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1 HOUSING SERVICES 157 Roosevelt Rd., Suite 200 P. O. Box 1416 St. Cloud, MN fax Before you begin, please read all instructions. 1. Do not fax this application. See #8 below. 2. Fill out the entire application. Sign in all designated places. 3. Include photocopies of these documents We do NOT accept applications without all the documents: State-issued photo ID (adults only) Social security card (all household members) State-issued birth certificate (all household members) If not yet a US citizen, photocopy of I-94, green card, or US Passport instead of birth certificate. 4. If applying for more than one property, submit a separate application for each. Make copies of blank application as needed before you begin. 5. Each adult must sign a consent form. Only one is included; make copies as needed. 6. Each adult must sign an OMB Control # Only one is included; make copies as needed. 7. Residence History: Provide previous landlord s or property management s FAX number. 8. Mail or drop off completed applications. Address is at top of this page. Only complete applications will be accepted and placed on a waiting/tracking list for the complex and unit size (meaning number of bedrooms) requested. This does not mean you have been approved. The approval process can take more than a month. You will be notified by letter regarding outcome of approval process. Rent varies in our complexes, as not all units in some buildings are subsidized. Call us for more information. Maple Apartments in Richmond: 1 or 2 bedroom Fairview Apartments in Holdingford: 1 or 2 bedroom Hollow Park Apartments in St. Joseph: 1 or 2 bedroom Rosemill Apartments in Melrose: 2 bedrooms only Housing for special needs all are smoke free. La Paz Apartments in St. Cloud: 1 or 2 bedrooms (for people with disabilities) St. Joseph Apartments in St. Joseph: 1 or 2 bedrooms (age 62+ or with a disability) Sauk Centre Apartments in Sauk Centre: 1 or 2 bedrooms (age 62+ or with a disability) We cannot predict how long it will take until you can move into an apartment. Please wait to be notified by letter. Do not call for a time frame, but do notify us immediately if your mailing address changes. 1

2 Catholic Charities Housing Services 157 Roosevelt Rd; Suite 200 PO Box 1416 St. Cloud MN Phone Apartment complex: Size of unit wanted: Applicant Name: Address: Address: Applicant s Employer Name: Employer Address: Phone: Employer Phone: Co-applicant Name: Address: Address: Co-Applicant s Employer Name: Employer Address: Phone: Employer Phone: Proposed Household Composition List the head of household and anyone else who will be living in the apartment. Full Name Relationship Birth Date Gender Age SSN/ Student? Self/HoH Is an addition expected to your family? Yes No If yes, what date? Do you have children? Yes No IF YES, do you have full custody? Yes No If no, please explain custody arrangements: 2

3 EMERGENCY CONTACT INFORMATION Emergency contact name: Address: Relationship: Phone: City/State/Zip Code List addresses from other states except Minnesota in which all household members have lived in: Applicant Co-Applicant Are you in need of a special handicapped accessible apartment? Is your current rent based on your income? Have you ever been evicted from any type of housing? Are you being evicted from your current residence? If yes, please explain: YES NO YES NO HOUSEHOLD INCOME INFORMATION All information will be verified by a third party. These questions apply to all adults AND minor children. Are you currently employed? (This includes any money received from wages, salaries, tips, bonuses, commissions or money from self-employment.) Applicant: Do you receive any income from Social Security or SSI? (Including minor children.) Applicant: Do you receive any Unemployment or Severance benefits? Applicant: Do you receive MFIP, MSA, GA or Food Stamps? (Please indicate where money is from.) Applicant: Do you receive VA benefits or pay from the armed forces? Applicant: Do you receive any Disability or Workman s Compensation payments? Applicant: 3

4 Do you receive any money from a pension or other retirement benefits? (Pera, railroad, etc.) Applicant: Do you receive any money from child support or spousal maintenance? Applicant: Do you work for someone who pays you cash? Applicant: Do you receive any education grants, scholarships or VA student benefits? Applicant: Do you receive any other sources of income? This includes: Tribal Benefits, inheritances, insurance settlements, lottery winnings or other regular cash contributions from other people not living with you? If so, please list the source of this income: Applicant: Do you pay for childcare which enables you or another family member to go to work or school? Yes No List anyone who is 18 or over and enrolled in college: Name: Date enrolled: Name and address of school: Name: Date enrolled: Name and address of school: Asset Information Do you have any of the following? Include information for ALL household members. For each yes answer, provide a balance. All information will be verified by a third party. Applicant Co-applicant Enter balance if yes Bank name Enter balance if yes Bank name EBT/Debit Card Checking account Savings account CD account Stocks, bonds, securities Trusts/IRA/KEOGH 4

5 Do you hold a contract for deed? Do you own a home, farm, or other real estate? Applicant Co-Applicant YES NO YES NO Have you disposed of any real property or assets in the past 2 years? If yes, please explain: Do you receive rental income from a home, farm, or property? Do you have any other assets not listed above? If yes, please explain: Do you have any assets that are held jointly with another person? OTHER INFORMATION: Are you in this country legally? Applicant Co-Applicant YES NO YES NO Have you ever been convicted of the illegal manufacture or distribution of a controlled substance or convicted for the illegal use of a controlled substance? Have you or members of your household ever been convicted of a felony? Are you or any members of your household subject to lifetime State Sex Offender Registry? If yes which household member and what state(s) registered in? By Social Security definition, is either the head or co-head of household considered disabled? Yes No Elderly (62+) or disabled (head or co-head) families only: Do you pay for Medicare? Yes No Do you pay a medical insurance premium? Yes No If yes, who is it through?,what is the monthly amount? Do you receive Medical Assistance through county Human Services? Yes No Do you have outstanding medical bills that you are making monthly payments on? Yes No Do you expect medical expenses during the next 12 months? Yes No If yes, how much? 5

6 Applicant s Residence History What is your current address: Do you currently: (Address) If you rent: Move in date: Fax # of Landlord/Leasing Co: What was your previous Address: Did you: If you rent: (Address) Move in date: Move out date: What was your previous Address: Did you: If you rent: (Address ) Move in date: Move out date: Co-Applicant s Residence History What is your current address: Do you currently: (Address ) If you rent: Move in date: What was your previous Address: Did you: If you rent: (Address ) Move in date: Move out date: What was your previous Address: Did you: If you rent: (Address ) Move in date: Move out date: 6

7 Applicant Certification: I certify that if selected to move into this development, the unit I occupy will be my only residence. I understand that the above information is being collected to determine my eligibility. I authorize the Owner and their representatives to verify all information provided on this application and to contact previous or current landlords or other sources for credit and verification information which may be released to appropriate Federal, State, or local agencies. I certify that the statements made in this application are true and complete to the best of my knowledge and belief. I understand that false statements or information are punishable under Federal law and will lead to cancellation of this Application or termination of tenancy after occupancy. Applicant Co-Applicant Male Gender Select One Male Gender Select One Female Female Hispanic or Latino Ethnicity Select One Hispanic or Latino Ethnicity Select One Not-Hispanic or Latino Not-Hispanic or Latino Race American Indian or Alaska Native Select All That Apply Race American Indian or Alaska Native Select All That Apply Asian Asian Black or African American Black or African American Native Hawaiian or Other Pacific Islander Native Hawaiian or Other Pacific Islander White White Other: Other: Applicant Signature: Date: Co-Applicant Signature: Date: Demographic Information: The information regarding race, national origin, and gender designation solicited on this application is requested in order to assure the Federal government, acting through the Department of HUD and/or Rural Development, that federal laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial status, age, and handicap are complied with. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. Return completed application to: Catholic Charities Housing Services 157 Roosevelt Rd PO Box 1416 St. Cloud MN Phone Equal Housing Opportunity and Service Provider For Office Use Only Received App Fee Paid $ 7

8 HOUSING SERVICES 157 Roosevelt Rd., Suite 200 P. O. Box 1416 St. Cloud, MN fax Consent Form Must be completed by all adult household members I authorize Rental Research Services, Inc., 7525 Mitchell Road, Suite 301, Eden Prairie, Minnesota, to prepare a Consumer Report and/or an Investigative Consumer Report for Catholic Charities for the purpose of resident screening. This report may include searches of public and/or private data sources, criminal history, housing history, employment history and/or any other information deemed necessary, including a Consumer Credit report from Equifax, TransUnion and/or Experian. I have personally filled in and/or reviewed all of the information provided on this rental application and hereby certify its accuracy and completeness. I understand that failure to disclose information or any attempt to misrepresent, mislead or otherwise submit fraudulent information will be considered grounds for immediate denial of this rental application. First Name Middle Name Last Name Alias Names-Please list any other name you have ever used. First, Middle, Last / / - - Date of Birth (Mo/Dy/Yr) Social Security Number Present Address City/State/Zip Signature Date Catholic Charities Housing Services is a fair housing provider and will grant equal opportunity to all persons under the law. 8

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