Providence Place. 2-Bedroom, 1 Bathroom Apartments. Newly Renovated Energy Efficient. Washer/Dryer Hook-Up. New Kitchen Appliances.

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1 Providence Place A Subsidiary of 2-Bedroom, 1 Bathroom Apartments Newly Renovated Energy Efficient Washer/Dryer Hook-Up New Kitchen Appliances $500 / Month Water and Sewer Provided Gas, Electric, Phone, Cable are paid by the Tenant Regular and Handicap accessible units available Income Qualified Listed below is the maximum household income allowed for these units. This includes all income for all household members. Family Size Max Annual Household $29,400 $33,600 $37,800 $41,940 Income IHCDA Effective 4/14/17 The application for Providence Place Apartments is on the Desert Rose website at

2 Providence Place A Subsidiary of NOTICE TO Rental Applicants After carefully reading and filling out the attached Housing Application completely, please gather the items on the following page, which pertain to you, or anyone living in the residence. All items, which apply to you or anyone, that will be residing in the apartment MUST be sent in order for your application to be processed quickly and efficiently. Please carefully gather all the materials that pertain to your household and mail, fax or scan and all the information together to the address, fax number or address below to start your qualification process. Your eligibility determination will take approximately two (2) weeks from the date your documents are received. If you have any questions or need additional information, please feel free to contact us. Angie Richards Harmony Housing, LLC P.O. Box 440 Edinburgh, IN Phone: Fax: harmonyhousingllc@yahoo.com (on behalf of Desert Rose Foundation, Inc.) Or Julie Myers Desert Rose Foundation, Inc. P.O. Box 1754 Martinsville, IN Phone: Fax: jmyers@desertrose.cc

3 Providence Place A Subsidiary of APPLICATION FOR PROVIDENCE PLACE APARTMENTS; A Subsidiary of Desert Rose Foundation, Inc. Affordable Rental Project INSTRUCTIONS: Please complete all pages and areas of this application to the best of your knowledge. The information listed below is for purposes of statistical reporting ONLY to U.S. Department of Housing and Urban Development, (HUD). All application information will be kept in the strictest confidence. If you have questions or need assistance please do not hesitate to contact Angie Richards with Harmony Housing LLC at or Julie Myers with Desert Rose Foundation at Number of Persons in Household 2. Is the head of the household age 62 or older? 3. Is this a Hispanic Household? 4. Is there an individual in this household who is disabled or handicapped? 5. Ethnic Background: (please check one) White 11 Black/African-American 12 Asian 13 American Indian/Alaskan Native 14 Native Hawaiian or Pacific Islander 15 American Indian/Alaskan Native & White 16 Asian & White 17 Black/African American & White 18 American Indian/Alaskan Native & Black/African American 19 Other Multi-Racial 20 I choose not to provide ethnic background information. Page 1

4 The information collected below will be used to determine whether you qualify as a renter under the HOME Investment Partnership Program and Affordable Housing Program. This information will not be disclosed outside the Desert Rose Foundation or its affiliates (including, but not limited to Providence Place and/or Desert Rose Foundation Inc. without your consent except to your employer for verification of income and employment and to financial institutions for verification of information, and as required and permitted by law. APPLICANT CURRENT INFORMATION Applicant s Name: Phone:( ) - (Last) (First) (Middle) Address: Present Street Address (City) (State) (Zip) Driver s License No. Number of Dependents (Living in home) Self-Employed? Yes No If you are employed, complete the following information. If you are not employed, please check here: Name of Employer Address of Employer (City) (State) (Zip) Business Phone Number: ( ) Business Fax Number: ( ) Business Position/Title: No. of Yrs. on Job: Yrs. in this line of work: CO-APPLICANT CURRENT INFORMATION (The Co-Applicant is an individual whom shares the household liability such as a spouse.) Co-Applicant s Name: Phone:( ) - (Last) (First) (Middle) Address: Do you... Own? Rent? Present Street Address (City) (State) (Zip) Number of Dependents (Living in home) Self-Employed? Yes No Page 2

5 If you are employed, complete the following information. If you are not employed, please check here: Name of Employer Address of Employer (City) (State) (Zip) Business Phone Number: ( ) Business Fax Number: ( ) Business Position/Title: No. of Yrs. on Job: Yrs. in this line of work: HOUSEHOLD COMPOSITION (List the head of your household and all members who live in your home. Give the relationship of each family member to the head, their date of birth and SS#.) Member No. Head of Household Full Name Relationship DOB Social Security No LIST 2 YEARS OF LANDLORD HISTORY Current Address: Monthly Housing Cost $ Do you own or rent this property? Contact Phone If Own list mortgagee below. If Rent list name of community, landlord or manager s name. How long have you lived here? Previous Address: Monthly Housing Cost $ How long have you lived here? Page 3

6 Do you own or rent this property? If Own list mortgagee below. If Rent list name of community, landlord or manager s name. Contact Phone Previous Address: Monthly Housing Cost $ How long have you lived here? Dos you own or rent this property? Contact Phone If Own list mortgagee below. If Rent list name of community, landlord or manager s name. APARTMENT REQUIREMENTS AND OTHER MATERIAL INFORMATION Is there anyone living with you now who won t be living with you at this property? If yes, explain: Do you expect any additional people in your household with the next 12 months? If yes, explain: Are there any absent household members who under normal conditions would live with you? If yes, explain: Does an adult of the household have primary physical custody of every child listed on this application? If no, explain: Does your household have or anticipate having any pets other than those used as service animals? Describe: Height: Weight: Have you or anyone else named on this application filed for bankruptcy? Explain: Provide Dates: Have you or anyone else named on this application been convicted of a felony? Explain: Have you or anyone else named on this application been convicted of dealing or manufacturing illegal drugs? Explain: Have you or anyone else named on this application had legal action taken against you for nonpayment of a bill? Explain: Have you or anyone else named on this application broken a rental agreement or lease contract? Explain: Have you or anyone else named on this application been sued for property damages? Explain: Have you or anyone else named on this application been evicted or asked to move from a rental unit of any type, including an apartment, home, mobile home or trailer? Explain: MOTOR VEHICLES Automobile Model Year Color License Plate Number Automobile Model Year Color License Plate Number Page 4

7 Name: EMERGENCY NOTIFICATION Phone: Address: Relationship: Name: Phone: Address: Relationship How did you hear about Providence Place Apartments? When do you wish to occupy the apartment? Explain: ANNUAL INCOME estimate your household s gross annual income in the following categories: Source Applicant Co-Applicant Other working household members 18 or older Salary Overtime Pay Commissions Fees Tips Bonuses Interest and/or Dividends Net Income from Business Social Security Pensions, Retirement Funds, etc., Received Periodically Address of Agency Issuing Pension or Agency with: Address: Address: Address: TOTAL Unemployment Benefits Workers Compensation, etc. Alimony, Child Support Welfare Benefits Other (City) (State) (Zip) (City) (State) (Zip) (City) (State) Zip) TOTAL: Page 5

8 If you do not have the following accounts, please write no accounts or NA next to the account you do not have. ASSETS Type Cash Value Bank/Institution NAME Contact address & phone number and fax if possible Checking Account(s) Savings Account(s) Credit Union Account(s) Stocks Life Insurance Real Estate Cash On-Hand Estimated Value Consent Agreement I hereby declare the information provided in this rental application is true, correct and complete to the best of my knowledge. I/We understand that any willful misstatement of material fact will be grounds for disqualification. Furthermore, I hereby authorize the holder of this consent agreement to obtain investigative credit reports from prior landlords and other reasonable reports in connection with this application. This report may include information as to my character, general reputation, personal characteristics and/or mode of living and credit standing. The information received by the management relative to this application and consent agreement will be regarded as confidential in nature and protected accordingly to the extent permitted by law initial initial. Applicant Date Co-Applicant Date Dependent Date Page 6

9 Send 2 years income tax returns Sign employment verification form that follows Send a current print out of benefits Send documentation of benefits/income Send a current statement of benefits Send a current statement of benefits Send a current statement of benefits Send a current statement of benefits Send documentation of benefits/assistance Send print out from the court Send print out from the court Send payment history or agreement Page 7

10 Send 2 years income tax returns Send most recent bank statement & sign bank verification that follows Send most recent bank statement and sign bank verification that follows Send documentation of Trust Send documentation of value of property Send most recent bank statement from brokerage firm. Send most recent bank statement and sign bank verification that follows Send most recent bank statement from brokerage firm. Send statement showing current cash value. Page 8

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12 Harmony Housing, LLC PO Box 440, Edinburgh, IN Fax: On behalf of Desert Rose Foundation, Inc. Page 10

13 Harmony Housing, LLC PO Box 440, Edinburgh, IN Fax: On behalf of Desert Rose Foundation, Inc. Page 11

14 Authorization to Access Credit and Background Report PLEASE COMPLETE THIS FORM AND INCLUDE A COPY OF A DRIVERS LICENSE Applicant Name: Last Name (Print) First Name Middle Name Social Security Number Date of Birth Street Address City State Zip Code Co-Applicant Name: Last Name (Print) First Name Middle Name Social Security Number Date of Birth Street Address City State Zip Code Telephone Number: I (we) authorize Desert Rose Foundation and Providence Place Apartments, located at Prospect and Colfax Streets in Martinsville, IN, to secure credit and/or background information. The purpose of the credit information is for eligibility as a rental tenant. NOTICE TO APPLICANT: This information is used by Desert Rose Foundation, Inc. and Providence Place Apartments, or their assignees, for the purposes of Tenant Eligibility. It will not be disclosed to any outside agency except as required and permitted by law. Applicant Signature Date Co-Applicant Signature Date Page 12