A. GENERAL INFORMATION Applicant Name: Street: Apt.# City: State: ZIP: Daytime Phone: Evening Phone: Email: No. of BR’s in current unit: Do you RENT or OWN Rent Own Amount of current monthly rental or mortgage payment: $ If owned, do you receive monthly rental income from property? No Yes Check utilities paid by you: Heat Electricity Gas Other Approximate monthly cost of utilities paid by you (excluding phone and cable TV): $ Bedroom size requested: Studio One BR Two BR Three BR Four BR Handicap Unit Do you have a Section 8 Voucher or any other type of voucher? No Yes How did you hear about this property? Local Newspaper New Neighborhoods Website Other: Add another applicant B. HOUSEHOLD COMPOSITION "List ALL persons who will live in the apartment. List the head of the household first." No. Name: Relationship to head Marital Status: Birth Date: Age: SS#: Student: 1. single married divorced legal separation estranged No Yes Add another household member button Have there been any changes to the household composition in last twelve months? No Yes If yes, explain Do you anticipate any changes in household composition in the next twelve months? No Yes If yes, explain Is there someone not listed above who would normally be living with the household? No Yes If yes, explain Is anyone in the household 62 years of age as of January 1, 2010, who does not have a social security number and was receiving HUD rental assistance a current or previous residence? No Yes Will ALL of the persons in the household be or have been full-time students during five calendar months of this year or plan to be in the next calendar year at an educational institution (other than a correspondence school) with regular faculty and students? No Yes IF YES, ANSWER THE FOLLOWING QUESTIONS: Are any full-time student(s) married and filing a joint tax return? No Yes Are any student(s) enrolled in a job-training program receiving assistance under the Job Training Partnership Act? No Yes Are any full-time student(s) a TANF or a title IV recipient? No Yes Are any full-time student(s) a single parent living with his/her minor child who is not a Dependent on another’s tax return? No Yes Is any student a person who was previously under the care and placement of a foster care program (under Part B or E of Title IV of the Social Security Act)? No Yes C. INCOME Household Member Name: Source of Income Gross Monthly Amount: Source of Income Employment Social Security SSI Benefits Long Term Medical Care Insurance Payments in excess of $180/day Pension (list source) Veteran’s Benefits (list claim #), Unemployment Compensation Title IV/TANF Contributions to the Household (monetary or not) Full-Time Student Income (18 & Over Only) Financial Aid (excluding loans) Annuities (list source) Interest Income (list source) Scheduled Payments from Investments Child Support Alimony Other (list source) Source number: Employer: Position held: How long employed: Are you entitled to receive alimony? No Yes If yes, list the amount you are entitled to receive: $ Do you receive alimony? No Yes If yes list amount you receive: $ Are you entitled to receive child support? No Yes If yes list the amount you are entitled to receive: $ Do you receive child support? No Yes If yes, list the amount you receive: $ Add another source of income Add another household member TOTAL GROSS ANNUAL INCOME (Based on the monthly amounts listed above x 12): $ TOTAL GROSS ANNUAL INCOME FROM PREVIOUS YEAR: $ Do you anticipate any changes in this income in the next 12 months? No Yes If yes, explain: Is any member of the household legally entitled to receive income assistance? No Yes Is any member of the household likely to receive income or assistance (monetary or not)? No Yes From someone who is not a member of the household listed on page 5 etc.? No Yes If yes to any of the above, explain: Is the income received? No Yes D. ASSETS Type of account: Checking Savings Trust Certificates Credit Union Last 4 digits of account number: # Bank: Balance: $ Add another account Savings Bonds #: Maturity Date: Value: $ Add another savings bond Life Insurance Policy #: Cash Value: $ Add another life insurance policy Mutual Funds Name: # of shares: Interest or Dividend: $ Value: $ Add another mutual fund Stocks Name: # of shares: Dividend paid: $ Value: $ Add another stock Bonds Name: # of shares: Interest or Dividend: $ Value: $ Add another bond Investment Property Appraised value: $ Add another bond Real Estate Property Do you own any property? Yes No Radio buttons, default no No Yes If yes, type of property: Street: Apt.# City: State: ZIP: Appraised Market Value: $ Mortgage or outstanding loans balance due: $ Amount of annual insurance premium: $ Amount of most recent tax bill: $ Add another property Does any member of the household have an asset(s) owned jointly with a person who is NOT a member of the household? No Yes If yes, describe: Do they have access to the asset(s)? Yes No Radio buttons, default no No Yes Have you sold/disposed of any property in the last 2 years? No Yes If yes, type of property: Market value when sold/disposed: $ Amount sold/disposed for: $ Date of transaction: Add another property Have you disposed of any other assets in the last 2 years (Example: Given away money to relatives, set up Irrevocable Trust Accounts)? No Yes If yes, describe the asset: Date of disposition: Amount disposed: $ Add another disposition Do you have any other assets not listed above (excluding personal property)? No Yes If yes, please list: E. ADDITIONAL INFORMATION Are you or any member of your family currently using an illegal substance? No Yes Have you or any member of your family ever been convicted of a felony? No Yes If yes, describe: Have you or any member of your family ever been evicted from any housing? No Yes If yes, describe: List all states that you or a member of your household has lived in: Are you, or any member of your household required to register on the lifetime sex offender registry in any state? No Yes Have you ever filed for bankruptcy? No Yes If yes, describe Will you take an apartment when one is available? No Yes Briefly describe your reasons for applying: F. REFERENCE INFORMATION Current Landlord Name: Address: Home Phone: Bus. Phone: How Long? Prior Landlord Name: Address: Home Phone: Bus. Phone: How Long? Credit Reference #1: Address: Account #: Phone #: Credit Reference #2: Address: Account #: Phone #: Credit Reference #3: Address: Account #: Phone #: Personal Reference #1: Address: Relationship: Phone #: Personal Reference #2: Address: Relationship: Phone #: Relationship: Address: Relationship: Phone #: Personal Reference #3: Address: Relationship: Phone #: In case of emergency notify: Name: Relationship: Phone #: Address: G. VEHICLE AND PET INFORMATION (if applicable) List any cars, trucks, or other vehicles owned. Parking will be provided for one vehicle. Arrangements with Management will be necessary for more than one vehicle. Type of Vehicle: License Plate #: Year/Make: Color: Add another vehicle Do you own any pets? No Yes If yes, describe: Is your pet moving into the apartment? No Yes Is your pet current with all vaccines? No Yes CERTIFICATION I/We hereby certify that I/We Do/Will Not maintain a separate subsidized rental unit in another location. I/We further certify that this will be my/our permanent residence. I/We understand I/We must pay a security deposit for this apartment prior to occupancy. I/We understand that my eligibility for housing will be based on applicable income limits and by management’s selection criteria. I/We certify that all information in this application is true to the best of my/our knowledge and I/We understand that false statements or information are punishable by law and will lead to cancellation of this application or termination of tenancy after occupancy. All adult applicants, 18 or older, must sign application. SIGNATURE (S): (Signature of Tenant) Clear e-signature Date: Add another signature AUTHORIZATION FOR RELEASE OF CREDIT, CRIMINAL & SEX OFFENDER REPORTS Your signature on this form, and the signatures of each member of your household who is 18 year of age or older, authorizes the U.S. Department of Housing and Urban Development (HUD) and New Neighborhoods, Inc. to obtain credit, criminal and sex offender information. Sensitive Information: the consent granted by this form may be used as basis to collect sensitive information which is protected by the Privacy Act. Such information will not be disclosed or released outside of HUD except to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. Please see the Federal Privacy Act Statement for a more detailed description of your privacy rights. Instructions: Each adult member of the household must sign the form as part of the application process. Additional signatures must be obtained from new adult members whenever they join the household. Conditions: I agree that photocopies of this authorization may be used to obtain necessary credit and criminal information. If I or any adult member of my household fails to sign this authorization, I understand that this action may constitute ground s for denial of eligibility. Signature: Clear Date of Birth: SS #: Driver’s License #: Add another signature New Neighborhood does not discriminate on the basis of handicapped status, race, gender, religion, or ethnic background. Send Thank you for your message. It has been sent.