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Application for admission – Mahal Plaza Apartments

Head of Household

Name(Required)

Social Security #(Required)

Drivers Lic. #

Sex(Required)

Male

Female

Birth date(Required)

MM slash DD slash YYYY

State

Marital Status of Head of Household(Required)

Married

Separated

Unmarried (single, divorced or widowed)

Email(Required)

List all others who will occupy the unit:

Name

Social Security #

Birth date

Sex

Relationship to Applicant

Drivers Lic. #

State

Does anyone live with you now who is not listed above?

Yes

No

If yes, who?

Relationship

The subsidy program at this project allows for a $400 disability or handicap adjustment to income. Do you request this deduction for our household?

Yes

No

If yes, please complete the following: Which member of your household entitles you tot his deduction?

Do you wish to request a handicap accessible unit?

Yes

No

Specify:

Are there any reasonable accommodations or services that you would like to request?

Yes

No

Specify:

Are you or any member of your household 18 or older attending school?

Yes

No

If yes, who:

Do you own a pet?

Yes

No

If yes, how many?

Description (cat, bird, etc.)

Do you have a waterbed?

Yes

No

If yes, do you have waterbed insurance?

Yes

No

Name of insurance Company:

APARTMENT SIZE REQUESTED:(Required)

2 Bedroom

3 Bedroom

4 Bedroom

CURRENT ADDRESS:

Street Address Address Line 2 City State ZIP Code

PHONE NUMBER:

Dates you lived here:

CURRENT MAILING ADDRESS:

Street Address City State ZIP Code

CURRENT LANDLORD:

Address:

PHONE NUMBER:

If Apt., Name of Complex

Reason you want to move:

Amount of rent you are paying

Are you currently living in a subsidized complex

Yes

No

Type

Do you have Section 8 Certificate?

Yes

No

Are you being displaced?

Yes

No

If yes, why?

Are you being displaced?Has your household’s assistance or tenancy in a subsidized housing program ever been terminated for fraud, non-payment of rent or failure to cooperate with the Recertification procedures:

Yes

No

If yes, circumstances:

PREVIOUS ADDRESS:

Previous Address:

Dates you lived here:

If Apt, Name of Complex:

Reason for moving:

Previous Landlord:

Phone Number:

Address:

Previous Address:

Dates you lived here:

If Apt, Name of Complex:

Reason for moving:

Previous Landlord:

Phone Number:

Address:

PERSONAL REFERENCES (do not list relatives):

Name

Address

Phone #

Relationship

EMERGENCY CONTACT PERSON:

Name

Address

Phone #

Relationship

AUTOMOBILE

Make:

Color:

Year:

License Plate #:

Do you own a trailer, boat, camper, moped, motorcycle, etc?

Yes

No

If yes, what type:

HOUSEHOLD FINANCIAL OBLIGATIONS:

Include all medical expenses, car payments, child support, loans, etc...

HOUSEHOLD FINANCIAL OBLIGATIONS:

PAYABLE TO : (company name)

MONTHLY PAYMENT

INCOME:

Do you or any member of your household anticipate receiving income from any of the following sources during the next twelve months? (Please mark every question YES or NO. If you answer any question:

Employment (Earned Income)

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Child Support

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Pension or Retirement Benefits

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Alimony Gifts

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

School Grants or Scholarships

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Social Security

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Supplemental security Income

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Unemployment compensation

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Veterans Administration

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Workers Disability/Compensation

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Other

Yes

No

AMOUNT RECEIVED

(Per time period)

BY WHICH FAMILY MEMBER

SOURCE OF INCOME

(name, address & phone)

Do you anticipate any change in this income in the next 12 months

Yes

No

If yes, explain:

CHILDCARE:

(Complete only if your child/children is/are 12 years of age or younger and living in your household)

Do you pay for child care expenses?

Yes

No

If yes, how much?

To whom is this expense paid?

Name:

Address:

Do you employ childcare in order for a household member to work or continue education?

Yes

No

ELDERLY HOUSEHOLDS

(Applicate only if the head of household or spouse is 62 or older or handicapped or disabled)

Do you anticipate having ANY medical expenses with in the next twelve (12) months that are not paid for by Medicare or an insurance policy?

Yes

No

If yes, explain:

(Examples: medical or dental expenses, including cost of insurance, prescriptions, eyeglasses, hearing aids or nursing care.) DO NOT INCLUDE expenses that are reimbursed or paid by others outside your household.

HANDICAPE OR DISABLED:

(Applicate only if a household member is handicapped or disabled)

Does your household have any handicap or Attendant care Expenses?

Yes

No

If yes, do you employ an attendant in order for a family member to work?

Yes

No

If yes, name and address of attendant:

Name of attendant:

Address of attendant:

ASSETS:

Have you received or do you expect to receive any LUMP SUM payments such as inheritance, lottery winnings, or insurance settlements?

Yes

No

If yes, source of income:

In the last TWO years have you sold, given away or disposed of assets or real property (examples, 3 real estate and other items held for investment purposes such as gems, jewelry, coins, or collections)?

Yes

No

If yes what type of asset:

If yes, source of income:

ASSETS:

Please mark every question either YES or NO. If you answer with a YES, complete the blanks on the right.

DO YOU HAVE.....?

Name of parties that have the following:

Checking Account (S)

Yes

No

Bank Name

Acct. Number

Savings Account (S)

Yes

No

Bank Name

Acct. Number

Money Market Account (S)

Yes

No

Bank Name

Acct. Number

Certificate/Time Deposit

Yes

No

Bank Name

Acct. Number

Trust Account(S)

Yes

No

Bank Name

Acct. Number

Stocks or Bonds

Yes

No

Bank Name

Acct. Number

IRA/Keogh/Life ins. Or other Retirement

Yes

No

Bank Name

Acct. Number

Rental/Property

Yes

No

Bank Name

Acct. Number

Other

Yes

No

Bank Name

Acct. Number

Consent(Required)

I/We certify the housing I/We will occupy at MAHAL PLAZA APARTMENTS will be my /our permanent residence and I/We will not maintain a separate rental unit in a location. I/We authorize the owner to obtain a report and to contact current and previous landlords.(Required)

Consent(Required)

I/We also certify that the information given is accurate and complete and understand any misrepresentation will disqualify the applicant.(Required)

“In accordance with Federal Law and U.S. Department of Agriculture Policy, this institution is prohibited from discrimination on the basis of race, color, national origin, age, disability, religion, sex and familial status. (Not all prohibited bases apply to all programs).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800)795-3272 (voice) or (202)720-6382 (TDD).”

It is your responsibility as applicant to keep the Management notified of any changes in your application. This includes a change in household size, current address, income or assets.

Ethnicity:(Required)

Hispanic or Latino

Not Hispanic or Latino

American India or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Head of household gender:(Required)

Female

Male

RECEIPT AND ACKNOWLEDGEMENT APPROVAL FOR CREDIT CHECK

I understand that I have read this form, have been given the opportunity to ask questions regarding the information contained herein and received a copy.(Required)

Consent(Required)

I / We grant permission to Mahal Plaza to run my credit report. I /We am/are fully aware this may affect my credit. If approved; I will potentially be contacted for an interview.(Required)

I/We, do not grant permission to Mahal Plaza to run my credit report. I am fully aware that I will not go forward with a potential interview Application process.

Reason for Denial:

Consent(Required)

I also understand that the submission of false information or the omission of pertinent information may be grounds for rejection of my Rental Assistance or termination of tenancy.(Required)

Phone

This field is for validation purposes and should be left unchanged.

Δ

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