APPLICATION FOR ADMISSION TO HOUSING

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Date Date / MM / DD YYYY
First Name:
Last Name:
Address:
City:
State:
In what town or city do you need housing?
Home Phone: Home Phone: - ### - ### ####
Cell Phone: Cell Phone: - ### - ### ####
Number of Bedrooms needed:
In what town or city do you need housing?
Are you looking for subsidized rent?

Are you looking for subsidized rent? Yes No
Present monthly rent: $
TENANT #1
First Name:
Last Name:
Email:
Social Security Number:
Age:
Date of Birth: Date of Birth: / MM / DD YYYY
Automobile:
Driver's License Number:
Present Address: Present Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone: Phone: - ### - ### ####
Cell Phone: Cell Phone: - ### - ### ####
Present Landlord's Name:
Present Landlord's Phone:
Present Landlord's Address: Present Landlord's Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Present Monthly Rent:
Are Utilities Included?

Are Utilities Included? Yes No
How long at present address?
Employment:
Current Employer:
Position with company:
Company Address: Company Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone of Employer:
Weekly Wages:
Length of service:
Previous Employer:
Position with company:
Company Address: Company Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone:
Weekly wages:
Length of service:
CREDIT REFERENCE:
Company #1:
Account Number:
Company #2:
Account Number:
LIST CHILDREN AND DEPENDENTS THAT WILL BE LIVING WITH YOU:
Name:
Sex:

Sex: Male Female
Social Security Number:
_________________________________________________________________
Name:
Sex:

Sex: Male Emale
Social Security Number:
_________________________________________________________________
Name:
Sex:

Sex: Male Female
Social Security Number:
_________________________________________________________________
Name:
Sex:

Sex: Male Female
Social Security Number:
EMERGENCY CONTACT NUMBER
Name of Emergency Contact:
Phone:
Name of Emergency Contact:
Phone:
Name of Emergency Contact:
Phone:
PERSONAL REFERENCES FOR TENANT #1:
Name of references #1
Address references #1 Address references #1
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone references #1
____________________________________________________________
Name of references #1
Address references #1 Address references #1
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone:
______________________________________________________________
Name of references #1
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone:
SOURCE OF INCOME AND AMOUNT
Social Security Tenant #1
Social Security Tenant #2
Pensions Tenant #1
Pensions Tenant #2
Unemployment Tenant #1
Unemployment Tenant #2
Interest Tenant #1
Interest Tenant #2
Employment Tenant #1
Employment Tenant #2
TANF/ASPIRE Tenant #1
TANF/ASPIRE Tenant #2
Alimony/Child Support Tenant #1
Alimony/Child Support Tenant #2
Dividends Tenant #1
Dividends Tenant #2
Other income Tenant #1
Other income Tenant #2
Name of Bank Tenant #1
Name of Bank Tenant #1
Amount of savings in bank Tenant #1
Amount of savings in bank Tenant #2
Amount of checking in bank Tenant #1
Amount of checking in bank Tenant #2
Value of Stocks, Bonds, Certificates Tenant #1
Value of Stocks, Bonds, Certificates Tenant #2
Value of real estate owned Tenant #1
Value of real estate owned Tenant #2
Value of other assets tenant #1
Value of other assets tenant #2
APPLICANTS/TENANTS MUST ALSO DISCLOSE ANY ASSETS DISPOSED OF FOR LESS THEN MARKET VALUE IN THE TWO YEARS PRECEDING THE EFFECTIVE DATE OF THE CERTIFICATION OR RECERTIFICATION OF INCOME. HAVE YOU SOLD ANY ASSETS IN THE LAST TWO YEARS NOT LISTED ABOVE? IF YOU HAVE, PLEASE PROVIDE THE FOLLOWING INFORMATION:
Description:
Market Value:
Amount Received:
ANY ASSETS LISTED AS SOLD FOR LESS THEN ACTUAL CASH VALUE IN THE TWO YEARS PRECEDING THE EFFECTIVE DATE OF THE CERTIFICATION OR RECERTIFICATION OF INCOME WILL BE COUNTED AS ASSETS IF THE DIFFERENCE BETWEEN THE VALUE AND THE AMOUNT RECEIVED EXCEEDS $1,000.00.

Please answer Yes or No to the following questions.
Do you or any other household member require a specially designed unit?

Do you or any other household member require a specially designed unit? Yes No
DO YOU OR ANY OTHER HOUSEHOLD MEMBER REQUEST AN ELDERLY HANDICAP OR DISABILITY ADJUSTMENT?

DO YOU OR ANY OTHER HOUSEHOLD MEMBER REQUEST AN ELDERLY HANDICAP OR DISABILITY ADJUSTMENT? Yes No
Do you have any pets?

Do you have any pets? Yes No
If so, what kind of pet?
ARE YOU OR A FAMILY MEMBER A CURRENT USER OF AN ILLEGAL CONTROLLED SUBSTANCE?

ARE YOU OR A FAMILY MEMBER A CURRENT USER OF AN ILLEGAL CONTROLLED SUBSTANCE? Yes No
HAVE YOU OR FAMILY MEMBER HAD A PREVIOUS CONVICTION FOR THE USE OF AN ILLEGAL CONTROLLED SUBSTANCE?

HAVE YOU OR FAMILY MEMBER HAD A PREVIOUS CONVICTION FOR THE USE OF AN ILLEGAL CONTROLLED SUBSTANCE? Yes No
HAVE YOU OR A FAMILY MEMBER EVER BEEN CONVICTED OF THE MANUFACTURE OR DISTRIBUTION OF AN ILLEGAL CONTROLLED SUBSTANCE?

HAVE YOU OR A FAMILY MEMBER EVER BEEN CONVICTED OF THE MANUFACTURE OR DISTRIBUTION OF AN ILLEGAL CONTROLLED SUBSTANCE? Yes No
IF YOU ANSWERED QUESTIONS NUMBER 4 OR 5 WITH A "YES", HAVE YOU OR A FAMILY MEMBER INVOLVED, SUCCESSFULLY COMPLETED A CONTROLLED SUBSTANCE ABUSE RECOVERY PROGRAM OR ARE YOU OR THE FAMILY MEMBER PRESENTLY ENROLLED IN SUCH A PROGRAM?

IF YOU ANSWERED QUESTIONS NUMBER 4 OR 5 WITH A "YES", HAVE YOU OR A FAMILY MEMBER INVOLVED, SUCCESSFULLY COMPLETED A CONTROLLED SUBSTANCE ABUSE RECOVERY PROGRAM OR ARE YOU OR THE FAMILY MEMBER PRESENTLY ENROLLED IN SUCH A PROGRAM? Yes No
Date Apartment Wanted: Date Apartment Wanted: / MM / DD YYYY
Reason for moving?
TENANT #2
First Name of Tenant 2:
Last Name of Tenant 2:
Email of Tenant 2:
Social Security Number Tenant 2:
Age Tenant 2:
Date of Birth Tenant 2: Date of Birth Tenant 2: / MM / DD YYYY
Automobile Tenant 2:
Driver's License Number Tenant 2:
Present Address Tenant 2: Present Address Tenant 2:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Tenant 2: Phone Tenant 2: - ### - ### ####
Cell Phone Tenant 2: Cell Phone Tenant 2: - ### - ### ####
Present Landords Name:
Phone: Phone: - ### - ### ####
Address of present Landlord: Address of present Landlord:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Present monthly rent:
Are utilities included:

Are utilities included: Yes No
How long at present address:

APPLICATION FOR ADMISSION TO HOUSING

APPLICATION FOR ADMISSION TO HOUSING

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TENANT #1

Employment:

CREDIT REFERENCE:

LIST CHILDREN AND DEPENDENTS THAT WILL BE LIVING WITH YOU:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

EMERGENCY CONTACT NUMBER

PERSONAL REFERENCES FOR TENANT #1:

____________________________________________________________

______________________________________________________________

SOURCE OF INCOME AND AMOUNT

ANY ASSETS LISTED AS SOLD FOR LESS THEN ACTUAL CASH VALUE IN THE TWO YEARS PRECEDING THE EFFECTIVE DATE OF THE CERTIFICATION OR RECERTIFICATION OF INCOME WILL BE COUNTED AS ASSETS IF THE DIFFERENCE BETWEEN THE VALUE AND THE AMOUNT RECEIVED EXCEEDS $1,000.00.

TENANT #2