Step 1 of 5 20% Building InformationThis is an application for housing. This is not a lease or rental agreement. Resident Selection Statement Initials* Enter your initials to indicate that you have read and understand the resident selection criteria.Desired Unit Number* Desired Occupancy Date* MM slash DD slash YYYY Personal InformationFull Legal Name* Date of Birth* Month Day Year Phone Number*Email* Gender* Driver's License Number Marital Status* Single Married Divorced Separated (provide copy of legal document) Widowed Other OccupantsFull Legal NameRelationship to ApplicantDate of Birth (all occupants 18 years or older must fill out a separate application) Housing InformationList the past TWO years of housing history, beginning with your CURRENT addressPresent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Rent or Own?* Rent Own Present Landlord/Owner*NameEmailPhone Date Occupied From* MM slash DD slash YYYY Monthly Payment* Previous Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Rent or Own? Rent Own Previous Landlord/OwnerNameEmailPhone Dates Occupied From MM slash DD slash YYYY To MM slash DD slash YYYY Monthly Payment Have you been evicted or had a judgement for rent against you?* Yes No Household IncomeSource/Employer*Employer NamePositionAnnual IncomeEmployed Since Other Monthly Income Do you have any open bankruptcy?* Yes No Other InformationDo you expect any additions to the household within the next 12 months?* Yes No (Include unborn children)If yes,NameRelationshipExplanation Will you or any ADULT household member require a LIVE-IN CARE Attendant to live independently?* Yes No Have you been convicted of, plead guilty to, or been placed on probation for any crime, including dealing or manufacturing illegal drugs?* Yes No Are any criminal charges currently pending against you?* Yes No Does your household have or anticipate having any pets?* Yes No (This does not include service animals)If yes,TypeBreedName Vehicle Information (if applicable)Vehicle MakeColorYearLicense Plate # Emergency Contact*NameRelationshipPhone Number Permission Statement Initials* Place your initials in the box to indicate that you agree with the Permission Statement Digital Signature* I understand that management is relying on this information to prove my household’s eligibility which is required by the funding sources under which this property operates. I certify under penalty of perjury that all information and answers provided are true and complete to the best of my knowledge. I further understand that providing false information or making false statements may be grounds for denial of my application. I also understand that such action may result in criminal penalties. I will notify management of any changes to my income prior to move-in, or prior to the effective date of my recertification. I authorize my consent to have management verify the information contained in this application questionnaire and to perform a credit check and criminal background check for purposes of proving my eligibility for occupancy. I understand that my occupancy is also contingent on meeting the management’s resident selection criteria and other program requirements.
