Office Use Only Application Type: Bedroom Size: Application Date: Alias(es)

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Vernon Lane
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1 Rental Application (Please Print) Name of Head of Household Office Use Only Application Type: Bedroom Size: Application Date: Name of Spouse or Co- Head of Household Applicants Address City, State, & Zip Code Phone Number Marital Status: (Single, Married, Divorced, or Separated) Address Alternate Phone Number Alias(es) How did you hear about us? How Many Bedrooms? Housing Program? Circle One (Market Rent Public Housing Tax Credit) PLEASE ANSWER ALL QUESTIONS! WRITE N/A IF A PARTICULAR QUESTION IS NOT APPLICABLE. If you need additional space for answers to any paragraph listed below, attached additional sheets and made sure you include a reference to the paragraph number, your name and your social security number. Ethnicity (Must Choose One): Hispanic Non Hispanic Race(Must Choose One): Native Hawaiian/Pacific Islander Asian Caucasian American Indian/Alaska Native Black/ African American This information is required for statistical purposes for the Department of Housing & Urban Development. However, there is no penalty for persons that do not complete the Ethnicity or Race section in this rental application. Family Composition: Name(s) Relation to Head Sex Head M F M F M F M F M F M F M F Student PT / FT Social Security Number Date of Birth

2 Anticipated Income: Present Employment Source of Income: (Name of source) Position Dates From/To Address: Phone #: Contact: Address: Phone #: Contact: Address: Phone #: Contact: Address: Phone #: Contact: Gross Income/Monthly $ $ $ $ Are you entitled to any child support benefits? (Circle one) Yes No If yes, do you receive child support benefits? (Circle one) Yes ($ ) No If no, what attempts are you making to collect the entitled child support benefits? Have you ever been convicted of a felony?, if so when? Have you ever filed for bankruptcy?, if so when? Date of Discharge: Other Income (Check all that apply): SS $ Per Month KTAP $ Per Month Kinship Care $ Per Month SSI $ Per Month Alimony $ Per Month Foster Care $ Per Month Pension $ Per Month Stipend $ Per Month SNAP Benefits $ Per Month VA $ Per Month Unemployment $ Per Month Other $ Per Month Assets Is any member of the household sold or disposed of any asset during the past two years? (Please Circle) YES or NO Account Number Describe Type (stocks, Real Estate, Etc.) If Property, please indicate location Value Credit References: (Credit cards, School Loans, Car Payment, Mortgage Payments, etc.): Account Number Company Name (Creditor) Monthly Payment Balance Judgments/Bankruptcy? If yes, describe. $ $ $ $

3 Bank References: Account Number Bank Name Address Checking or Savings Average Balance Actual Interest Earned Vehicles (including company cars, motorcycles, etc.): Account Number Drivers License State Model Year Color Car Plate Number State Monthly Payment Character Reference (Other than Relatives): Name Address Phone No Residence History of Current and Previous Landlord: (Must be the past 5 years) Current Address & Move In Date Current Rent/Mo. Current Utilities/Mo. Reason for Leaving Landlord Name Landlord Address Landlord Phone No. Previous Address & Move In Date Previous Rent/Mo. Previous Utilities/Mo. Reason for Leaving Landlord Name Landlord Address Landlord Phone No. Previous Address & Move In Date Previous Rent/Mo. Previous Utilities/Mo. Landlord Name Landlord Address Landlord Phone No. Previous Address & Move In Date Previous Rent/Mo. Previous Utilities/Mo. Reason for Leaving Landlord Name Landlord Address Landlord Phone No. In case of emergency, notify: Name Address Phone Number

Special Needs Does anyone in your family have special housing needs (Circle one) Yes No Do you know of any special living accommodations that your household requires?

4 Special Needs Does anyone in your family have special housing needs (Circle one) Yes No Do you know of any special living accommodations that your household requires? (Circle One) Yes No If yes to either questions, please list: Subsidized Housing Experience: Have you ever lived in public housing or housing where part or all of your rent was paid by government assistance? Yes No If Yes, please list: Informal Support: Applicants must report as income any regular contributions and gifts from persons that will not be living in the apartment with the applicant household. These sources may include rent and utility payments paid on behalf of the family, and other cash or non-cash contributions provided on a regular basis. The following is not considered income under this section: groceries and/or contributions paid directly to a child care provider, and temporary, non-recurring, or sporadic income (including gifts). Do you have any informal support to report as defined above? (Circle one) Yes No If yes, please describe: NOTE: Informal Support income, if applicable, must be reported on all subsequent certifications completed by the applicant if accepted for housing. I authorized The Villages of Park DuValle to verify all information contained in this application for housing. I further agree that a full disclosure of pertinent facts may be made to The Villages of Park DuValle as to any aspect of this application. I understand that this application may be rejected as the result of my providing false or insufficient information. I understand that this application and all related inquiries will be used only for its relevance to screening and occupancy at The Villages of Park DuValle. I also understand that this application is for occupancy into program housing as described in The Villages of Park DuValle s Admission & Continuing Occupancy Policy, and that I will be required to complete annual certifications for my household. Signatures: Applicant (Head of Household) Date Applicant (Household Member 18+) Date Leasing Staff Date

Blackstone Falls Application for Subsidized Housing

Blackstone Falls 1485 High Street Central Falls, RI 02863 Tel: (401) 725-1188 Fax: (401) 726-8711 Email: manager@blackstonefalls.com Blackstone Falls Application for Subsidized Housing We thank you for