Application for Admission

Transcription

1 Application for Admission Schall Landings Apartments 2402 Schall Circle West Palm Beach, FL (561) For Office Use Only (Date Stamp) Applicants Current Information First Name Last Name SSN Street Address City, State, Zip Work Phone Household Size Emancipated Minor? Accessibility Features Requested? Vision Hearing Wheelchair Physical Mailing Address (Same as current address) Street Address City, State, Zip Current Landlord Telephone ( ) City, State, Zip Current Utility Information Gas Company Electric Company Water Company Pet Information Cat Dog Other Comments Reasons for Applying About to be or without housing Sub-Standard Housing Other (Please Specify) Previous Information Previous Address Previous Address Page 1 of 5

2 Previous Landlord Previous Landlord Previously lived in Public Housing? Previous HA Name Questionnaire 1. Has anyone in your household been arrested, cited or convicted for the use, sale, manufacture, or distribution of controlled substances (drugs)? 2. Does anyone in your household currently use a controlled or illegal drug? If yes, please explain. 3. Has anyone in your household been convicted of a felony or arrested for violent criminal activity? 4. Does anyone outside of your household pay for any of your bills or expenses? 5. Have you or any member of your household ever been evicted from a rental property? If yes, Which property/landlord 6. Are you or any member of your household currently receiving assistance from HUD? If yes, which property/landlord 7. Have you or anyone in your household ever participated in the Section 8 Program? If yes, When: 8. Have you or any member of your household ever been evicted in the last three years from a federally assisted housing for drug-related criminal activity? If yes: Which property/landlord 9. Are you or any other member of your household subject to the State Sexual Offenders Registration? If yes, list the State where the offense occurred: 10. How did you hear about our apartment community? Family Composition Information Head of Household Name SSN Student Relation to Head DOB Page 2 of 5

3 HOH Birth Place Gender Citizenship Status Alien Registration # Handicap Disabled I have a family member who is absent from the home due to: Employment Military Placement in Foster Care Temporarily in nursing home or hospital Permanently confined to nursing home Away at school Other: YES NO Expected changes in household: Baby due on Adopting a child(ren) on Obtaining custody of a child on Obtaining joint custody of a child(ren) on Receiving a foster child(ren) on YES NO Are any members of household enrolled as a student at an institution of Higher education as defined under section 102 of Higher Education Act of 1965 (20 U.S.C. 1002)? Income Are you or any other member of the household currently receiving income from any of the following sources? Wages Wages earned through a government program such as a Senior Aides, Older American Community Services Employment Program, Americorps If yes, which program Tips, Bonuses, Commissions, or Overtime Pay Scholarship, Education Grants or Work Study Income from operation of a business Social Security Disability/SSI Death Benefits Pensions/Retirement funds Annuities or non-revocable trust Unemployment Military Pay/Veterans Benefits Workman s Compensation Public Assistance/TANF Alimony Child Support Income from rent or sale of property Periodic payments from lottery winnings Regular recurring contributions from person or agencies outside of household Insurance policies Severance Pay Other: Recipient Amount Did you or any other member of your household file a federal tax return last year? Are there any adult members of the household (18 years of age or older) receiving income not listed above?? If yes, specify the source of the income. Page 3 of 5

4 Assets Do you or any other member of the household have any of the following? Checking account Savings Account Certificates of deposits Money market funds IRA/Keogh account Stocks Bonds Treasury Bills Trust Funds If yes, is the Trust irrevocable Real Estate Whole Life or Universal Life Insurance Policy Cash held in Safety Deposit Boxes of Home Assets held in another State of Foreign Country Other: Value of Assets Have you or any other member of the household any lump sum payments such as: Inheritance Lottery Winnings Insurance settlements Other: Value of Assets Have you or any other member of the household disposed of any assest(s) for less than fair market value in the past two years? If yes, please list: Do you or any other member of the household have any assets that are held jointly with another person? Value: Expenses Enter and Medical, Childcare or Handicapped Expenses that your household currently has. Childcare Medical Equipment Medical Care Medications Health Insurance Other: Recipient Amount Are there any full-time students 18 years of age or older in the household? Is any household member elderly (age 62 or older) or a person with disabilities? Do you have medical expenses that are not paid for by an outside source such as insurance? References Personal References Page 4 of 5

5 Special Unit Requirements Will you or any member of the family require any of the following? One Level Unit A separate bedroom Bedroom & Bathroom on 1 st Floor Do you or any family members need any features not mentioned? If yes, please indicate how the PHA should accommodate your family. Optional Information (Head of Household Only) Ethnic Categories Hispanic or Latino Not Hispanic or Latino Racial Categories American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Select One Select All That Apply Certification of Information WARNING! Title 18, Section 1001 of the United States Code, state that a person who knowingly and willingly makes a false or fraudulent statements to any Department or Agency of the U.S. government is guilty of a felony. I understand that any misrepresentation of information or failure to disclose information requested in this application any disqualify me from consideration for admission or participation, and may be grounds for eviction or termination of assistance. This application must be signed by all adults who will occupy the unit before it can be considered. In compliance with the FAIR CREDIT REPORTING ACT this notice is to inform you that the processing of this application includes but is not limited to making any inquiries deemed necessary to verify the accuracy of the information herein, including procuring consumer credit reporting agencies and obtaining credit information from other credit institutions. Additionally, I authorize all corporations, companies, landlords, law enforcement agencies, academic institutions, and current employers to release information they may have about me and release them from any liability and responsibility from doing so. I do hereby certify that the above information is true, accurate, and complete top the best of my knowledge. Applicant: Co-Applicant: Page 5 of 5