[[[["field28","equal_to","Yes"]],[["show_fields","field30,field31,field32,field33"]],"and"],[[["field35","equal_to","Yes"]],[["show_fields","field36"]],"and"],[[["field37","equal_to","Yes"]],[["show_fields","field38"]],"and"],[[["field105","equal_to","No"]],[["show_fields","field106"]],"and"],[[["field107","equal_to","Yes"]],[["show_fields","field108,field109,field110,field111"]],"and"],[[["field112","equal_to","Yes"]],[["show_fields","field113"]],"and"],[[["field118","equal_to","Yes"]],[["show_fields","field119"]],"and"],[[["field121","equal_to","Yes"]],[["show_fields","field122"]],"and"]]
1 Step 1
Personal Information
Full Nameyour full name
Social Security NumberSocial Security Number
Spouse Full NameSpouse Name
Spouse's Social Security NumberSpouse's Social Security Number
Addressyour home / office
CityCity
Zip CodeZip Code
How long?How long?
Home Phone NumberHome Phone Number
Landlord Information
Current Landlord's NameCurrent Landlord's Name
Phone NumberPhone Number
Addressyour home / office
CityCity
Zip CodeZip Code
Previous Landlord's NameCurrent Landlord's Name
Phone NumberPhone Number
Addressyour home / office
CityCity
Zip CodeZip Code
Employer Information
Name of EmployerName of Employer
Employer Phone NumberEmployer Phone Number
PositionPosition
How Long?How Long?
Is the applicant and/or any family member mobility impaired?
Who?Who?
Do the applicant and/or spouse use a walker or wheelchair?
Who?Who?
Would you require a barrier-free apartment?
Can you provide a doctor’s statement verifying the above answers?
Please list each state that you and/or any family member have resided in starting with the current one
0 /
Do you have a pet?If Yes, please request the Pet Policy and Deposit information
When would you be available to move-in?
Household Composition
Family Member #1
Nameyour full name
RelationshipRelationship
Place of BirthPlace of Birth
Birth DateBirth Date
date_range
Family Member #2
Nameyour full name
RelationshipRelationship
Place of BirthPlace of Birth
Birth DateBirth Date
date_range
Family Member #3
Nameyour full name
RelationshipRelationship
Place of BirthPlace of Birth
Birth DateBirth Date
date_range
Gross Yearly Income of Household
Family Members
0 /
Wages, salaries, etc.
0 /
Social Security, PensionSocial Security, Pension
0 /
SSI
0 /
Other income
0 /
Net Family Assets (Bank Accounts, Investments, Property, Etc.)

Checking Account

Value
Interest

Savings  Account

Value
Interest

Certificate of Deposit (CD’s)

Value
Interest

Other-Property, Homes, Etc

Value
Interest

Totals

Interest
Value
References

In the spaces provided below, please complete the information requested for either a relative or friend whom we many contact in the event we are unable to reach you:

Reference Name #1your full name
RelationshipRelationship
AddressAddress
City/State/ZipCity/State/Zip
Home PhoneHome Phone
Work PhoneWork Phone
Reference Name #2your full name
RelationshipRelationship
AddressAddress
City/State/ZipCity/State/Zip
Home PhoneHome Phone
Work PhoneWork Phone
Miscellaneous

The following question pertain to yourself and every member of your household who will occupy the unit. 

Are there any adult members in your household who are part-time or full-time students?If answering “YES” a STUDENT CERTIFICATION must be completed or the application will not be accepted.
Will anyone else live in the unit on either a full-time or part-time basis?
Do you have sole legal and physical custody of children?
Explain:
0 /
Are you now living or have you lived in a government-subsidized development?
When?When?
Name of DevelopmentName pf Development
AddressAddress
City/State/ZipCity/State/Zip
Has your housing assistance ever been terminated for fraud, non-payment of rent or utilities, failure to cooperate with recertification procedures, for drug-related criminal activity or for any other reason?
Explain:Explain:
Have you or any member of your household ever been arrested or convicted of a felony, or a misdemeanor other than a traffic violation?
Do you or any member of your household subject to a lifetime registration under the State sex offender registration program?
Do you or any member of your household have a pattern of alcohol abuse that would interfere with the health, safety or right to peaceful enjoyment of the premises by other tenants?
Do you or any member of your household use an illegal drug or other illegal controlled substance?
Have you or any member of your household ever used different names from the names given in this application?
Names:more details
0 /
Have you or any member of your household ever used social security numbers different from those listed in this application?
Have you or any member of your household lived in any other state within the past 10 years?
Which Ones?more details
0 /

I/We understand the information in this application will be used to determine eligibility for Section 8 housing assistance and that this information will be verified. I/We understand that any false information may make me/us ineligible for a unit. I/We certify that all information given in this application is true, complete and accurate. I/We understand that if any of this information is false, misleading or incomplete, management may decline my/our application or, if move-in has occurred, terminate my/our lease agreement. I/We understand that any action (s) by myself/ourselves or my/our household members, whether verbal or non-verbal, that harass, intimidate, threaten or are perceived by management to harass, intimidate or threaten the health or safety of the management stall or interfere with the management of the property is grounds for management to decline my/our application for housing. I/We authorized management to make any and all inquiries to verify this information, directly or through information exchanged now or later with rental and credit screening services, and to contact previous and current landlords or other sources for credit and verification information which may be
released to appropriate Federal, state or local agencies. If my/our application is approved, and move-in occurs, I/We certify that only those persons listed in this for whom I/we have, or expect to have, responsibility to provide housing. I/We agree to notify management in writing regarding any changes in household address, telephone number, income and household composition. My/Our signature (s), as indicated below, acknowledge that I/We have read and completed each section of this rental application, as applicable.

Applicant #1 SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature
Applicant #2 SignatureI agree to the terms and conditions
(Sign Here)
Clear Signature

PENALTIES FOR MISUISING 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. Any applicant or participant affected by negligent disclosure of information responsible for the unauthorized disclosure or improper use.
Penalty provisions for misusing the social security numbers are contained in the Social Security Act at 42 U.S.C 208(f), (g) and (h). Violations of these provisions are cited as violations of 42 U.S.C 408 (f),(g), and (h).

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