) Yes No Housing and Urban Development (Section 8) Yes No Tenant Based Rental Assistance (TBRA) Yes No Insurance (Homeowners) Yes No Other Yes No If other, Please Explain: P a g e 3 4

4 RENTAL APPLICATION SIGNATURE & ACKNOWLEDGEMENT APPLICANT CERTIFICATION - Please be aware that this information is being used to determine if your household appears eligible to participate under an Affordable Housing Program My/Our signature here or on the attached Release and Consent Form authorizes the release and/or verification of my/our employment information. Warning: Title 18, Section 1001 of the U.S Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action or damages, and seek other relief as may be appropriate against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the **Social Security Act as 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8) Applicant/Resident Printed Name Signature Date Co-Applicant/Resident Printed Name Signature Date Adult Member Printed Name Signature Date Management Representative Printed Name Signature Date If you are disabled or have difficulty understanding English, please request our assistance and we will ensure that you are provided with meaningful access based on your individual needs. UAH Property Management does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development s regulations implementing Section 504 (24 CFR, Par 8 dated June 2, 1988) Rob Dryman N. Central Expressway, Suite 500 Dallas, TX Office TTY P a g e 4 4

5 Michigan State Housing Development Authority CHECKLIST MSHDA PROGRAMS (Issued under P.A. of 1966 as amended and Section 8 of the U.S. Housing (program) Act of 1937.) Complete a separate form for each household member who is age 18 or older or an emancipated minor. Name: Unit Number: Yes No COMPLETE EACH ITEM: 1 I am a citizen of the United States or a permanent legal resident. 2 I am presently a student. Check one: Full-time Part-time Other 3 I was a student sometime during the past twelve-month period or anticipate becoming a student at sometime during the upcoming twelve-month period. INCOME 4 I have a job and receive money/wages, tips or bonuses. (List the businesses or companies that pay you.) 5 I am self-employed or operate my own business. (List the types of jobs you do.) 6 I earn income from periodic, temporary, seasonal or contractual employment /work. 7 I receive Social Security or Rail Road Retirement Act income. 8 I receive Supplemental Security Income (SSI). 9 I receive quarterly payments from DHS for the State-paid portion of a SSI grant. 10 I receive unearned income for a family member(s) age 17 or under (e.g.: Social Security, trust fund disbursements). 11 I receive periodic payments from retirement funds or pensions. If yes, how many funds or pensions? List name(s) of fund or pension provider. 12 I receive disability or death benefits other than Social Security. 13 I receive Veteran's Administration benefits. 14 I receive Public Assistance. (does not include food stamps or Medicaid) 15 I receive cash contributions or gifts including rent or utility payments, on an ongoing basis from persons not living with me. 16 I receive unemployment benefits. 17 I receive periodic payments from Workers' Compensation. 18 I receive periodic payments from trust, annuity or inheritance. If yes, from how many sources? 19 I receive income from the rental of real estate or personal property. 20 I receive periodic payments from lottery or other types of winnings. 21 I receive adoption assistance payments. 22 I receive alimony, maintenance, or spousal support. 23 I receive GI Bill benefits. 24 I receive military active duty allotments or regular pay as a member of the National Guard or Reservist pay. April 2015 Page 1 of 4

6 Yes No COMPLETE EACH ITEM: 25 I am a member of an Indian Tribe receiving gaming payments. 26 I receive periodic payments from insurance policies or any type of settlement, if yes, how many policies or settlements? 27 I receive long term care insurance payments that exceed $180/day or $67,000 annually. 28 I receive other recurring or periodic income not listed above. Describe 29 I receive student financial assistance. (does not include student loans) CHILD SUPPORT 30 I receive child support. If yes, from how many parents do you receive support? If yes, is child support paid directly to DHS 31 I have been awarded a judgment for child support but have not been receiving any payments or have not been receiving the full payments on a regular basis. 32 I anticipate filing a claim for child support within the next twelve months. ASSETS (Include all assets held or owned either in or outside of the United States) 33 I have a savings account(s) at: (List name(s) of institution) 34 I have a checking account(s) at: (List name(s) of institution) 35 I have certificates of deposit at: (List name(s) of institution) 36 I have a prepaid card, debit card, or paycard on which funds from Social Security, SSI, Child Support, DHS, unemployment or other agency are directly deposited. If yes, how many? From which Agency(ies)? 37 I have cash held in my home or in a safety deposit box. 38 I have savings bonds. If yes, how many? 39 I have Treasury Bills. If yes, how many? 40 I have stocks. 41 I have bonds 42 I have mutual funds or securities. 43 I have IRA's or Keogh account(s) at: (List name(s) of institution) 44 I have time certificate(s) at: (List name(s) of institution) 45 I own real estate and/or receive income from the rental of real estate. If yes, how many properties? 46 I own a mobile home. 47 I have land contracts. If yes, how many? 48 I hold a mortgage or deed of trust. 49 I have revocable trusts. If yes, how many trusts? 50 I have whole life or universal life insurance policy(ies). If yes, Somehow many policies? 51 I have personal property held for investment purposes (gems, jewelry, collections, etc.). 52 I have lump sum receipts or one-time receipts. April 2015 Page 2 of 4

7 Yes No COMPLETE EACH ITEM: 53 I have another name(s) listed on one or more of the above assets for beneficiary or other purposes, such as, power of attorney. These other persons do not own the assets and receive no income from the assets. 54 I have joint ownership on one or more of the above assets. 55 I have income/assets from sources other than those listed above. (Describe) 56 A member of my household is under the age of 18 and has assets. (Describe) Yes No COMPLETE EACH ITEM: ALLOWANCES / DEDUCTIONS (Complete the items below for Section 8, Section 236, and Moderate Projects Only) 57 I am Elderly (age 62 or older), Handicapped or Disabled and pay Medicare premiums. 58 I am Elderly (age 62 or older), Handicapped or Disabled and pay medical insurance premiums, other than Medicare. 59 I am Elderly (age 62 or older), Handicapped or Disabled and pay medical or prescription or chore provider expenses which are not reimbursed by insurance. 60 I am Elderly (age 62 or older), Handicapped or Disabled and pay long term care insurance premiums. 61 I pay child care expenses for a child age 12 or under in order to be gainfully employed or to further my education. 62 The Department of Human Services (DHS) pays child care expenses for a child(ren) age 12 or under in order for me to be gainfully employed or further my education. If yes, FIA pays 63 I pay handicap care expenses for a handicapped/disabled family member in order to be gainfully employed. 64 I pay handicap equipment expenses for a handicapped/disabled family member that are not covered by insurance. OTHER ITEMS 65 I have provided proof of Social Security number (or certification) for all household members. (The certification for individuals under 18 years of age will be executed by a parent or guardian.) DISPOSAL / DIVESTITURE OF ASSETS (all tenants and prospective residents in all types of projects must complete the section below) 66 I have sold, given away or otherwise transferred ownership of assets within the last two (2) years. Initial the Yes column or the No column at left. If yes, list item(s) and date(s): Assets include cash (totaling in excess of $999), cash held in savings and/or checking accounts, trust funds, equity in real estate and other capital investments, stocks, bonds, Treasury bills, certificates of deposit, money market funds, IRA accounts, retirement and pension funds, lump sum receipts (i.e., lottery winnings, insurance settlements, etc.), and personal property held as an investment (i.e., gem or coin collections, paintings, antique cars, etc.). Do not include necessary personal property such as furniture, automobiles, and clothing. Under penalties of perjury, I certify that the information presented in this certification is true and accurate to the best of my (our) knowledge. The undersigned further understands that providing false representation herein constitutes an act of fraud. I will notify the Resident Manager when circumstances change, for possible recertification. False, misleading or incomplete information may result in the termination of the lease agreement and/or benefits. April 2015 Page 3 of 4

8 Applicant / Tenant Signature Date April 2015 Page 4 of 4

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10 UNDER $5,000 ASSET CERTIFICATION For households whose combined net assets do not exceed $5,000. Complete only one form per household; include assets of children. Household Name: Unit No. Development Name: Huntley Villa Townhomes City: Holt Complete all that apply for 1 through 4: 1. My/our assets include: (A) Cash Value* (B) Int. Rate (A*B) Annual Income Source (A) Cash Value* (B) Int. Rate (A*B) Annual Income Source $ $ Savings Account $ $ Checking Account $ $ Cash on Hand $ $ Safety Deposit Box $ $ Certificates of Deposit $ $ Money market funds $ $ Stocks $ $ Bonds $ $ IRA Accounts $ $ 401K Accounts $ $ Keogh Accounts $ $ Trust Funds $ $ Equity in real estate $ $ Land Contracts $ $ Lump Sum Receipts $ $ Capital investments $ $ Life Insurance Policies (excluding Term) $ $ Other Retirement/Pension Funds not named above: $ $ Personal property held as an investment** : $ $ Other (list): PLEASE NOTE: Certain funds (e.g., Retirement, Pension, Trust) may or may not be (fully) accessible to you. Include only those amounts which are. *Cash value is defined as market value minus the cost of converting the asset to cash, such as broker's fees, settlement costs, outstanding loans, early withdrawal penalties, etc. **Personal property held as an investment may include, but is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary personal property such as, but not necessarily limited to, household furniture, daily-use autos, clothing, assets of an active business, or special equipment for use by the disabled. 2. Within the past two (2) years, I/we have sold or given away assets (including cash, real estate, etc.) for more than $1,000 below their fair market value (FMV). Those amounts* are included above and are equal to a total of: $ (*the difference between FMV and the amount received, for each asset on which this occurred). 3. I/we have not sold or given away assets (including cash, real estate, etc.) for less than fair market value during the past two (2) years. 4. I/we do not have any assets at this time. The net family assets (as defined in 24 CFR ) above do not exceed $5,000 and the annual income from the net family assets is $. This amount is included in total gross annual income. Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement. Applicant/Tenant Date Applicant/Tenant Date Under $5,000 Asset Certification (September 2000)

11 Michigan State Housing Development Authority ANNUAL STUDENT ELIGIBILITY CERTIFICATION (For LIHTC and Bond-Financed Projects) This form must be completed for all households in which any of the occupants are students, either fulltime or part-time. All household members age 18 or older (or if under 18 and qualified as Head, Co- Head, or Spouse) must complete, sign and date this form upon move-in and at least annually thereafter or whenever there is a change in student status during the entire compliance period of the project. Property Name: MSHDA #: Unit Address/Number: TIC Effective Date: Name of Household Member Currently a Student If not currently a student, was the member a student at any time during the past year? Head Yes No Yes No N/A 2 Yes No Yes No N/A 3 Yes No Yes No N/A 4 Yes No Yes No N/A 5 Yes No Yes No N/A 6 Yes No Yes No N/A A. At least one household member ( ) is currently a non-student and has not been (and will not be) a student during any part of any five different months of the calendar year. i A Student Status Verification form must be completed if this individual attended school at any time during the past twelve months. B. Household contains all students, but is qualified because the following occupant ( ) is currently a part-time student and this part-time student has not been (and will not be) a full-time student during any part of any five months (consecutive or different) of the calendar year. A Student Status Verification form is required for the part-time student. C. Household contains all full-time students but is qualified because the household meets one or more of the exceptions provided in IRC Section 42 and listed below. At least one student is receiving assistance under Title IV of the Social Security Act (i.e. welfare, AFDC, TANF, etc.) Yes No Program: At least one student was previously under the care and placement responsibility of the state agency responsible for administering foster care? If yes, attach documentation of previous foster care participation. Yes No At least one student participates in a program receiving assistance under the Job Training Partnership Act, Workforce Investment Act, or under other similar federal, state or local laws? If yes, attach documentation of current participation. Yes, Program Name: No Michigan State Housing Development Authority October 2015 Page 1 of 2 MSHDA LIHTC Form

12 At least one student is a single parent with child(ren) and this parent is not a dependent of another individual and the child(ren) is/are not dependent(s) of someone other than the other (or absent) parent? If yes, attach documentation such as a tax return or court order establishing custody. Yes No Explanation: At least one student is married and entitled to file a joint tax return. If yes, attach a copy of the marriage license or the most recently filed tax return. Yes No Document Attached: Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge. I/we agree to notify management immediately of any changes in this household s student status. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement. Signature of Applicant/Resident Printed Name of Applicant/Tenant Date Signature of Applicant/Resident Printed Name of Applicant/Tenant Date Note: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. i Note: The five months need not be consecutive. If the individual attended school full-time for even one day of calendar month, that month counts toward the five months. Michigan State Housing Development Authority October 2015 Page 2 of 2 MSHDA LIHTC Form

13 MSHDA EQUAL HOUSING OPPORTUNITY MICHIGAN STATE HOUSING DEVELOPMENT AUTHORITY FAMILY COMPOSITION Issued under P.A. 346 of 1966, as amended, and Section 8 of the U.S. Housing Act of Name: Home Telephone Number: Unit Address: City, State, ZIP Code: Work Telephone Number: Mailing Address: City, State, ZIP Code: Message Telephone Number: List yourself and all other persons who will live in the unit: Name Social Security # (if no SS# use Alien Registration Number) Relationship to Head of Household Yes/NoStudent? Birth Date Age Sex M/F Yes/NoDisabled? Hispanic or Latino? Yes/No *Race Code # s Yes/NoUS Citizen? Head of Household *Race Code # s (enter one or more): 11 White; 12 Black/African American; 13 Asian; 14 American Indian or Alaska Native; 15 Native Hawaiian orother Pacific Islander; 16 American Indian or Alaska Native AND White; 17 Asian AND White; 18 Black or African American AND White; 19 American Indian or Alaska Native AND Black or African American; 20 Other Multi-Racial If there are new births, please send a copy of proof of birth and social security card. Head of Household Please complete the following section (for statistical purposes only): Marital Status Enter Code # 1. Married 2. Single 3. Widowed 4. Divorced 5. Separated I certify that only the people listed above will occupy the unit. Signature of Head of Household Date Do you, as a person with a disability, require SPECIFIC accommodation(s) to fully use our programs and services? No Yes [List specific accommodation(s) required] After completing this form, please return to: Huntley Villa 1594 N. Aurelius Holt, MI Fax: Si no puedes leer este documento porque usted no lee a Inglés, o desea que esta comunicación sea interpretada o traducida y nadie que sabe usted puede traducir, por favor llame a nuestra oficina para obtener una lista de intérpretes o traductores. Nuestro número de teléfono es Penalties which may be imposed for intentionally submitting false or misleading information in obtaining Authority financing are set forth in the Michigan State Housing Development Authority Act of 1966 (MCLA ). MSHDA-CD-51aE ( rev )

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