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Application for Occupancy – Aytch Plaza

TO THE APPLICANT:

Please fill out this form completely. All references will be checked and if any information is found to be false or incomplete, the application may be rejected. Use additional pages if more space is needed.

HOUSEHOLD MEMBERS - List below all persons who will be living in the unit.

HOUSEHOLD MEMBERS

Social Security #

Birthdate

Sex

Drivers License # /State

Relationship To Applicant

Is any member of this household handicapped or disabled?

Yes

No

If yes, who?

Does this person use a wheel chair

Yes

No

Does this person receive attendant care?

Yes

No

If yes, is attendant live in?

Yes

No

Who, if anyone, in your household is receiving attendant care?

Who do you employ as an attendant in order for a family member to work?

Name

First Last

Address

Phone

Describe any pets you or anyone in your household own?

(Cat, Dog, Bird, etc.)

UNIT TYPE REQUESTED:(Required)

SRO

Studio

1 Bedroom

2 Bedroom

3 Bedroom

4 Bedroom

Handicapped

Name

First Last

Current Address:(Required)

Street Address Apt. #: City State ZIP Code

Name of Apartment Complex:

Name of Current Landlord:

Current Landlord's Telephone Number:

Lived Here From:

MM slash DD slash YYYY

Current Landlord's Address:

Monthly Rent:

Reason for Leaving:

Are you being, or have you ever been evicted?(Required)

Yes

No

If yes, explain:

Has any household member’s rental assistance or tenancy in a subsidized housing program ever been terminated for fraud, nonpayment of rent, or failure to cooperated with the recertification procedures?(Required)

Yes

No

If yes, explain the circumstances:

PREVIOUS LANDLORD:

Name of Landlord:

Landlord's Telephone Number:

Lived Here From:

MM slash DD slash YYYY

Address of Landlord:

Street Address Apt. #: City State ZIP Code

Name of Complex:

Reason for Leaving:

PREVIOUS LANDLORD:

Name of Landlord:

Landlord's Telephone Number:

Lived Here From:

MM slash DD slash YYYY

Address of Landlord:

Street Address Apt. #: City State ZIP Code

Name of Complex:

Reason for Leaving:

PREVIOUS LANDLORD:

Name of Landlord:

Landlord's Telephone Number:

Lived Here From:

MM slash DD slash YYYY

Address of Landlord:

Street Address Apt. #: City State ZIP Code

Name of Complex:

Reason for Leaving:

Name

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

Δ

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California Human Development • 3510 Unocal Place, Suite 200, Santa Rosa, CA 95403 • (707) 523-1155 • © California Human Development

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