STONEFIELD MANOR APARTMENTS P. O. Box 43 Greendale, WI (800)

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1 STONEFIELD MANOR APARTMENTS P. O. Box 43 Greendale, WI (800) Applicant s Name: First Middle Last Applicant s Address: Applicant s Phone Number: Applicant s Social Security No: Applicant s Birthdate: Applicant s Marital Status: Spouse/Co-Applicant s Name: First Middle Last Spouse/Co-Applicant s Birthdate: Social Security No: General Information Yes No [ ] [ ] Will there be any other people occupying the unit other than those listed above? [ ] [ ] Will a live-in attendant be a household member? [ ] [ ] Do you and/or your spouse/co-applicant have any pets? [ ] [ ] Do you have a vehicle in your name that will be parked at the project? If yes: Make Year Model License [ ] [ ] Are you and/or spouse/co-applicant receiving any rent assistance, vouchers or subsidies? Applicant s monthly amount $ Spouse/Co-Applicant $ [ ] [ ] Are you and/or spouse/co-applicant a full time student? This institution is an equal opportunity provider and employer. Page 1

2 Landlord History Please list below any former rental addrsses within the past 10 years, starting with present. Rental Address: Owner Manager: (Name) (Address) Owner Manager Phone: Dates of Residency to Rental Address: Owner Manager: (Name) (Address) Owner Manager Phone: Dates of Residency to Rental Address: Owner Manager: (Name) (Address) Owner Manager Phone: Dates of Residency to Income Information Yes No [ ] [ ] Do you and/or your spouse/co-applicant receive Social Security payments? [ ] [ ] Do you and/or your spouse/co-applicant receive SSI payments? [ ] [ ] Do you and/or your spouse/co-applicant receive SSDI payments? [ ] [ ] Are you and/or your spouse/co-applicant employed? Applicant s and Spouse/Co-Applicant s Employment Income per Year: $ Applicant s Employer: Company Phone Address Spouse/Co-Applicant s Employer: Company Phone Address This institution is an equal opportunity provider and employer. Page 2

3 Income Information continued [ ] [ ] Do you and/or your spouse/co-applicant receive unemployment? Applicant s monthly amount $ Spouse/Co-Applicant s$ [ ] [ ] Do you and/or your spouse/co-applicant receive pension payments? Institution: Phone: Address: Institution: Phone: Address: [ ] [ ] Do you and/or your spouse/co-applicant receive public assistance/afdc? Applicant s monthly amount $ Spouse/Co-Applicant s$ [ ] [ ] Do you and/or your spouse/co-applicant receive severance pay? Applicant s monthly amount $ Spouse/Co-Applicant s$ [ ] [ ] Do you and/or your spouse/co-applicant own and/or operate a business? Name/Type of Business: Yearly Income from Business: $ [ ] [ ] Do you and/or your spouse/co-applicant receive military compensation? [ ] [ ] Do you and/or your spouse/co-applicant receive income from temporarily absent family members? [ ] [ ] Do you and/or your spouse/co-applicant receive income from persons permanently confined to nursing homes, etc? [ ] [ ] Do you and/or your spouse/co-applicant receive Worker s Compensation? [ ] [ ] Do you and/or your spouse/co-applicant receive recurring gifts/contributions? [ ] [ ] Do you and/or your spouse/co-applicant receive periodic lottery payments? [ ] [ ] Do you and/or your spouse/co-applicant receive periodic Veterans Administration benefits? [ ] [ ] Do you and/or your spouse/co-applicant receive rental income? This institution is an equal opportunity provider and employer. Page 3

4 Asset Information Yes No [ ] [ ] Do you and/or your spouse/co-applicant have a checking account? [ ] [ ] Do you and/or your spouse/co-applicant have a savings account? [ ] [ ] Do you and/or your spouse/co-applicant have a CD/Money Market account? [ ] [ ] Do you and/or your spouse/co-applicant have cash on hand? [ ] [ ] Do you and/or your spouse/co-applicant own a trust account? [ ] [ ] Do you and/or your spouse/co-applicant own an annuity account? [ ] [ ] Do you and/or your spouse/co-applicant own a land contract? [ ] [ ] Do you and/or your spouse/co-applicant own stocks/bonds? [ ] [ ] Do you and/or your spouse/co-applicant own treasury bills? [ ] [ ] Do you and/or your spouse/co-applicant own an IRA/Keough fund? [ ] [ ] Do you and/or your spouse/co-applicant own personal property that is an investment? [ ] [ ] Do you and/or your spouse/co-applicant own your own home or other real estate? [ ] [ ] Do you and/or your spouse/co-applicant own a life insurance policy that has a cash value? [ ] [ ] Have you and/or your spouse/co-applicant disposed of an asset within the past two years? If you answered yes to any of the Asset Information questions above, please list the assets below. Asset Type Value Institution that holds the asset Phone *Please attach an additional page if needed. This institution is an equal opportunity provider and employer. Page 4

5 Please provide two names of people to be contacted in case of an emergency: 1st Contact: Phone: Relationship: 2nd Contact: Phone: Relationship: The information regarding race, national origin, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through its Wisconsin Housing and Economic Development Authority and the Farmers Home Administration, that the Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, marital 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. However, if you choose not to furnish it, the owner is required to note the race/national origin and sex of individual applicants on the basis of visual observation or surname. APPLICANT Race/National Origin (Not of Hispanic Origin) [ ] White [ ] Black [ ] Hispanic [ ] Asian or Pacific Islander [ ] American Native/Alaskan Native [ ] Other (Specify) STATEMENT REQUIRED BY THE PRIVACY ACT The Wisconsin Housing and Economic Development Authority (WHEDA) and the Farmers Home Administration (FmHA) are authorized by Title V of the Housing Act of 1949 as amended (42 U.S.C et. Seq.) to solicit the information requested on this form. Disclosure of the information requested is voluntary. However, failure to disclose certain items of information may result in a delay in the processing of your eligibility or rejection, except that it is unlawful for WHEDA and/or FmHA to deny eligibility because of the refusal to disclose the Social Security Account Number. I/we hereby certify and warrant that all of the information given by me/us in this application is true and correct to the best of my knowledge and belief. I/we agree to give the Owner permission to obtain third party verification for all the information submitted by me/us in this application. I/we understand that this form is only an application and that the submission of this application does not reserve, nor in any way, guarantee a unit. Applicant s Signature Date Spouse/Co-Applicant s Signature Date This institution is an equal opportunity provider and employer. Page 5

6 Addendum to Application for Occupancy Definitions based upon FmHA Instruction HB Individual with Disabilities: The term disability is considered equivalent to the term handicap. Eligibility requirements for fully accessible units are contained in 7 CFR (g)(1)(i) and (b). A person is considered to have a disability if either of the following two situations occur: As defined in section 501(b) of the Housing Act of The person is the head of household (or his or her spouse) and is determined to have an impairment which: (i) (ii) (iii) Is expected to be of long-continued and indefinite duration; Substantially impedes his or her ability to live independently; and Is of such nature that such ability could be improved by more suitable housing conditions, or if such person has a developmental disability as defined in section 102(7) of the Developmental Disability and Bill of Rights Act (42 U.S.C. 6001(7)). As defined in the Fair Housing Act; the Americans with Disabilities Act; and section 504 of the Rehabilitation Act of The person has a physical or mental impairment which substantially limits one or more of such person s major life activities; a record of such impairment; or being regarded as having such an impairment. The term does not include current, illegal use of or addiction to a controlled substance. As used in this definition, physical or mental impairment includes: (i) (ii) (iii) (iv) (v) Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive; digestive; genito-urinary, hemic and lymphatic; skin; and endocrine; Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. The term physical or mental impairment includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, Human Immunodeficiency virus (AIDS), mental retardation, emotional illness, drug addiction (other than addiction caused by current, illegal use of a controlled substance), and alcoholism; Major life activities means functions such as caring for one s self, performing major tasks, walking, seeing, hearing, speaking, breathing, learning, and working; Has a record of such an impairment means has a history of, or has been misclassified as having, a mental or physical impairment that substantially limits one or more major life activities; Is regarded as having and impairment means: (a) Has a physical or mental impairment that does not substantially limit one or more major life activities but that is treated by another person as constituting such a limitation; (b) Has a physical or mental impairment that substantially limits one or more major life active ties only as a result of the attitude of others toward such impairment; or (c) Has none of the impairments described in this definition but is treated by another person as having such an impairment. This institution is an equal opportunity provider and employer. Page 6

7 STONEFIELD MANOR APARTMENTS P.O. Box 43, Greendale, WI (414) Fax (414) RELEASE OF INFORMATION AUTHORIZATION I hereby give permission to Stonefield Manor Apartments to obtain verification at any time of any/all information regarding my income/expenses and to verify wage/unemployment information with the State Wage Information Collection Agency, by submitting a copy of this permission form to source. This includes information necessary to verify and document household composition, income, assets, public and private financial benefits, public and private non-financial benefits, credit history, medical expenses, medical benefits, educational expenses, educational benefits, medical documentation of physical/emotional/psychological disability or handicap. WARNING: Section 1001 of title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the U.S. as to any matter within its jurisdiction. Signature of Authorizing Individual Date *************************************************************************************** Information as to Race, Ethnic Group and Sex Designation is to provide on a voluntary basis for statistical purposes only. This information is requested by the apartment owner in order to assure the Federal Government, acting through its Wisconsin Housing Economic and Development Authority and Farmers Home Administration, that Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, marital 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. However, if you choose not to furnish it, the owner is required to note the race/national origin and sex of individual applicants on the basis of visual observation or surname. STATEMENT REQUIRED BY THE PRIVACY ACT The Wisconsin Housing Economic and Development Authority (WHEDA) and the Farmers Home Administration (FmHA) are authorized by Title V of the Housing Act of 1949 as amended (42 U.S.C et. Seq.) to solicit the information requested on this form. Disclosure of the information requested is voluntary. However, failure to disclose certain items of information may result in a delay in the processing of your eligibility or rejection, except that it is unlawful for WHEDA and/or FmHA to deny eligibility because of the refusal to disclose the Social Security Account Number. The principal purposes for collecting the requested information are to determine eligibility for occupancy in the WHEDA and/or FmHA financed rental project and to determine the amount of tenant contribution for rent. The information collected on this form may be released to appropriate Federal, State and Local Agencies when relevant to civil, criminal or regulatory proceedings. This institution is an equal opportunity provider and employer. Page 7

8 This institution is an equal opportunity provider and employer. Page 8

Name Sex Birthdate Social Security # Student Status F/T P/T No F/T P/T No F/T P/T No F/T P/T No. Model Make Tag # Color

Name Sex Birthdate Social Security # Student Status F/T P/T No F/T P/T No F/T P/T No F/T P/T No. Model Make Tag # Color Page 1 of 6 EQUAL HOUSING OPPORTUNITY RECERTIFICATION QUESTIONNAIRE (RD/HUD) Apartment #: Name of Resident: Social Security #: Are you or will you be a Student anytime during the next 12 months? Name of