Application for Housing

Persons Occupying the Unit

Housing Information

Applicant:

Co-Applicant:

Income:

Please indicate each source of ESTIMATED GROSS ANNUAL income that you receive or anticipate receiving in the next twelve (12) months:

Employment Head of Household

Select One:

Employment Co-Applicant

Select One:

Self-Employment (2 years taxes)

Select One:

Other Income

Select One:

Social Security/SSI

Select One:

Public Assistance (Cash)

Select One:

Public Assistance (Food)

Select One:

Child Support/Alimony

Select One:

Assets:

Please list where the asset(s) is held, the current value of each asset(s) and all income derived from the assets over the previous twelve (12) months for ALL household member.

Checking Acct. Head of Household

Select One:

Checking Acct. Co-Applicant

Select One:

Savings Acct. Head of Household

Select One:

Savings Acct. Co-Applicant

Select One:

Certificate of Deposits

Select One:

Real Estate (FMW - Mortgage balance)

Select One:

Whole Life Insurance Policy

Select One:

Assets disposed of in the past 2 years

Select One:

Other

Select One:

Medical/Insurance Deductions:

Medical Insurance Premiums

Select One:

Medical Bills

Select One:

Prescriptions

Select One:

General Information:

Are you or anyone in the household currently or soon to become a student?


Consent To Release Information:

The undersigned certify that the information and statements provided above are true and complete to the best of my/our knowledge and belief. I/We consent to release the information in order to qualify for housing. I/We understand that providing false information or making false statements may be grounds for denial of my/our application and may subject me/us to criminal penalties. I/We agree to provide verifications of all income and assets as required by the Owner or its agent. I/We further authorize disclosure of all information which will verify my/our income and assets. Subject to approval, I certify this will be my/our primary residence.
I authorize management to complete credit check, criminal history, and applicable landlord references. By completing this application, applicant grants management permission to confirm the above information supplied by applicant. By signing below, I hereby certify that the unit that is assigned will serve as the household primary residence.

EACH APPLICANT 18 YEARS OF AGE OR OLDER MUST DIGITALLY SIGN BELOW

Property Manager is acting on behalf of and performing compliance services for the owner.

PENALTIES FOR MISUSING THIS CONSENT:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States government. HUD, The PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of Information collected based on the consent form. Use of the Information collected based on this verification form is restricted to the purposes cited above. Any person, who knowingly or willfully requests, obtains or discloses any Information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.00. Any applicant or participant affected by negligent disclosure of Information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA Of the owner responsible for the unauthorized disclosure or Improper use.

Fair Housing Statement

The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service that the Federal Laws prohibiting discrimination against tenant applications 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 or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.

Applicant

Gender:

Ethnicity:

Race:

Co-Applicant

Gender:

Ethnicity:

Race:

How Did You Hear About Us?

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

  1. Mail:
    U.S. Department of Agriculture
    Office of the Assistant Secretary for Civil Rights
    1400 Independence Avenue, SW
    Washington, D.C. 20250-9410
  2. Fax:
    (202) 690-7442; or
  3. Email:
    program.intake@usda.gov


    1. USDA is an equal opportunity provider, employer, and lender.