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Application for Housing

Apartment you are applying for:

Home you are applying for:

Address/Property Name

# of Bedrooms:

Desired move-in Date:

I am requesting to move in with an existing tenant Unit #:

I am requesting a unit transfer requiring a new application

I have applied for multiple properties

Persons Occupying the Unit

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Last:

First:

Middle:

Relationship:

Social Security Number:

Date of Birth:

Housing Information

You must list at least 2 years of housing history. If there is not enough space below, please use the comment box near the end of the application

Applicant:

Current Mailing Address:

City:

State:

ZIP:

From:

To:

Reason for leaving:

Primary Phone #:

Alternate Phone #:

Email:

Do you own this residence?

Yes

No

If No, do you rent this residence?

Yes

No

Owner/Landlord Name:

Owner/Landlord Address:

Phone #:

Fax #:

Owner/Landlord Email:

Monthly Payment:

Previous Address:

City:

State:

ZIP:

From:

To:

Reason for leaving:

Do you own this residence?

Yes

No

If No, do you rent this residence?

Yes

No

Owner/Landlord Name:

Owner/Landlord Address:

Phone #:

Fax #:

Owner/Landlord Email:

Monthly Payment:

Applicant Monthly Expenses/Income Report

Income:

Regular Income (after taxes):

Public Assistance:

Child Support:

Other:

Expences:

Car Payment:

Insurance:

Utilities:

Cable:

Telephone:

Credit Card:

Groceries:

gas:

Tobacco/Beverages:

Pet Food/Care:

Entertainment:

Meals Out:

Gifts Vacation:

Household Products:

Clothing:

Day Care:

Medication/Doctor Visits:

Student Loans:

Other:

Pets?

Yes

No

How many cats?

How many dogs?

How many children?

Co-Applicant:

Present Address:

City:

State:

ZIP:

From:

To:

Reason for leaving:

Primary Phone #:

Alternate Phone #:

Email:

Do you own this residence?

Yes

No

If No, do you rent this residence?

Yes

No

Owner/Landlord Name:

Owner/Landlord Address:

Phone #:

Fax #:

Owner/Landlord Email:

Monthly Payment:

Previous Address:

City:

State:

ZIP:

From:

To:

Reason for leaving:

Do you own this residence?

Yes

No

If No, do you rent this residence?

Yes

No

Owner/Landlord Name:

Owner/Landlord Address:

Phone #:

Fax #:

Owner/Landlord Email:

Monthly Payment:

Co-Applicant Monthly Expenses/Income Report

Income:

Regular Income (after taxes):

Public Assistance:

Child Support:

Other:

Expences:

Car Payment:

Insurance:

Utilities:

Cable:

Telephone:

Credit Card:

Groceries:

gas:

Tobacco/Beverages:

Pet Food/Care:

Entertainment:

Meals Out:

Gifts Vacation:

Household Products:

Clothing:

Day Care:

Medication/Doctor Visits:

Student Loans:

Other:

Pets?

Yes

No

How many cats?

How many dogs?

How many children?

Income:

Please indicate each source of Estimated Gross Annual or Estimated Gross Monthly income that you receive or anticipate receiving in the next twelve (12) months:

Be aware that some projects are income restricted. Make sure to list your total GROSS income (gross income is what you make BEFORE any deductions are made, if you make 10.00 per hour and work 2080 per year your annual GROSS is $20,800) from ALL sources. We will have to verify you income and if you understate it your application may be rejected.

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

I acknowledge the above information

Employment Head of Household

Include ALL household income before taxes and other deductions.

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Employment Co-Applicant

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Self-Employment (2 years taxes)

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Other Income

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Social Security/SSI

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Public Assistance (Cash)

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Public Assistance (Food)

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

Child Support/Alimony

Select One:

Yes

No

Monthly Gross Income:

Yearly Gross Income:

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:

Yes

No

Name, Phone #, Fax #, Email Address:

Checking Acct. Co-Applicant

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Savings Acct. Head of Household

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Savings Acct. Co-Applicant

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Certificate of Deposits

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Real Estate (FMW - Mortgage balance)

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Whole Life Insurance Policy

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Assets disposed of in the past 2 years

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Other

Select One:

Yes

No

Name, Phone #, Fax #, Email Address:

Medical Insurance Premiums

Select One:

Yes

No

Name of Company or Pharmacy:

Medical Bills

Select One:

Yes

No

Name of Company or Pharmacy:

Prescriptions

Select One:

Yes

No

Name of Company or Pharmacy:

General Information:

Do you or any member of your household own a pet? If yes, what kind?

Yes

No

Weight?

Do you or any member of your household have a service animal? If yes, what kind?

Yes

No

Have you or any member of your household ever been convicted of a crime? If yes, please explain:

Yes

No

Are you or any member of your household subject to a State Lifetime Sex Offender Registration?

Yes

No

Have you or any member of your household ever been evicted for any reason in the past 5 year? If yes, please explain:

Yes

No

Will you or any other household member need a barrier free or wheel chair accessible unit?

Yes

No

Will you or any other household member need any other reasonable accommodations? If yes, please explain:

Yes

No

List all states that you and your household members have lived in:

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

Yes

No

Full-Time

Part-Time

List name of student(s):

Are any of your household members temporarily absent? Who?

Yes

No

How Long?

Do you expect any changes to your household in the next 12 months? If yes, please explain:

Yes

No

Are you or any member of your household an active member or veteran of the United States Military?

Yes

No

Are you receiving a housing voucher?:

Yes

No

Agency:

Currently Receiving:

Yes

No

or Applied for:

Yes

No

Do you or any member of your household have a guardian or conservator? If yes, please name?:

Please include any additional information you would like considered

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

Signature:

I Accept...

Signature:

I Accept...

Signature:

I Accept...

Signature:

I Accept...

Signature:

I Accept...

Signature:

I Accept...

Signature:

I Accept...

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

I do not wish to furnish this information.

Gender:

Male

Female

Ethnicity:

Hispanic

Not Hispanic or Latino

Race:

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Co-Applicant

I do not wish to furnish this information.

Gender:

Male

Female

Ethnicity:

Hispanic

Not Hispanic or Latino

Race:

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

How Did You Hear About Us?

Sign

Facebook

Craigslist

Agency

Friend that does not live at this property

Newspaper?

Name of paper:

Internet?

Website:

Walk-In

What prompted you to walk-in?:

Current Resident?

Resident's Name:

Other

Please explain:

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:

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

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

Equal Housing Opportunity

© Copyright GLD Management Company. All rights reserved.
TDD Number: 711
This institution is an equal opportunity provider.