Test application form - New Neighborhoods

A. GENERAL INFORMATION

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.							No Yes

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:

D. ASSETS

Type of account:

Last 4 digits of account number: #

Bank:

Balance: $

Savings Bonds #:

Maturity Date:

Value: $

Life Insurance Policy #:

Cash Value: $

Mutual Funds Name:

# of shares:

Interest or Dividend: $

Value: $

Stocks Name:

# of shares:

Dividend paid: $

Value: $

Bonds Name:

# of shares:

Interest or Dividend: $

Value: $

Investment Property

Appraised value: $

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: $

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:

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: $

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:

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)

e-signature Date:

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:

Date of Birth:

SS #:

Driver’s License #:

New Neighborhood does not discriminate on the basis of handicapped status, race, gender, religion, or ethnic background.

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