THE FUCCI COMPANY 6 Regency Manor, Suite 1, Rutland, VT 05701 Tel. 802-773-9107 Fax 802-773-0518 PLEASE PRINT ALL INFORMATION CLEARLY : PROJECT APPLYING FOR: BEDROOM SIZE: ANY SPECIAL ACCOMODATIONS NEEDED?: HOW SOON DO YOU NEED AN APARTMENT?: GENERAL INFORMATION: NAME: HOME PHONE: ADDRESS: WORK PHONE: MESSAGE PHONE: PLEASE LIST BELOW EACH AND EVERY INDIVIDUAL TO BE INCLUDED IN YOUR HOUSEHOLD INCLUDING YOURSELF. HOUSEHOLD MEMBER RELATIONSHIP TO HEAD OF HOUSE OF BIRTH SOCIAL SECURITY # PLACE OF BIRTH PLEASE PROVIDE OUR OFFICE WITH A PHOTOCOPY OF ALL HOUSEHOLD MEMBERS SOCIAL SECURITY CARDS PER GOVERNMENT REGULATIONS. HOUSING STATUS: NUMBER OF BEDROOMS IN PRESENT UNIT: PRESENT RENT: $ /MONTH IF RENT DOES NOT INCLUDE UTILITIES, PLEASE INDICATE WHAT UTILITIES COST YOU PER MONTH: $ ARE YOU CURRENTLY LIVING IN SUBSIDIZED HOUSING? DO YOU HAVE A RENTAL ASSISTANCE VOUCHER? ARE YOU BEING DISPLACED? IF SO, WHY? IS YOUR CURRENT UNIT IN A SUBSTANDARD CONDITION? IF SO, DESCRIBE: HAVE YOU EVER FILED AN APPLICATION WITH THE FUCCI COMPANY? HAVE YOU EVER BEEN A TENANT OF THE FUCCI COMPANY BEFORE? HAVE YOU EVER BEEN EVICTED? IF SO, EXPLAIN: ARE YOU HANDICAPPED OR DISABLED? IF SO, EXPLAIN: HOW LONG HAVE YOU LIVED AT YOUR CURRENT ADDRESS? WHY DO YOU WISH TO MOVE? ARE YOU APPLYING FOR STATUS AS AN ELDERLY HOUSEHOLD, WHERE THE TENANT OR CO-TENANT IS 62+ YEARS OLD OR HANDICAPPED OR DISABLED, AS DEFINED BY HUD AND RURAL DEVELOPMENT, AND IF SO, ARE YOU AWARE YOU WILL RECEIVE A $400.00 ELDERLY HOUSEHOLD AND MEDICAL DEDUCTION? IF SO, PLEASE INDICATE. PLEASE BE AWARE THAT ELIGIBILITY MUST BE VERIFIED. DO YOU REQUEST A HANDICAP (BARRIER FREE) UNIT? DO YOU REQUEST ANY MODIFICATIONS OF AN APARTMENT? HAVE YOU OR ANYONE IN YOUR HOUSEHOLD EVER BEEN CONVICTED OF A CRIME? YES NO IF YES, PLEASE EXPLAIN: (To be verified through Criminal Background check) ARE YOU LEGALLY CAPABLE OF ENTERING INTO A LEASE AGREEMENT? YES NO C:\staging\471F6469-1303-08AFB6\in\471F6469-1303-08AFB6.doc Page 1
OTHER INFORMATION: VEHICLES: LIST ALL VEHICLES IN HOUSEHOLD. MAKE: YEAR: PLATE # MAKE: YEAR: PLATE # DO YOU OWN A PET? YES NO IF YES, DESCRIBE ARE YOU A FULL-TIME STUDENT? The Fucci Company does not discriminate on the basis of race, color, religion, marital status, age or handicap/disability. The Fucci Company will make every reasonable accommodation for persons with handicaps/disabilities. To remain current on our waiting list you must write or telephone the Fucci Company every six (6) months to confirm your interest in housing and to update any pertinent information. APPLICANT EMPLOYMENT INFORMATION: Applicant name: CURRENT EMPLOYER: EMPLOYER ADDRESS: S EMPLOYED: TO. PREVIOUS EMPLOYER: EMPLOYER ADDRESS: S EMPLOYED: TO. CO-APPLICANT EMPLOYMENT INFORMATION: Applicant name: CURRENT EMPLOYER: EMPLOYER ADDRESS: S EMPLOYED: TO. PREVIOUS EMPLOYER: EMPLOYER ADDRESS: S EMPLOYED: TO. OTHER INCOME AND ASSET INFORMATION: PLEASE LIST BELOW ALL HOUSEHOLD INCOME FROM OTHER SOURCES. THIS INCLUDES, BUT IS NOT LIMITED TO, FULL AND/OR PART-TIME EMPLOYMENT, ANFC, SOCIAL SECURITY, SSI, SSD, PENSIONS, UNEMPLOYMENT COMPENSATION, CHILD CARE, ALIMONY AND CHILD SUPPORT, ANY INTEREST ON ASSETS, DIVIDENDS, ANNUITIES, AND ANY REGULAR CONTRIBUTIONS FROM PEOPLE NOT RESIDING WITH YOU. HOUSEHOLD MEMBER NAME & ADDRESS OF INCOME SOURCE TYPE OF INCOME (I.E. PENSION) MONTHLY GROSS AMOUNT DO YOU ANTICIPATE ANY CHANGES IN THIS INCOME IN THE NEXT 12 MONTHS? IF SO, EXPLAIN C:\staging\471F6469-1303-08AFB6\in\471F6469-1303-08AFB6.doc Page 2
ASSETS: CHECKING ACCT BANK: BALANCE: $ RATE % SAVINGS ACCT CERTIFICATE DO YOU OWN ANY STOCKS OR BONDS? IF SO, PLEASE DETAIL: DO YOU OWN ANY REAL ESTATE? IF SO, PLEASE DETAIL: HAVE YOU SOLD; DISPOSED OF; OR OTHERWISE GIVEN AWAY ANY ASSETS OR REAL ESTATE IN THE LAST 2 YEARS (EXAMPLES: GIVEN MONEY OR REAL ESTATE TO RELATIVES, SET UP IRREVOCABLE TRUST ACCOUNTS) IF SO, PLEASE EXPLAIN: MEDICAL, CHILD CARE, AND HANDICAP ASSISTANCE EXPENSES: MEDICAL COSTS: Complete only if head or spouse is 62 or older, handicapped or disabled. MEDICARE MONTHLY AMOUNT: $ MEDICAL INSURANCE MONTHLY AMOUNT: $ ANTICIPATED PRESCRIPTION COSTS, NOT COVERED BY INSURANCE MONTHLY $ ANY OTHER MEDICAL EXPENSES NOT COVERED BY INSURANCE: LIST TYPE AND AMOUNTS: $ HANDICAP ASSISTANCE EXPENSE: (COMPLETE ONLY IF A MEMBER OF THE HOUSEHOLD IS ABLE TO WORK AS A RESULT OF THE ASSISTANCE PROVIDED) TYPE OF EXPENSE: WEEKLY AMOUNT $ PAID TO: CHILD CARE EXPENSES: (COMPLETE FOR CHILDREN 12 AND YOUNGER) WEEKLY COST: $ PAID TO: REFERENCE INFORMATION: CREDIT REFERENCES: TELEPHONE # PERSONAL REFERENCES: The Fucci Company is authorized to obtain credit reports to establish my credit worthiness, or for any other purpose. I hereby certify that I do not and will not maintain a separate, subsidized rental unit in another location. I understand I must pay a security deposit for this apartment prior to occupancy. I certify that the housing I will occupy will be my permanent residence. I understand that eligibility for housing will be based on the Department of HUD s eligibility criteria; Rural Development s eligibility criteria and/or The Fucci Company s resident selection criteria. I understand that this application in no way ensures occupancy and that my application can be rejected based on, but not limited to, poor credit or personal references, police records indicating unacceptable or criminal behavior, or poor personal interview. I understand that the site will deny my household s application if any adult household member has been convicted of a felony crime. I certify that the information given in this application is true to the best of my knowledge. I understand that any false information is punishable by law, and could be grounds for cancellation of this application or termination of residency after occupancy. Release of information authorization: I do hereby authorize The Fucci Company and its staff to attain any information or materials deemed necessary to determine my eligibility for housing, including contacting agencies, offices, groups or organizations, which may provide information that could substantiate or verify information given in this application; for example, local police department, welfare agency, or senior service agency. By signing this form, I consent to the release of my credit report and criminal record to the site, and I agree that I will not file any claim or lawsuit relating to the site s use of my criminal record for screening purposes. Signature of Applicant Date Signature of Co-Applicant Date The following information is required for statistical purposes so the Dept. of HUD and Rural Development may determine the degree to which its programs are utilized by minority families. Ethnicity: Hispanic or Latino Not Hispanic or Latino Gender: Male Female Race: (Mark one or more) White Black or African American American Indian/Alaskan Native Native Hawaiian or Other Pacific Islander Asian Other The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through HUD/Rural Development that Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial status, age, and disability 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 LEGAL or LANDLORD to discriminate against REFERENCES you in any way. FOR However, THE if PAST you choose TEN not YEARS to furnish it, the owner is required to note the race/ethnicity and sex of an individual applicant on the basis of visual observation or surname. C:\staging\471F6469-1303-08AFB6\in\471F6469-1303-08AFB6.doc Page 3
DO NOT LIST FAMILY MEMBERS OR FRIENDS AS LEGAL LANDLORDS. (If evicted, a copy of the eviction is required.) INDICATE WHEN LIVING AT HOME WITH FAMILY AT END OF LIST. Legal Landlord: Tel #: Address of your apartment: on Lease: Legal Landlord: Tel #: Address of your apartment: on Lease: Legal Landlord: Tel #: Address of your apartment: on Lease: Legal Landlord: Tel #: Address of your apartment: on Lease: Parent/Family Member: Tel #: Parent/Family Member: Tel #: Parent/Family Member: Tel #: C:\staging\471F6469-1303-08AFB6\in\471F6469-1303-08AFB6.doc Page 4
ABSENT PARENT INFORMATION *IF DIVORCED: ATTACH COPY OF COURT DOCUMENTS REGARDING CUSTODY OF MINOR CHILDREN Absent Parent Information (re: all children that will be living with/visiting you) Child s Absent Parent s Street Address City State Last Contact Date Comments Visitation How often? If separated or divorced, list name and address of spouse/ex-spouse as follows or last known legal residence: Street Address Street Address City, State, Zip City, State, Zip Social Security # (if known) Social Security # (if known) DO YOU EXPECT ANYONE TO MOVE IN OR OUT OF YOUR HOUSEHOLD WITHIN THE NEXT 12 MONTHS YES NO IF YES, NAME: RELATIONSHIP: IS THERE ANYONE LIVING WITH YOU NOW THAT IS NOT LISTED ABOVE? YES NO IF YES, NAME: RELATIONSHIP: EQUAL HOUSING OPPORTUNITY C:\staging\471F6469-1303-08AFB6\in\471F6469-1303-08AFB6.doc Page 5