Application Instructions Dear Applicant, Welcome to The Retreat Assisted Living. As we begin the process of qualifying you to become part of our family we encourage you to follow the instructions in completing the attached application. It is necessary to complete every page and box of the application. If a page or a box does not apply write NA or NONE. Leave no space blank. Use of white out is prohibited. Provide us with as much information as you can, e.g. account numbers, name and address of banks, pensions, and life insurance as this will expedite the qualification process. Please include copies of Power of Attorney or Conservator of Estate certificates as well as a copy of your Social Security card and/or birth certificate. We look forward to working with you. If you need clarification of any questions, do not hesitate to contact us. Please do not forget to sign and date the application. Thank you very much. Maria Michele Tax Credit Manager Phone (860) 560-5857 Fax (860) 560-5850 The Retreat Assisted Living, 90 Retreat Avenue, Hartford, CT 06106 The Fair Housing Act prohibits discrimination in the sale, rental or financing of housing on the basis of race, color, religion, sex handicap, familial status, or national origin. Complaints of discrimination may be forwarded to the Fair Housing Administrator, U.S. Department of Housing and Urban Development, Washington, D.C. 20410, Phone 1-800-669*-9777. Connecticut law also prohibits discrimination in all of the above categories: lawful source or income, marital status, sexual orientation, use of a guide dog, and age (except when program regulations restrict the housing to an age specific category) Complaints of discrimination may be forwarded to the Commission on Human Rights & Opportunities at 1-860-541-3400.
APPLICATION FOR HOUSING Low-Income Housing Tax Credit Property / Assisted Living Please Print Clearly This is an application for housing at: Development: The Retreat Assisted Living 90 Retreat Avenue Hartford, CT 06106 Please complete this application and return to: Name: The Retreat Assisted Living 90 Retreat Avenue, Hartford, CT 06106 Att. Maria Michele Applications are placed in order of date and time received. An applicant may be interviewed only after the receipt of this tenant application. A. GENERAL INFORMATION Applicant Name(s): Street Apt.# City State Zip Code Daytime Phone: No. of BRs in current unit: Evening Phone: Do you ٱ RENT or ٱ OWN (check one) Amount of current monthly rental or mortgage payment: $ If owned, do you receive monthly rental income from property? ٱ Yes ٱ No (check one) Check utilities paid by you: ٱ Heat ٱ Electricity ٱ Gas ٱ Other (specify) Approximate monthly cost of utilities paid by you (excluding phone and cable TV): $ Bedroom size requested: ٱ Studio ٱ One BR ٱ Two BR ٱ Three BR ٱ Handicap BR Application for Housing Page 1 of 8
B. HOUSEHOLD COMPOSITION List ALL persons who will live in the apartment. List the head of household first. Head Name (Last, First, M.I.) Relationship to head H head of household S - spouse A - adult co-tenant C - child F foster child(ren)/adult(s) O - other family member L - live-in caretaker N none of the above Marital Status M--married D--divorced S--single L--legal separation E--estranged Birth (mm/dd/yyyy) Age SS# or Alien Reg. # Student Y/N Sex M/F Race 1--white 2--black 3--hispanic 4--other Co-T 3. 4. 5. 6. 7. 8. Do you anticipate any additions to the household in the next twelve months? ٱ Yes If yes, explain: ٱ No Will any of the persons in the household be or have been full-time students during five calendar months of this year or plan to be in the next calendar year at an educational institution (other than a correspondence school) with regular faculty and students? ٱ Yes ٱ No IF YES, ANSWER THE FOLLOWING QUESTIONS: Are any full-time student(s) married and filing a joint tax return? ٱ Yes ٱ No Are any student(s) enrolled in a job-training program receiving assistance under the Job Training Partnership Act? ٱ Yes ٱ No Are any full-time student(s) a TANF or a title IV recipient? ٱ Yes ٱ No Are any full-time student(s) a single parent living with his/her minor child who is not a Dependant on another s tax return? ٱ Yes ٱ No Application for Housing Page 2 of 8
C. INCOME List ALL sources of income as requested below. If a section doesn t apply, cross out or write NA. Gross Monthly Household Member Name Source of Income Amount Social Security $ Social Security $ Social Security $ Social Security $ SSI Benefits $ SSI Benefits $ SSI Benefits $ SSI Benefits $ Pension (list source) $ Pension (list source) $ Pension (list source) $ Veteran s Benefits (list claim #) $ Veteran s Benefits (list claim #) $ $ Unemployment Compensation $ Unemployment Compensation $ Title IV/TANF $ Title IV/TANF $ Title IV/TANF $ Full-Time Student Income (18 & Over Only) $ Full-Time Student Income (18 & Over Only) $ Interest Income (source) $ Interest Income (source) $ Interest Income (source) $ Interest Income (source) $ Application for Housing Page 3 of 8
Household Member Name Source of Income Employment amount $ Employer: Position Held How long employed: Employment amount $ Employer: Position Held Monthly Amount How long employed: Employment amount $ Employer: Position Held How long employed: Employment amount $ Employer: Position Held How long employed: Alimony Are you entitled to receive alimony? ٱ Yes ٱ No If yes, list the amount you are entitled to receive. $ Do you receive alimony? ٱ Yes ٱ No If yes, list amount you receive. $ Child Support Are you entitled to receive child support? ٱ Yes ٱ No If yes, list the amount you are entitled to receive. $ Do you receive child support? ٱ Yes ٱ No If yes, list the amount you receive. $ Other Income $ Other Income $ Other Income $ TOTAL GROSS ANNUAL INCOME (Based on the monthly amounts listed above x 12) $ TOTAL GROSS ANNUAL INCOME FROM PREVIOUS YEAR $ Do you anticipate any changes in this income in the next 12 months? ٱ Yes ٱ No If yes, explain: Application for Housing Page 4 of 8
D. ASSETS If your assets are too numerous to list here, please request an additional form. If a section doesn t apply, cross out or write NA. Checking Accounts Savings Accounts Trust Account Certificates Credit Union Savings Bonds # Maturity Value $ # Maturity Value $ # Maturity Value $ Life Insurance Policy # Cash Value $ Life Insurance Policy # Cash Value $ Mutual Funds Name: #Shares: Interest or Dividend $ Value $ Name: #Shares: Interest or Dividend $ Value $ Name: #Shares: Interest or Dividend $ Value $ Stocks Name: #Shares: Dividend Paid $ Value $ Name: #Shares: Dividend Paid $ Value $ Name: #Shares: Dividend Paid $ Value $ Bonds Name: #Shares: Interest or Dividend $ Value $ Name: #Shares: Interest or Dividend $ Value $ Investment Property Appraised Value $ Application for Housing Page 5 of 8
Real Estate Property: Do you own any property? ٱ Yes ٱ No If yes, type of property Location of property Appraised Market Value $ Mortgage or outstanding loans balance due $ Amount of annual insurance premium $ Amount of most recent tax bill $ Have you sold/disposed of any property in the last 2 years? ٱ Yes ٱ No If yes, type of property Market value when sold/disposed $ Amount sold/disposed for $ of transaction Have you disposed of any other assets in the last 2 years (Example: Given away money to relatives, set up Irrevocable Trust Accounts)? ٱ Yes ٱ No If yes, describe the asset: of disposition Amount disposed $ Do you have any other assets not listed above (excluding personal property)? ٱ Yes ٱ No If yes, please list E. ADDITIONAL INFORMATION Are you or any member of your family currently using an illegal substance? ٱ Yes ٱ No Have you or any member of your family ever been convicted of a felony? ٱ Yes ٱ No If yes, describe: Have you or any member of your family ever been evicted from any housing? ٱ Yes ٱ No If yes, describe: Have you ever filed for bankruptcy? ٱ Yes ٱ No If yes, describe: Application for Housing Page 6 of 8
Will you take an apartment when one is available? ٱ Yes ٱ No Briefly describe your reasons for applying: F. REFERENCE INFORMATION Name: Current Landlord Home Phone: Bus. Phone: How Long? Name: Prior Landlord Home Phone: Bus. Phone: How Long? Credit Reference #1: Account #: Phone #: Credit Reference #2: Account #: Phone #: Credit Reference #3: Account #: Phone #: Personal Reference #1: Relationship: Phone #: Personal Reference #2: Relationship: Phone #: Personal Reference #3: Relationship: Phone #: Application for Housing Page 7 of 8
In case of emergency notify: Relationship: Phone #: G. VEHICLE AND PET INFORMATION (if applicable) List any cars, trucks, or other vehicles owned. Parking will be provided for one vehicle. Arrangements with Management will be necessary for more than one vehicle. Type of Vehicle: License Plate #: Year/Make: Color: Type of Vehicle: License Plate #: Year/Make: Color: Do you own any pets? Yes No If yes, describe: CERTIFICATION I/We hereby certify that I/We Do/Will Not maintain a separate subsidized rental unit in another location. I/We further certify that this will be my/our permanent residence. I/We understand I/We must pay a security deposit for this apartment prior to occupancy. I/We understand that my eligibility for housing will be based on applicable income limits and by management s selection criteria. I/We certify that all information in this application is true to the best of my/our knowledge and I/we understand that false statements or information are punishable by law and will lead to cancellation of this application or termination of tenancy after occupancy. All adult applicants, 18 or older, must sign application. SIGNATURE (S): (Signature of Tenant) (Signature of Co-Tenant) (Signature of Co-Tenant) (Signature of Co-Tenant) Application for Housing Page 8 of 8
Dear applicant, Verification Forms Instructions Please sign your name and include the date in the appropriate Release box. Do not complete anything under the Release box on these verification forms, as this is the third party space to complete. It is very important that you supply us with addresses and phone numbers (except for the Social Security office) of pensions, banks, life insurance etc. on these verification forms. Please note: Social Security office does not recognize Power of Attorney. Thank you Maria Michele
ASSET INCOME VERIFICATION Send To: Applicant/Tenant/ Dependent Minor: Unit #: Soc. Security #: Development Name: RELEASE I,, hereby consent to the release of all information requested on this form. Applicant s / Tenant s Signature 1. Checking Accounts: Account # Current Balance Average 6 Month Balance # $ $ % # $ $ % # $ $ % Interest Rate (N/A if no interest) 2. Savings Accounts: Account # Current Balance Interest Rate (N/A if no interest) 3. Certificates of Deposit: Account # Amount Interest Rate of Maturity Early Withdrawal Penalty Asset Income Verification CONNECTICUT HOUSING FINANCE AUTHORITY JUNE 2013 Page 2 of 3
4. Bonds/Other Securities: If applicable, describe asset amount and income projected for the next 12 months. Account # Amount Interest Rate of Maturity Early Withdrawal Penalty 5. Keogh; 401K; IRA: Account # Type of Account Current Cash Value Interest Rate Early Withdrawal Penalty $ % $ % $ % $ % COMMENTS: AUTHORIZED SIGNATURE Print Name: Signature: Telephone: Title: : RETURN TO: - - OFFICE USE ONLY - - Sent: Received: Comments: Asset Income Verification CONNECTICUT HOUSING FINANCE AUTHORITY JUNE 2013 Page 3 of 3
PENSION VERIFICATION Send To: Applicant/Tenant: Unit #: Soc. Security #: Development Name: RELEASE I,, hereby consent to the release of all information requested on this form. Applicant s / Tenant s Signature Monthly Gross Pension Amount Before Deductions: $ Is this Pension a fixed monthly total or is it subject to change? If subject to change, please list circumstances: ٱ Fixed ٱ Subject to Change AUTHORIZED SIGNATURE Print Name: Signature: Telephone: Title: : RETURN TO: - - OFFICE USE ONLY - - Sent: Received: Comments: Pension Verification Page 1 of 1
LIFE INSURANCE VERIFICATION (Whole Life or Universal Life Policies Only) Send To: Applicant/Tenant: Unit #: Soc. Security #: Development Name: RELEASE I,, hereby consent to the release of all information requested on this form. Applicant s / Tenant s Signature Pursuant to federal regulations, we are required to verify all income/assets of persons seeking or continuing residency in an apartment governed by the LIHTC/Assisted Living Program under Section 42 of the Internal Revenue Code. This information will only be used for the determination of residency eligibility under this Program. Please complete the following information and return as soon as possible via FAX or mail in the enclosed self-addressed envelope provided. Your prompt attention and return of this information will be appreciated. (Comments: Should Net Asset Value prove less than $0, consider asset to have $0 value.) Dividend Interest Rate Policy Account # Cash Surrender Value ( N/A if no interest) Balance of any outstanding loans against policy/policies: $ Penalty fee or % of Cash Surrender Value charged to cash in each policy: $ % NET ASSET VALUE = Total Cash Values (less) Loan Balances (less) Penalties = $ AUTHORIZED SIGNATURE Print Name: Signature: Telephone: Title: : RETURN TO: - - OFFICE USE ONLY - - Sent: Received: Comments: Life Insurance Verification Page 1 of 1
VETERAN S PENSIONS / BENEFITS VERIFICATION Send To: Applicant/Tenant: Unit #: Soc. Security #: VA #: Development Name: RELEASE I,, hereby consent to the release of all information requested on this form. Applicant s / Tenant s Signature Monthly Gross Veteran s Benefit: $ Do you anticipate a change in the gross monthly amount of the income during the next 12 months? ٱ Yes ٱ No If Yes, date of change: Amount of increase: $ Amount of decrease: $ Comments: AUTHORIZED SIGNATURE Print Name: Signature: Telephone: Title: : RETURN TO: - - OFFICE USE ONLY - - Sent: Received: Comments: Veteran s Pensions / Benefits Verification Page 1 of 1
ANNUITY VERIFICATION Send To: Applicant/Tenant: Unit #: Soc. Security #: Development Name: RELEASE I,, hereby consent to the release of all information requested on this form. Applicant s / Tenant s Signature Type of Annuity held: FIXED VARIABLE HYBRID IMMEDIATE LIFE OTHER Annuity was issued: Is this the original owner of the Annuity? YES NO Total Amount paid into the Annuity by the individual: $ Current Value $ Cash Value $ Annual earnings or interest rate $ % Does the holder have access to the funds? YES NO What is the surrender fee or withdrawal penalty to covert this asset to cash? $ Are regular withdrawals/payments being made? YES NO Amount: $ Frequency: What is the total amount withdrawn since the contract issue date? $ AUTHORIZED SIGNATURE Print Name: Signature: Telephone: Title: : RETURN TO: - - OFFICE USE ONLY - - Sent: Received: Comments: Annuity Verification CONNECTICUT HOUSING FINANCE AUTHORITY NOV. 2005 Page 1 of 1
THIS FORM MAY BE PHOTOCOPIED AUTHORIZATION TO RELEASE INFORMATION RE: Applicant/Tenant: Unit # Property Name: The Retreat Assisted Living 90 Retreat Avenue Hartford, CT 06106 As managing agents for this Low Income Housing Tax Credit Project, Federal Regulations require we verify the program eligibility of all members of families applying for admission and verify this information periodically for residents. To comply with this requirement, your cooperation is needed in supplying the information requested. This information will be held in strict confidence for use in determining eligibility status and income for this family. A signed authorization for your release appears below. Please complete the attached form and return it to the address below at your earliest convenience. Thank you for your assistance. Authorized Signature Maria Michele Print Name Tax Credit Manager Title Release by Applicant/Tenant I hereby authorize you to furnish all requested information. Signature Verification form is attached. Authorization to Release Information SPECTRUM ENTERPRISES 2004 Page 1 of 1
STS Supplemental Data Information Please answer the following questions to the best of your ability. Please circle your answer Education None Grades 0-8 Grades 9-12/non-graduate High School or GED 12+ years of education 2 or 4 years of college Vocational School Disability (defined by a certification by a physician) Yes No Military Experience Yes No Food Stamps Yes No How much per month? Answer the following questions below: Are you willing to be interviewed to share your life story? Yes No How did you hear about CRT/The Retreat? What made you choose us?