SUBJECT: APPLICATION FOR RESIDENCY

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Peregrine Domenic Carr
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1 SUBJECT: APPLICATION FOR RESIDENCY COMMUNITY: PROGRAM: ORIGINAL DATE: TIME: UPDATE: TIME: HOW DID YOU HEAR ABOUT US? APPLICANT NAME: APARTMENT SIZE: CURRENT ADDRESS: CITY STATE, ZIP: HOME PHONE #: WORK PHONE #: PREVIOUS ADDRESS: CITY, STATE, ZIP: I. HOUSEHOLD COMPOSITION AND CHARACTERISTICS 1. List the Head of Household (HOH) and all other members who will be living in the apartment. Indicate the relationship of each family member to the head of household. MEMBER S FULL NAME STATUS* DRIVER S LICENSE # RELATIONSHIP DATE OF BIRTH AGE SEX SOCIAL SECURITY # * Single (s) Married (m) Widowed (w) Separated (sp) Divorced (d) MEMBERS 17 AND UNDER FULL NAME RELATIONSHIP TO HOH DATE OF BIRTH AGE SEX SOCIAL SECURITY # SCHOOL NAME ABSENT PARENT S NAME & ADDRESS If separated or divorced, list name and address of spouse/ex-spouse as follows: S.S. #: (If known): S.S. #: (If known): 2. Are you or any household member currently a student at an institution of higher education? Yes No 3. Does anyone live with you now who is not listed above? Yes No 4. Does anyone plan to live with you in the future who is not listed above? Yes No If yes, explain: 5. Have you, or any member of your household ever used different names from the above name shown? Yes No If yes, please list names used and dates when such names were used: FG817 Revised 4/07 FOURMIDABLE does not discriminate on the basis of disability or any other protected category in admission or access to any community and a Coordinator has been designated to monitor Section 504 compliance. Inquiries can be made to (248) or TTY (800) Page 1 of 7

2 6. Will any of the above household members live anywhere except the apartment? Yes No Are there any other persons who will live in the apartment on less than a full time basis? Yes No If either question is answered yes, please explain: 7. It MAY be a requirement of eligibility into this housing program that you, your spouse or head of household fall into one of the following categories. Please check all items which may apply: Over age 62 Disabled. 8. If any of the above categories were checked, is a reasonable modification required and, if so, what kind? Yes No Apartment with Accessibility Features Sight Impaired Apartment Hearing Impaired Apartment Other 9. Are you or any household member now living or have you lived in a federally subsidized housing apartment? Yes No If yes: Name of Community: Move-In : Address: Name of Manager: II. INCOME AND ASSET INFORMATION Move-Out : City/State/Zip: Phone No._ Please answer each of the following questions. For each yes, provide details in the charts below. Do you, or any member of your household: Yes No 1. Work full-time, part-time or seasonally? 2. Expect to work for any period during the next year? 3. Work for someone who pays cash? 4. Expect a leave of absence from work due to layoff, medical, maternity or military leave? 5. Now receive or expect to receive unemployment benefits? 6. Now receive or expect to receive child support? 7. Entitled to child support that he/she is not now receiving? 8. Now receive or expect to receive alimony? 9. Have an entitlement to receive alimony that is not currently being received? 10. Now receive or expect to receive public assistance (excluding Food Stamps)? 11. Now receive or expect to receive Social Security benefits? 12. Now receive or expect to receive income from a pension or annuity? 13. Now receive or expect to receive regular contributions from organizations or from individuals not living in the apartment? 14. Receive income from assets including interest on checking or savings accounts, interest and dividends from certificates of deposit, stocks or bonds or income from rental property? 15. Own real estate? 16. Have you sold or given away real property or other assets (including cash) in the past two years? 17. Does any member of your household receive money from school-aid, scholarship or educational grants? 18. TOTAL HOUSEHOLD INCOME: List all money earned or received by everyone living in your household. This includes money from wages, self-employment, child support, contributions, Social Security, disability payments (SSI), Workers Compensation, retirement benefits, AFDC, Veterans benefits, rental property income, stock dividends, income from bank accounts, alimony and all other sources. HOUSEHOLD EMPLOYER TOTAL AFDC CHILD SOCIAL SECURITY UNEMPLOYMENT ALL MEMBER WEEKLY MONTHLY SUPPORT BENEFITS BENEFITS OTHER WAGES MONTHLY MONTHLY BI-WEEKLY Page 2 of 7

3 III. ASSETS 1. List all checking and savings accounts (including IRAs, Keogh accounts and Certificates of Deposits) of all household members. MEMBER NO. BANK NAME TYPE OF ACCOUNT ACCOUNT NO. BALANCE 2. List the value of all stocks, bonds, trusts, real estate and other assets owned by any household member: 3. List the value of any assets disposed of for less than their fair market value during the past two years. IV. EXPENSES YES NO Do you have expenses for child care of a child aged 12 or younger? If yes, provide the name, address and telephone number of the care provider. Name: Address: Phone No.: Phone No.: What is the weekly cost to you of the child care? Do you pay a care attendant or for any equipment for any disabled household member(s) necessary to permit that person or someone else in the household to work? If you pay a care attendant, provide their name, address and telephone number. Name: Address: Phone No.: Phone No.: What is the cost to you for the care attendant and/or equipment? ELDERLY FAMILIES ONLY Do you have Medicare? If yes, what is your month premium? Do you have any other kind of medical insurance? If yes, answer the following questions: Name: Address: Policy No: Premium Amount: Policy No: Premium Amount: Do you have outstanding medical bills? If yes, explain. What medical expenses do you expect to incur in the next twelve months? If you use the same pharmacy regularly, please provide name, address and phone number: Name: Address: Phone No. Page 3 of 7

4 V. REFERENCES Please provide the name, address and phone number of one personal reference that is not related to a household member. Phone No.: Please provide the name, address and phone number of closest relative. Phone No.: Please provide the name, address and phone number of your Primary Physician and Social Worker (if applicable). Phone No.: Phone No.: VI. RENTAL HISTORY Present Landlord: Address City, State, Zip: Phone No: Fax No. : Your Address: How long have you lived there? Reason for leaving? Former Landlord: Address City, State, Zip: Phone No: Fax No. : Your Address: How long did you live there? Reason for leaving? Former Landlord: Address City, State, Zip: Phone No: Fax No. : Your Address: How long did you live there? Reason for leaving? Have you, or any member of your household ever been evicted or otherwise removed from rental housing? Yes No If yes, please list names, addresses and dates: Has any place where you, or any member of your household were living, been destroyed or damaged by fire? Yes No If yes, please provide details: Page 4 of 7

5 VII. EMPLOYMENT HISTORY Name and address of Head of Household s present Employer: Phone No: I.D. #: of Hire: Name and address of Spouse s/co-head of Household s Employer: Phone No: I.D. #: of Hire: Name and address of Head of Household s previous Employer: Phone No: I.D. #: Name and address of Spouse s/co-head of Household s Previous Employer: Phone No: I.D. #: Length of employment to Length of employment to VIII. EMERGENCY CONTACTS Relationship: Phone No: Relationship: Phone No: IX. VEHICLE REGISTRATION Do you or any household members have a vehicle? Yes No If yes, how many? X. OTHER Do you or any other member of your household currently use any illegal drug or other illegal controlled substance? Yes No If yes, which household member(s)? Is household member seeking treatment? Yes No If yes, Name of Facility: Contact: Address: Have you or any other person named on the application as intended to reside in the apartment ever been evicted from a federally subsidized housing apartment for drug-related criminal activity? Yes No Have you or any member of your household ever been arrested for, charged with, or convicted of a felony? Yes No If yes, which household member(s)? Page 5 of 7

6 Where did the incident take place? Explain the circumstances, outcome and present status: Have you or any member of your household ever been arrested for, charged with, or convicted of any drug-related criminal activity, such as use, possession, distribution, trafficking or manufacturing of an illegal drug, or any other criminal activity that poses a threat to the health, safety and welfare of others? Yes No If yes, which household member(s)? Where did incident take place? Explain the circumstances, outcome and present status: Upon acceptance of your application, we will make a preliminary determination of eligibility. If your household appears to be eligible for housing, your application will be placed on the Waiting List, however, this does not guarantee that your household will be offered an apartment. If later processing establishes that your household is not eligible or not qualified for housing, your application will be rejected. We will process your application according to standard procedures which are summarized in the Resident Selection Criteria posted in the Management Office. It is your responsibility to contact us whenever your address, telephone number, income situation, family composition or federal preference changes. APPLICANT CERTIFICATION I/We certify that if selected to receive assistance, the unit I/we occupy will be my/our only residence. I/We understand that the above information is being collected to determine my/our eligibility. I/We authorize the owner/manager to verify all information provided on this application which may be required to complete the application. I/We certify that the statements made in this application are true and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal Law. Provision of false information on this housing application or any other forms completed or refusal to provide management with complete and accurate information will result in automatic rejection of the application for housing. Prior to acceptance, a credit report, current and previous landlord verification, a home visit and background check will be completed. I/We understand that I/we will be removed from the waiting list if I/we fail to notify the Management Office if my/our address, telephone number, income situation, family composition or federal preference changes. Signature of Head of Household Signature of Spouse/Co-Head of Household Family Members 18 years or over Signature of Management Page 6 of 7

7 APPLICATION ATTACHMENTS: 1. Fraud, Is It Worth It? 9. Credit Report 2. HUD Fact Sheet How Your Rent Is Determined 10. Home Visit 3. HUD Fact Sheet (Government Assisted Only) 11. Police/Court Record Info. Release 4. HUD 9887 (Government Assisted Only) 12. Personal Certification (FG816) (if applicable) 5. HUD 9887A (FG893) (Government Assisted Only) 13. Preference Verification (if applicable) 6. Copy of Birth Certificate & Social Security Card 14. Family Summary Sheet (FG8142) 7. Landlord Verification (FG838) 15. Applicant Declaration Format (FG8139) 8. HUD 9886 (Public Housing Only) 16. Race & Ethnic Data Reporting Form STATUS OF APPLICATION: Application Received: Verifications Mailed: Application Denied: Reason: Notice of Eligibility Letter Mailed: s Waiting List Confirmation Mailed: s Application Updated: s Apartment Offered: Placed Inactive : Move-In : Other Action: Page 7 of 7

COMMUNITY: PROGRAM: ORIGINAL DATE: TIME: UPDATE: TIME:

SUBJECT: APPLICANT FOR RESIDENCY TAX CREDIT COMMUNITIES COMMUNITY: PROGRAM: ORIGINAL DATE: TIME: UPDATE: TIME: HOW DID YOU HEAR ABOUT US? APARTMENT SIZE: APPLICANT NAME (FIRST, MIDDLE, LAST): CURRENT ADDRESS: