RELEASE OF INFORMATION The attached document is a state required form. FROM: WALNUT GROVE APARTMENTS 3100 S. WALNUT STREET PIKE BLOOMINGTON, IN 47401 Phone: (812) 339-3980 Fax: (812) 339-1037 The undersigned individual(s) has applied for residency at our apartment community. The property is operated under the RHTC program within Section 42 of the Internal Revenue Code, which requires that we obtain written confirmation of the income of all applicants and other household members. In order to comply with Federal regulations requesting verification of all income, assets and allowances for residents of RHTC housing, please complete the following form in full and return it to the sender at your earliest convenience. The undersigned understands that, depending on program policies and requirements, previous or current information regarding me/us may be needed. Verifications and inquiries that may be requested included but are not limited to: CREDIT AND CRIMINAL ACTIVITY IDENTITY AND MARITAL STATUS RESIDENCES AND RENTAL ACTIVITY EMPLOYMENT, INCOME AND ASSETS MEDICAL ALLOWANCES STUDENT STATUS The groups or individuals that may be asked to release/verify the above information (depending on program requirements) include but are not limited to: COURTS AND POST OFFICES PAST AND PRESENT EMPLOYERS UTILITY COMPANIES LAW ENFORCEMENT AGENCIES STATE UNEMPLOYMENT AGENCIES CREDIT PROVIDERS AND BUREAUS MEDICAL PROVIDERS VETERANS ADMINISTRATION WELFARE AGENCIES RETIREMENT SYSTEMS SOCIAL SECURITY ADMINISTRATION INTERNAL REVENUE SERVICE BANKS AND OTHER FINANCIAL INSTITUTIONS PREVIOUS LANDLORDS (INCLUDING PHA S) I/we agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file in the management office. I/we understand that I/we have a right to review my/our file and correct any information that can be proven as incorrect. The undersigned hereby authorizes the release of any information requested in order to determine my/our eligibility for the RHTC program. TO BE COMPLETED BY APPLICANT: Applicant/Resident Name (Printed): Social Security Number: Date: Authorizing Signature: Co-Applicant/Co-Resident Name (Printed): Social Security Number: Date: Authorizing Signature:
WALNUT GROVE APARTMENTS RENTAL APPLICATION OFFICE USE ONLY APARTMENT NUMBER: RENT AMOUNT: QUALIFY AT: NEW APPLICATION HOUSEHOLD ADDITION TRANSFER Applicant Name: Phone #: Aliases or Maiden Names: Present Address: Street City State Zip Marital Status (circle one): Divorced Married Separated Single Driver s License or State ID #: State: Full Name HOUSEHOLD COMPOSITION List ALL persons that will be occupying the unit at least 50% of the year. Relationship to Head of Date of Birth Social Security Employed? Household Number or Full Time Student? or RESIDENTIAL HISTORY Past Two Years (attach additional sheets, if necessary) Present Landlord Name: Phone: Landlord Address: Dates of Occupancy: to Related? How? Present Landlord Name: Phone: Landlord Address: Dates of Occupancy: to Related? How? Present Landlord Name: Phone: Landlord Address: Dates of Occupancy: to Related? How?
WALNUT GROVE APARTMENTS RENTAL APPLICATION YES NO 1. Have you or any household member ever been convicted of a felony? Date of Conviction: 2. Have you ever been evicted? Reason: Date of Eviction: 3. Have you or any household member been arrested / convicted of a drug related crime? Date of Arrest / Conviction: 4. Does anyone not listed in the household composition on page one plan to live with you in the next 12 months? If yes, explain: 5. Will the Household be receiving Section 8 housing assistance? (If yes list agency name, contact person and phone number) 6. Are there any absent household members who under normal conditions would live with you? 7. Does an adult of this household have primary physical custody of every child listed on this application? 8. Does your household have or anticipate having any pets other than those used as a service animal? 9. Does anyone in your household have special needs? If yes, explain? CREDIT REFERENCES Loans: Credit Cards: Other: Please tell us how you heard about Walnut Grove Apartments. ForRent.com Craigslist Phone Book Drive-by Word of Mouth Flyer Location of Flyer: Agency Referral Agency: Resident Referral Name of Resident: Past Resident Date & Apt. #: Other Explain:
WALNUT GROVE APARTMENTS RENTAL APPLICATION EMERGENCY CONTACT NUMBER In case of emergency, notify: Home Phone: Work Phone: Applicant certifies the above information is true and accurate and understands that false or inaccurate information shall be cause for denial of this application or termination of any subsequent rental agreements. I/We are the only person(s) who will reside in the apartment if this application is approved. Apartment owner or agents may verify all information given directly or through reporting agencies. Acceptance of the application is not binding on apartment owner or agent until approved in writing. You have applied to live in an apartment that is governed by the Low Income Housing Tax Credit Program. This Program requires us to certify all of your income, asset and eligibility information as part of determining your household s eligibility. Program requirements state that we must verify each income and asset source as well as other claims of eligibility. We must determine this prior to granting your eligibility and, if such eligibility is granted, each subsequent year you remain in the unit. The undersigned is the person(s) named above and hereby authorizes Apartment Credit Services to conduct a search of my Criminal Record, Police Record and Motor Vehicle Record information for the purpose of obtaining housing. Additionally, I authorize all companies and law enforcement agencies to release such information, and release them from any liability and responsibility from doing so. A faxed copy of this authorization shall be as valid as the original. If applicant cancels after two (2) days, all moneys deposited shall be forfeited to the apartment owner. If approved all moneys deposited with this application will be applied toward security deposit and/or processing fee at owner s discretion. If an application is denied for ANY reason a 90-day wait period is required before reapplying to this property. Head Signature: Date: Co-head Signature: Date:
TENANT INCOME CERTIFICATION QUESTIONNAIRE NOTE: A separate questionnaire must be completed by each adult member of the household. OFFICE USE ONLY NAME: Phone #: Initial Certification BIN #: Recertification Unit #: Household Addition Total # Household Members: # Adults (18 or older) # Children YES NO I receive Section 8 rental assistance. If yes, list the housing authority below. INCOME INFORMATION YES NO I am self employed. List nature of self employment. MONTHLY GROSS INCOME I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation. List the businesses and/or companies that pay you: Name of Employer: I receive cash contributions of gifts including rent or utility payments, on an ongoing basis from persons not living with me. I receive unemployment benefits. I receive Veteran s Administration, GI Bill, or National Guard/Military benefits/income. I receive periodic social security payments. The household receives unearned income from family members age 17 or under (example: Social Security, Trust Fund disbursements, etc.). I receive Supplemental Security Income (SSI). I receive disability or death benefits other than Social Security. I receive Public Assistance Income (examples: TANF, AFDC). DO NOT INCLUDE FOOD STAMPS. I am entitled to receive child support payments. I am currently receiving child support payments. If yes, from how many persons do you receive support? I am/are currently making efforts to collect child support owed to me. List efforts being made to collect child support. I receive alimony/spousal maintenance payments.
I receive periodic payments from trusts, annuities, inheritance, retirement funds or pensions, insurance policies, or lottery winnings. If yes, list sources: I receive income from real or personal property. I receive student financial assistance (grants, scholarships, etc.) not including loans. *NOTE: Count as income only if household receives Section 8 rental assistance ASSET INFORMATION YES NO INTEREST RATE CASH VALUE I have a checking account(s). If yes, list bank(s): I have a savings account(s). If yes, list bank(s): I have a revocable trust(s). If yes, list bank(s): I own real estate. If yes, provide description: I own stocks, bonds or Treasury Bills. If yes, list sources/bank names: I have Certificates of Deposit (CD) or Money Market Account(s). If yes, list sources/bank names: I have an IRA/Lump Sum Pension/Keogh Account/401(k). If yes, list bank(s): 1) I have a whole life insurance policy. If yes, list name of insurance company: If yes, how many policies? I have cash on hand. I have disposed of assets (i.e., gave away money/assets) for less than their fair market value in the past 2 years. If yes, list items and date disposed: I have income from assets or sources other than those listed above. If yes, list type below:
STUDENT STATUS INFORMATION YES NO Does the household consist entirely of persons who are all full-time students (kindergarten and higher)? Examples: Elementary School, Middle School, High School, College/University, trade school, etc. Does your household anticipate becoming a full-time student household in the next 12 months? Does your household consist entirely of persons who were full-time students for parts of five or more months of the current calendar year? If you answered yes to any of the previous three questions, are you: Receiving assistance under Title IV of the Social Security Act (AFDC, TANF)? Enrolled in a job training program receiving assistance through the Job Training Participation Act (JTPA) or other similar program? Married and entitled to file a joint tax return? Household consists entirely of single parent(s) with a dependent child or children and neither the parent(s) nor the child(ren) are dependents of another individual, with the exception that the child(ren) may be claimed by the absent parent. Previously under the care and placement responsibility of the state agency responsible for administering foster care? UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE INFORMATION PRESENTED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY/OUR KNOWLEDGE. THE UNDERSIGNED FURTHER UNDERSTANDS THAT PROVIDING FALSE REPRESENTATIONS HEREIN CONSTITUTES AN ACT OF FRAUD. FALSE, MISLEADING OR INCOMPLETE INFORMATION WILL RESULT IN THE DENIAL OF APPLICATION OR TERMINATION OF THE LEASE AGREEMENT. PRINTED NAME OF APPLICANT/RESIDENT SIGNATURE OF APPLICANT/RESIDENT DATE SIGNATURE OF OWNER/REPRESENTATIVE DATE
IRS Student Status Self-Certification Name: Check A, B, or C, as applicable (note that students include those attending public or private elementary schools, middle or junior high schools, senior high schools, colleges, universities, technical, trade, or mechanical schools, but does not include those attending on-the-job training courses). A. Household contains at least one occupant who is not a student, has not been a student, and will not be a student for five or more months during the current and/or upcoming calendar year (months need not be consecutive). If this item is checked, no further information is needed. The following occupants are not students, as defined above:. B. Household contains all students, but is qualified because the following occupant(s) is/are a part-time student(s). Documentation of part-time student status is required for at least one member of the household. C. Household contains all full-time students for five or more months during the current and/or upcoming calendar year (months need not be consecutive). If item C is checked, questions 1-5 below must be circled (ONLY IF C IS CHECKED ABOVE): 1. Is at least one student receiving assistance under Title IV of the Social Security Act? 2. Was at least one student previously under the care and placement responsibility of the state agency responsible for administering foster care? (Provide documentation of participation.) 3. Does at least one student participate in a program receiving assistance under the Job Training Partnership Act, Workforce Investment Act, or under other similar federal, state or local laws? (Provide documentation of participation.) 4. Household consists entirely of single parent(s) with child(ren) and this parent is not a dependent of another individual and the child(ren) is/are not a dependent(s) of someone other than a parent? 5. Are the students married and entitled to file a joint tax return? Households composed entirely of full-time students that are income-eligible and satisfy one or more of the above conditions are considered eligible. If questions 1-5 are marked NO, or verification does not support the exception indicated, the household is considered to be an ineligible student household. One form should be completed by each adult member of the household. Tenant Signature: Date: Tenant Printed Name:
PET POLICY, RULES AND REGULATIONS Pet Premium Fee of $250 is non-refundable and must be paid in full prior to the pet being allowed on property. Pet owner must provide paperwork from veterinarian verifying pet has been spayed or neutered Pet owner must provide paperwork from veterinarian verifying pet is current on vaccinations. Resident is only allowed 1 pet maximum per apartment. Pet owner must clean up after pet inside and outside apartment. Resident will hold Landlord harmless from liabilities/judgments/expenses and/or claims by third parties for injury to any person or damage to property caused by residents pet. Resident must complete pet application and pet addendum. Residents may have only common household pets, such as a dog, cat, aquarium fish, or bird in a cage. Pet will be allowed outside only with human companion and on a hand-held leash or in carrier. Resident is totally responsible for the care and cleanliness of the pet. Any damage caused by pet is full responsibility of the resident. Resident understands and agrees that resident will allow the Landlord to professionally fumigate the premises for fleas and ticks and clean all carpets when resident vacates the property. Resident to provide adequate food and water and provide regular veterinary care for the pet. Resident will not leave pet unattended in apartment for extended lengths of time. Resident must maintain cleanliness of sleeping and feeding areas and litter pans by removing and properly cleaning any pet waste. We do not allow PIT BULLS, ROTTWEILERS, DOBERMAN PINSCHERS, AKITAS, GERMAN SHEPHERDS AND/OR CHOWS on the property including visiting the property. Failure to comply could result in eviction. 1. Does your household have or anticipate having any pets? a. Is your current pet or will your household s anticipated pet be considered a service animal? b. Please specify the type and breed of pet your household has or anticipates having. Type of Pet (circle one): Cat Dog Fish Bird Pet Breed: Signature Date Signature Date Management Signature Date Rev. 8/1/2013