Application for Admission - Christopher Community · All applicants will be screened in order to determine their capability of fulfilling 5

1 revised 6/2015

EQUAL HOUSING OPPORTUNITY

(Office use only) Property Name: ________________________ Date Received: ___________________ Address: ______________________________ Time Received: ___________________ ______________________________________ Answering Questions on your Application: Please answer all questions truthfully. We will verify your answers through the appropriate third party source. Any misrepresentation of information related to eligibility, preference for admission, allowances, rent, family composition or prior resident history is grounds for rejection. Additionally, you should be aware that Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful, false statements or misrepresentations of any material fact involving the use of or obtaining federal funds. All information is kept confidential.

Applicant Name: _________________________________________ Phone No: _______________________

Present Address: ________________________________________

________________________________________

HOUSEHOLD COMPOSITION LIST THE HEAD OF HOUSEHOLD FIRST. (MUST BE AT LEAST 18 YEARS OF AGE OR OLDER)

LIST ALL PERSONS WHO WILL LIVE IN THE UNIT.

MEMBER #1 APPLICANT FULL NAME OF HOUSEHOLD MEMBER

HEAD OF

HOUSEHOLD

CITIZENSHIP STATUS US CITIZEN_____ ELIGIBLE NON-CITIZEN_____ INELIGIBLE NON-CITIZEN_____

DATE OF BIRTH

SOCIAL SECURITY NUMBER

GENDER: _____Male _____Female _____prefer not to disclose

PLEASE INDICATE ALL STATES WHERE THIS PERSON HAS LIVED: __Alabama, __Alaska, __Arizona, __Arkansas, __California, __Colorado, __Connecticut, __Delaware, __Florida, __Georgia, __Hawaii, __Idaho, __Illinois, __Indiana, __Iowa, __Kansas, __Kentucky, __Louisiana, __Maine, __Maryland, __Massachusetts, __Michigan, __Minnesota, __Mississippi, __Missouri, __Montana, __Nebraska, __Nevada, __New Hampshire, __New Jersey, __New Mexico, __New York, __North Carolina, __North Dakota, __Ohio, __Oklahoma, __Oregon, __Pennsylvania, __Rhode Island, __South Carolina, __South Dakota, __Tennessee, __Texas, __Utah, __Vermont, __Virginia, __Washington, __West Virginia, __Wisconsin, __Wyoming, __Washington D.C

Application for Admission

Equal Housing Opportunity

2 revised 6/2015

FULL NAME OF HOUSEHOLD MEMBER #2

RELATIONSHIP TO HEAD OF HOUSEHOLD CO-HEAD/Spouse _____ Child _____ Other Adult _____ Foster adult/child _____ Live-in Aide _____ None of Above _____

GENDER _____Male __Female _____prefer not to disclose

DATE OF BIRTH


CITIZENSHIP STATUS _____US CITIZEN _____ELIGIBLE NON-CITIZEN _____INELIGIBLE NON-CITIZEN

PLEASE INDICATE ALL STATES WHERE THIS PERSON HAS LIVED: __Alabama, __Alaska, __Arizona, __Arkansas, __California, __Colorado, __Connecticut, __Delaware, __Florida, __Georgia, __Hawaii, __Idaho, __Illinois, __Indiana, __Iowa, __Kansas, __Kentucky, __Louisiana, __Maine, __Maryland, __Massachusetts, __Michigan, __Minnesota, __Mississippi, __Missouri, __Montana, __Nebraska, __Nevada, __New Hampshire, __New Jersey, __New Mexico, __New York, __North Carolina, __North Dakota, __Ohio, __Oklahoma, __Oregon, __Pennsylvania, __Rhode Island, __South Carolina, __South Dakota, __Tennessee, __Texas, __Utah, __Vermont, __Virginia, __Washington, __West Virginia, __Wisconsin, __Wyoming, __Washington D.C.



GENDER _____Male ____Female _____prefer not to disclose

DATE OF BIRTH



PLEASE INDICATE ALL STATES WHERE THIS PERSON HAS LIVED: __Alabama, __Alaska, __Arizona, __Arkansas, __California, __Colorado, __Connecticut, __Delaware, __Florida, __Georgia, __Hawaii, __Idaho, __Illinois, __Indiana, __Iowa, __Kansas, __Kentucky, __Louisiana, __Maine, __Maryland, __Massachusetts, __Michigan, __Minnesota, __Mississippi, __Missouri, __Montana, __Nebraska, __Nevada, __New Hampshire, __New Jersey, __New Mexico, __New York, __North Carolina, __North Dakota, __Ohio, __Oklahoma, __Oregon, __Pennsylvania, __Rhode Island, __South Carolina, __South Dakota, __Tennessee, __Texas, __Utah, __Vermont, __Virginia, __Washington, __West Virginia, __Wisconsin, __Wyoming, __Washington D.C.

3 revised 6/2015



GENDER _____Male __Female _____prefer not to disclose

DATE OF BIRTH



PLEASE INDICATE ALL STATES WHERE THIS PERSON HAS LIVED: __Alabama, __Alaska, __Arizona, __Arkansas, __California, __Colorado, __Connecticut, __Delaware, __Florida, __Georgia, __Hawaii, __Idaho, __Illinois, __Indiana, __Iowa, __Kansas, __Kentucky, __Louisiana, __Maine, __Maryland, __Massachusetts, __Michigan, __Minnesota, __Mississippi, __Missouri, __Montana, __Nebraska, __Nevada, __New Hampshire, __New Jersey, __New Mexico, __New York, __North Carolina, __North Dakota, __Ohio, __Oklahoma, __Oregon, __Pennsylvania, __Rhode Island, __South Carolina, __South Dakota, __Tennessee, __Texas, __Utah, __Vermont, __Virginia, __Washington, __West Virginia, __Wisconsin, __Wyoming, __Washington D.C

If you have no Social Security Number, you claim you are exempt because:

____ You are an ineligible non-citizen ____ You were 62 as of 1/31/2010 and receiving HUD housing assistance as of 1/31/2010

CITIZENSHIP NOTIFICATION and CERTIFICATION : (For program eligibility purposes only)

In properties subject to the restriction of assistance to noncitizens, housing will be contingent upon the submission and verification of evidence of citizenship or eligible immigration status prior to the time housing is made available. Based on the evidence submitted at that time, assistance may be prorated, denied or terminated following appeals and informal hearing processes. Is the Head-of household or co-head/spouse 62 or older? ____ YES ____ NO If the head-of household or co-head/spouse is not 62 or older, do you claim eligibility because the head-of household, co-head or spouse has one or more disabilities? ____ YES ____ NO Are you currently receiving housing assistance from HUD or a PHA? ____ YES ____ NO

4 revised 6/2015

DISABILITY STATUS (For program and unit eligibility purposes only)

Christopher Community does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in federally assisted programs and activities. The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June2, 1988) V.P. of Property Management, Christopher Community, Inc., 990 James Street, Syracuse, NY 13203 Phone: (315) 424-1821 Fax: (315) 424-6048 TDD/TTY: (800) 662-1220 Note: Answers to questions on your application concerning disability status are optional, but please note that families with disabled members may be entitled to (1) certain deductions from income that affect rent or (2) units designed to be accessible for individuals with disabilities. Without this information we may not be able to calculate your rent correctly or verify your eligibility to live in an accessible unit. In addition, Person(s) with disabilities have the right to request reasonable accommodations to participate in the application process. A reasonable accommodation is some modification or change that we can make to policies or procedures that will assist an otherwise eligible applicant with a disability to take advantage of the programs under which we operate. We may be able to provide alternative methods of taking your application. You may contact our office with your request for a reasonable accommodation or structural modifications to the unit or premises. Appropriate assistance will be handled in a confidential manner and setting. If you request special unit features, the owner/agent may verify the need for those features in accordance with HUD Handbook 4350.3 Revision 1. Please identify any special housing needs your household has (For example, hearing impaired, wheelchair unit, live in aide, modification to a typical unit). Mobility Disability (Use of Walker, Cane, Wheelchair) ______YES ______NO Visual Impairment (Legally Blind) ______YES ______NO Hearing Impairment (50% Loss of Hearing or Greater) ______YES ______NO Other: ____________________________________________________________________________________________

STUDENT ELIGIBILITY Will any of the persons in the household under the age of 24 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? ______YES ______NO If YES, please answer the following questions: Are any full time student(s) married and filing a joint tax return ? ____ YES ____ NO Are any student(s) enrolled in a job training program receiving assistance under the Job Training Partnership Act? ____YES ____NO Are any full time student(s) a TANF recipient? ____YES ____NO 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? ____YES ____ NO

5 revised 6/2015

All applicants will be screened in order to determine their capability of fulfilling the lease agreement including:

criteria regarding ability to pay rent on time, with or without assistance.

The Violence Against Women Act (VAWA) provides protections to women or men who are the victims of domestic

violence, dating violence, sexual assault or stalking. The owner/agent understands that regardless of whether state

or local laws protect victims of domestic violence, dating violence, sexual assault or stalking, people who have been

victims of violence have certain rights under federal fair housing regulation.

If any applicant or resident wishes to exercise the protections provided in the VAWA, he/she should contact the

owner/agent immediately. The owner/agent is committed to ensuring that the Privacy Act is enforced in this and

all other situations.

In order to receive the protections outlines in the VAWA, the applicant/resident must specify that he/she wishes to

exercise these protections.

RENTAL HISTORY

(Please list for the past five years. If you require additional space, please attach a page.)

Are you currently homeless? ____YES ____NO If yes, please skip questions about your current landlord and

answer questions related to your most recent landlord.

Current Landlord: _________________________________________________________________________________

Address: ________________________________________________________________________________________

City, State, Zip code:_______________________________________________________________________________

Contact Name (if known):___________________________________________________________________________

Phone Number:___________________________________________________________________________________

How long have you lived at this address? ______________________________________________________________

Reason for leaving? _______________________________________________________________________________

Did you owe the previous landlord any money when you left or do you currently have an outstanding balance owed to

this landlord? ____ YES ____ NO

Have you been evicted or is this landlord attempting to evict you or another person currently living with you?

____ YES ____ NO Have you given this landlord notice that you will be moving? ____ YES ____ NO

Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control?

includes roaches, rodents, bed bugs etc… ____ YES ____ NO

6 revised 6/2015

PREVIOUS LANDLORD #1:___________________________________________________________________________

Address:_________________________________________________________________________________________

City, State, Zip code:_______________________________________________________________________________


Phone Number:___________________________________________________________________________________

How long did you live at this address? _________________________________________________________________





includes roaches, rodents, bed bugs etc… ____ YES ____ NO

PREVIOUS LANDLORD #2:___________________________________________________________________________

Address:_________________________________________________________________________________________

City, State, Zip code: _______________________________________________________________________________


Phone Number: ___________________________________________________________________________________

How long did you live at this address? _________________________________________________________________





Includes roaches, rodents, bed bugs etc… ____ YES ____ NO

HOUSEHOLD CHARACTERISTICS

Are you enlisted or a veteran of the U.S. Military? ____YES ____NO

Are you a victim of a presidentially declared disaster? ____YES ____NO

7 revised 6/2015

PETS & ASSISTANCE/COMPANION ANIMALS:

THE PRESENCE OF ANY ANIMAL MUST BE APPROVED BEFORE THE ANIMAL IS ALLOWED TO BE KEPT IN THE UNIT.

Do you plan to house an animal in the unit? ____ YES ____ NO If NO, please move onto the next section.

If YES, please provide the following information:

ANIMAL TYPE BREED HEIGHT (measured at shoulders WEIGHT______________

______________________________________________________________________________________________

Is this animal required to live in the unit to alleviate the symptom(s) of a disability for a household member?

____YES ____NO

UTILITY PROVIDERS Do you have any current outstanding balances owed to any utility provider? ____ YES ____ NO Will you be able to establish utilities in your unit? ____ YES ____ NO

RACE/ETHNICITY INFORMATION (For statistical purposes only)

The information regarding race, ethnicity and sex designation solicited on this application is requested for statistical purposes only.

You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your

application or to discriminate against you in any way.

Race of Head of Household (please check all that apply): _____American Indian/or Alaska Native _____Asian _____Black or African American _____Native Hawaiian or Pacific Islander _____White _____Other Ethnicity of Head of Household (please check one): _____Hispanic or Latino _____Not Hispanic or Latino

MARKETING

How did you hear about this apartment complex?

___FRIEND/RELATIVE ____ NEWSPAPER/TELEVISION ___ SOMEONE YOU KNOW LIVES IN BUILDING _____ DRIVE BY PROPERTY ___WEBSITE _____ AGENCY/OTHER (please explain below):

8 revised 6/2015

THE OWNER/AGENT WILL NOT PROCESS THE APPLICATION IF THESE FIELDS ARE NOT COMPLETE.

INCOME

List all sources of income as requested below. Please write 0.00, N/A or None if you will receive no income from these sources. List all gross monthly income (income before taxes are taken out) SOCIAL SECURITY? ____ CHECK ____ DIRECT DEPOSIT ____PRE-PAID DEBIT CARD $_______________________

SSI? ____CHECK ____DIRECT DEPOSIT ____PRE-PAID DEBIT CARD $_______________________

RETIREMENT BENEFITS? CHECK DIRECT DEPOSIT PRE-PAID DEBIT CARD $_______________________

VA BENEFITS? CHECK DIRECT DEPOSIT PRE-PAID DEBIT CARD $_______________________

UNEMPLOYMENT BENEFITS? CHECK DIRECT DEPOSIT PRE-PAID DEBIT CARD $_______________________

CHILD SUPPORT? CHECK DIRECT DEPOSIT PRE-PAID DEBIT CARD $_______________________

ALIMONY AMOUNT? CHECK DIRECT DEPOSIT PRE-PAID DEBIT CARD $_______________________

PUBLIC ASSISTANCE? CHECK DIRECT DEPOSIT ____ PRE-PAID DEBIT CARD $_______________________

INCOME FROM A PENSION OR ANNUITY OR OTHER ASSET? $_______________________

PERIODIC PAYMENTS FROM LONG-TERM CARE INSURANCE, DISABILITY OR DEATH BENEFITS? $_______________________

ANY LUMP SUM AMOUNTS FROM DELAY OF PAYMENTS FOR SSI OR VA DISABILITY? $_______________________

REGULAR CONTRIBUTIONS FROM ORGANIZATIONS OR FROM INDIVIDUALS NOT LIVING IN THE UNIT? $_______________________

CONTRIBUTIONS FROM FAMILY FOR RENT, CHILD CARE OR OTHER BILLS? $_______________________

DO YOU RECEIVE FINANCIAL AID FOR EDUCATION ASSISTANCE? ___ YES ____NO $_______________________

OTHER? $_______________________

In order to determine eligibility and to ensure that you and your family receive the correct assistance, please provide

the following information: Are you employed? ____YES ____NO

(If YES, Please provide the name and address of your present employer below)

Employer #1 (Name) ___________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________

City, State, Zip: _______________________________________________________________________________________________

Phone: ____________________________________________________________________________________________

How much gross employment income do you expect to receive in the next 12 months? $____________________________

9 revised 6/2015

Employer #2 (Name) ___________________________________________________________________________________________

Address: _____________________________________________________________________________________________________

Address: _____________________________________________________________________________________________________

City, State, Zip: ________________________________________________________________________________________________

Phone: ______________________________________________________________________________________________________

How much gross employment income do you expect to receive in the next 12 months? $____________________________

ASSETS INFORMATION

THE OWNER/AGENT WILL NOT PROCESS THE APPLICATION IF THESE FIELDS ARE NOT COMPLETE.

(PLEASE WRITE 0.00, N/A OR None if the asset value is zero) HAVE YOU SOLD OR GIVEN AWAY REAL PROPERTY OR OTHER ASSETS VALUED AT $1,000.00 OR MORE INCLUDING CASH DONATIONS IN THE PAST TWO YEARS? ____YES __NO HAVE YOU GIVEN ANY MONEY TO CHARITIES IN THE PAST TWO YEARS? ____ YES _ NO

ARE ANY BENEFITS DEPOSITED INTO A DIRECT EXPRESS DEBIT CARD ACCOUNT? ___ YES __NO

DO YOU HAVE A CHECKING ACCOUNT? _____ YES ___NO

(If you answered yes, you will be required to provide the most recent six month’s bank statements so that we may

estimate the value of the asset in accordance with HUD requirements.

DO YOU HAVE A SAVINGS ACCOUNT? _YES NO CURRENT BALANCE-$________________

DO YOU HAVE CASH THAT IS NOT DEPOSITED IN AN ACCOUNT? ____YES _ NO AMOUNT-$_______________

DO YOU OWN AN IRA OR OTHER RETIREMENT ACCOUNT? ___YES __NO CURRENT BALANCE-$___________ ____

DO ANY OF YOUR RETIREMENT ACCT’S HAVE A REQUIRED MINIMUM DISTRIBUTION? ___YES __NO AMT-$________ ____

DO YOU OWN A HOME OR OTHER PROPERTY? __YES _ _NO CURRENT VALUE-$__________

DO YOU HAVE BUSINESS INCOME? ___YES __NO CURRENT VALUE OF BUSINESS-$ _________

DO YOU OWN STOCKS/BONDS, CERTIFICATES OF DEPOSIT (CD) ___YES __NO CURRENT VALUE-$_____________ ____

DO YOU OWN A LIFE INSURANCE POLICY? ___YES ___NO CURRENT VALUE- $______________________________

DO YOU OWN AN ANNUITY? ____YES NO CURRENT VALUE -$____________________________

IS THERE A TRUST FUND IN YOUR NAME OR HAVE YOU ESTABLISHED A TRUST FUND FOR SOMEONE ELSE? ____YES ____NO

CURRENT VALUE- $_______________

DO YOU HAVE A SAFETY DEPOSIT BOX? ____YES ____NO

10 revised 6/2015

ARE ASSETS STORED IN THE SAFETY DEPOSIT BOX SUCH AS SAVINGS BONDS, CASH, and STOCKS ETC…? ____YES ___NO

DO YOU HAVE ACCESS TO ANY OTHER ASSETS, PROPERTY, INSURANCE POLICIES, BUSINESSES, ETC…? ____YES ____NO PROVIDE A DESCRIPTION OF THE ASSSET(S) AND THE CURRENT VALUE BELOW: __________________________________________________________________________________________________

DEDUCTIONS HOUSEHOLD INCOME CAN BE REDUCED BASED ON THE AMOUNT OF QUALIFIED MONTHLY EXPENSES. HOUSEHOLDS IN WHICH THE HEAD OF HOUSEHOLD, CO-HEAD OF HOUSEHOLD OR SPOUSE ARE DISABLED OR AT LEAST 62 YEARS OLD QUALIFY FOR DEDUCTIONS BASED ON OUT OF POCKET MEDICAL EXPENSES. PLEASE LET US KNOW IF YOU OR ANY MEMBERS OF YOUR HOUSEHOLD HAVE OUT OF POCKET EXPENSES FOR THE FOLLOWING: HEALTH INSURANCE #1 –ANNUAL PREMIUM $_____________________________________________________________________

HEALTH INSURANCE #2- ANNUAL PREMIUM $_____________________________________________________________________

HEALTH INSURANCE #3- ANNUAL PREMIUM $_____________________________________________________________________

DR. VISIT/MEDICAL TREATMENTS- ANNUAL OUT-OF-POCKET EXPENSE: $______________________________________________

PRESCRIPTION DRUGS- ANNUAL OUT-OF-POCKET EXPENSE $________________________________________________________

DO YOU HAVE AN HMO, MEDICAL PLAN OR HEALTH INSURANCE POLICY WHICH PAYS ALL OR PART OF THE COST OF YOUR

MEDICATIONS? ____YES ____NO IF YES, PLEASE GIVE THE NAME OF THE HMO, PLAN, INSURANCE COMPANY BELOW:

____________________________________________________________________________________________________________

WHAT AMOUNT OR % MUST YOU PAY? $_______________________ %_____________________

IF YOU MUST PAY FOR THE MEDICINES YOURSELF, ARE YOU LATER REIMBURSED ALL OR PART OF THE COST? _____YES ____NO

IF YES, WHO REIMBURSES YOU? ___________________________________________ _ _

OVER- THE- COUNTER MEDICAL EXPENSES TO TREAT A SPECIFIC MEDICAL CONDITION, ANNUAL OUT-OF-POCKET EXPENSE TO YOU

EXAMPLE: ASPIRIN FOR HEART CONDITION, CALCIUM SUPPL FOR OSTEOPOROSIS $_____________________ _____________

PERSONAL USE ITEMS ANNUAL OR OUT–OF-POCKET EXPENSE: GLASSES, INCONTINENCE SUPPLIES, HEARING AIDS $_ __________

COST/CARE FOR ASSISTANCE/COMPANION ANIMALS ANNUAL OUT OF POCKET EXPENSE $______________________________

MILEAGE TO/FROM MEDICAL APPOINTMENTS, total number of miles: ____________________________ _______

ARE THERE ANY OTHER MEDICAL EXPENSES, WHICH YOU PAY, THAT WE SHOULD CONSIDER WHEN CALCULATING YOUR RENT?

____________________________________________________________________________________________________________

ANNUAL CHILD CARE FOR A MINOR 12 YRS. OF AGE OR YOUNGER: _$___________________________

CHILD CARE IS NEEDED: THE PARENT/GUARDIAN IS: ____EMPLOYED ____SEEKING EMPLOYMENT ____ATTENDING SCHOOL?

PROVIDER NAME: ____________________________________________________________________________________________

PROVIDER ADDRESS: __________________________________________________________________________________________

CITY, STATE, ZIP: ______________________________________________________________________________________________

11 revised 6/2015

ANNUAL COST OF CARE FOR A DISABLED FAMILY MEMBER TO ALLOW ANY ADULT FAMILY MEMBER TO WORK: $________________

PROVIDER NAME: _____________________________________________________________________________________________

CITY, STATE, ZIP: ______________________________________________________________________________________________

EXPENSES FOR AUXILIARY AIDES FOR A DISABLED FAMILY MEMBER: $___________________________________________________

CRIMINAL HISTORY ALL APPLICANTS:

All applicants and household members will be screened for criminal history.

Have you or any member of your household ever been convicted of manufacturing or distributing a controlled

substance? ______YES ______NO

Have you or any member of your household ever been convicted of a crime or sexual offense? ______YES______NO

If yes, please describe: _______________________________________________________________________________

Are you or any member or your household on the sex offender registry in any state? ____YES____NO

If answered yes, are you subject to lifetime offender registration in any state? ____YES ____NO

PENALTIES FOR MISUSING THIS FORM

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making

false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner

(or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or

improper uses of information collected based on the consent form. Use of the information collected based on this

verification form is restrcited to the purposes cited above. Any person who knowingly or willfully request, obtains

ordiscloses any information under false pretenses concerning an applicant or particpant may be subject to a

misdemeanor and fined not more than $5000. Any applicant or participant affected by negligent disclosure of

information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or

employee of HUD, the PHA or the owner responsible for the unauthorized discloseure or improper use. Penalty

provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8).

Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

12 revised 6/2015

APPLICANT CERTIFICATION

I/WE certify that if selected to move into this project, the unit I/WE occupies will be my/our only residence. I/WE understand that the above information is being collected to determine my/our eligibility for assistance. I/WE authorize the owner to verify all information provided on this application and to contact previous or current landlords or other sources for credit and verification information which may be released to appropriate Federal, State or Local agencies. I/WE certify that the statements made in this application are true and complete to the best of my/our knowledge. I/WE understand that false statements or information are punishable under Federal law and could result in this application being rejected. I/WE understand that my occupancy is contingent on meeting management’s Tenant Selection Plan and the Federal Rental Assistance Program requirements. I/WE also give authorization to complete a background check on All household members listed, 18 years of age or older. All Adult Household members (18 years of age or older) must sign below:

Print Name Head of Household: ______________________________________ Signature: ________________________________________________________ Date __________ Management Signature: ______________________________________________ Date___________

APPLICANT CERTIFICATION

I/WE certify that if selected to move into this project, the unit I/WE occupies will be my/our only residence. I/WE understand that the above information is being collected to determine my/our eligibility for assistance. I/WE authorize the owner to verify all information provided on this application and to contact previous or current landlords or other sources for credit and verification information which may be released to appropriate Federal, State or Local agencies. I/WE certify that the statements made in this application are true and complete to the best of my/our knowledge. I/WE understand that false statements or information are punishable under Federal law and could result in this application being rejected. I/WE understand that my occupancy is contingent on meeting management’s Tenant Selection Plan and the Federal Rental Assistance Program requirements. Print Name: ______________________________________________________ Signature: _________________________________________________________ Date __________

OMB Control # 2502-0581 Exp. (02/28/2019)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Applicant Name:

Mailing Address: Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization: Address: Telephone No: Cell Phone No: E-Mail Address (if applicable): Relationship to Applicant: Reason for Contact: (Check all that apply)

Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent

Assist with Recertification Process Change in lease terms Change in house rules Other: ______________________________

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

Form HUD- 92006 (05/09)

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and costly to the owner or m

anager than contacting your incom

e source directly for verifi cation.

Property ow

ners and managers are able to use the

EIV

system to determ

ine if you:•

correctly reported your income

They will also be able to determ

ine if you:

• U

sed a false social security number

• Failed to report or under reported the incom

e of a spouse or other household m

ember

• R

eceive rental assistance at another property

Is my con

sent req

uired

to get in

formation

abou

t me from

EIV

?

Yes. When you sign form

HU

D-9887, N

otice and C

onsent for the Release of Inform

ation, and form

HU

D-9887-A

, Applicant’s/Tenant’s C

onsent to the R

elease of Information, you are giving your consent

for HU

D and the property ow

ner or manager

to obtain information about you to verify your

employm

ent and/or income and determ

ine your eligibility for H

UD

rental assistance. Your failure to sign the consent form

s may result in the denial

of assistance or termination of assisted housing

benefi ts.

Wh

o has access to th

e EIV

in

formation

?

Only you and those parties listed on the consent form

H

UD

-9887 that you must sign have access to the

information in E

IV pertaining to you.

Wh

at are my resp

onsib

ilities?

As a tenant in a H

UD

assisted property, you must

certify that information provided on an application

for housing assistance and the form

used to certify and recertify your assistance (form

H

UD

-50059) is accurate and honest. This is also described in the Tenants R

ights &

Responsibilities brochure

that your property owner or

manager is required to give to

you every year.

Ow

ne

r’s C

ertific

atio

n o

f Co

mp

lian

ce

U

. S. D

ep

artm

en

t of H

ou

sin

g

with

HU

D’s

Te

na

nt E

ligib

ility

An

d U

rba

n D

ev

elo

pm

en

t

(Exp. 1

2/3

1/2

007)

Office of H

ousing OM

B Approval Num

ber 2502-0204a

nd

Re

nt P

roc

ed

ure

sF

ed

era

l Ho

usin

g C

om

mis

sio

ne

r

Se

ctio

n A

. A

ck

no

wle

dg

em

en

ts

Pu

blic

Re

po

rting

Bu

rde

n.

Th

e re

po

rting

bu

rde

n fo

r this

co

llectio

n o

f info

rma

tion

is e

stim

ate

d to

ave

rag

e 5

5 m

inu

tes p

er re

sp

on

se

, in

clu

din

g th

e tim

e fo

r revie

win

g in

stru

ctio

ns, s

ea

rch

ing

exis

ting

da

ta s

ou

rce

s, g

ath

erin

g a

nd

ma

inta

inin

g th

e d

ata

ne

ed

ed

, an

d c

om

ple

ting

a

nd

revie

win

g th

e c

olle

ctio

n o

f info

rma

tion

. Se

nd

co

mm

en

ts re

ga

rdin

g th

is b

urd

en

estim

ate

or a

ny o

the

r asp

ect o

f this

co

llectio

n o

f in

form

atio

n in

clu

din

g s

ug

ge

stio

ns fo

r red

ucin

g th

is b

urd

en

, to th

e O

ffice

of M

an

ag

em

en

t an

d B

ud

ge

t, Pa

pe

rwo

rk R

ed

uctio

n P

roje

ct (2

50

2-

02

04

), Wa

sh

ing

ton

, DC

20

50

3. T

he

info

rma

tion

is b

ein

g c

olle

cte

d b

y H

UD

to d

ete

rmin

e a

n a

pp

lica

nt's

elig

ibility, th

e re

co

mm

en

de

d u

nit

siz

e, a

nd

the

am

ou

nt th

e te

na

nt(s

) mu

st p

ay to

wa

rd re

nt a

nd

utilitie

s. H

UD

use

s th

is in

form

atio

n to

assis

t in m

an

ag

ing

ce

rtain

HU

D

pro

pe

rties, to

pro

tect th

e G

ove

rnm

en

t's fin

an

cia

l inte

rest, a

nd

to v

erify

the

accu

racy o

f the

info

rma

tion

furn

ish

ed

. HU

D o

r a P

ub

lic H

ou

sin

g

Au

tho

rity (P

HA

) ma

y c

on

du

ct a

co

mp

ute

r ma

tch

to v

erify

the

info

rma

tion

yo

u p

rovid

e. T

his

info

rma

tion

ma

y b

e re

lea

se

d to

ap

pro

pria

te

Fe

de

ral, S

tate

, an

d lo

ca

l ag

en

cie

s, w

he

n re

leva

nt, a

nd

to c

ivil, c

rimin

al, o

r reg

ula

tory

inve

stig

ato

rs a

nd

pro

se

cu

tors

. Ho

we

ve

r, the

in

form

atio

n w

ill no

t be

oth

erw

ise

dis

clo

se

d o

r rele

ase

d o

uts

ide

of H

UD

, exce

pt a

s p

erm

itted

or re

qu

ired

by la

w. Y

ou

mu

st p

rovid

e a

ll of th

e

info

rma

tion

req

ue

ste

d, in

clu

din

g th

e S

ocia

l Se

cu

rity N

um

be

rs (S

SN

s) y

ou

, an

d a

ll oth

er h

ou

se

ho

ld fa

mily

me

mb

ers

ag

e s

ix (6

) ye

ars

an

d

old

er, h

ave

an

d u

se

. Giv

ing

the

SS

Ns o

f all fa

mily

me

mb

ers

ag

e s

ix (6

) ye

ars

an

d o

lde

r is m

an

da

tory

; no

t pro

vid

ing

the

SS

Ns w

ill affe

ct

yo

ur e

ligib

ility. Fa

ilure

to p

rovid

e a

ny in

form

atio

n m

ay re

su

lt in a

de

lay o

r reje

ctio

n o

f yo

ur e

ligib

ility a

pp

rova

l.

Re

ad

this

be

fore

yo

u c

om

ple

te a

nd

sig

n th

is fo

rm H

UD

-50

05

9

Priv

ac

y A

ct S

tate

me

nt.

Th

e D

epa

rtme

nt o

f Ho

usin

g a

nd

Urb

an

De

ve

lop

me

nt (H

UD

) is a

uth

oriz

ed

to c

olle

ct th

is in

form

atio

n b

y th

e U

.S.

Ho

usin

g A

ct o

f 19

37

, as a

me

nd

ed

(42

U.S

.C. 1

43

7 e

t. se

q.); th

e H

ou

sin

g a

nd

Urb

an

-Ru

ral R

eco

ve

ry A

ct o

f 19

83

(P.L

. 98

-18

1); th

e

Ho

usin

g a

nd

Co

mm

un

ity D

eve

lop

me

nt T

ech

nic

al A

me

nd

me

nts

of 1

98

4 (P

.L. 9

8-4

79

); an

d b

y th

e H

ou

sin

g a

nd

Co

mm

un

ity D

eve

lop

me

nt

Act o

f 19

87

(42

U.S

.C. 3

54

3).

Wa

rnin

g to

Ow

ne

rs a

nd

Te

na

nts

. B

y s

ign

ing

this

form

, yo

u a

re in

dic

atin

g th

at y

ou

ha

ve

rea

d th

e a

bo

ve

Priv

acy A

ct S

tate

me

nt a

nd

are

a

gre

ein

g w

ith th

e a

pp

lica

ble

Ce

rtifica

tion

.

Fa

lse

Cla

im S

tate

me

nt.

Wa

rnin

g: U

.S. C

od

e, T

itle 3

1, S

ectio

n 3

72

9, F

als

e C

laim

s, p

rovid

es a

civ

il pe

na

lty o

f no

t less th

an

$5

,00

0 a

nd

n

ot m

ore

tha

n $

10

,00

0, p

lus 3

time

s th

e a

mo

un

t of d

am

ag

es fo

r an

y p

ers

on

wh

o k

no

win

gly

pre

se

nts

, or c

au

se

s to

be

pre

se

nte

d, a

fals

e o

r fra

ud

ule

nt c

laim

; or w

ho

kn

ow

ing

ly m

ake

s, o

r ca

use

d to

be

use

d, a

fals

e re

co

rd o

r sta

tem

en

t; or c

on

sp

ires to

de

frau

d th

e G

ove

rnm

en

t by

ge

tting

a fa

lse

or fra

ud

ule

nt c

laim

allo

we

d o

r pa

id.

Ow

ne

r's C

ertific

atio

n -

I ce

rtify th

at th

is T

en

an

t's e

ligib

ility, ren

t an

d a

ssis

tan

ce

pa

ym

en

ts h

ave

be

en

co

mp

ute

d in

acco

rda

nce

with

HU

D's

re

gu

latio

ns a

nd

ad

min

istra

tive

pro

ce

du

res a

nd

tha

t all re

qu

ired

ve

rifica

tion

s w

ere

ob

tain

ed

.

Te

na

nt(s

)' Ce

rtifica

tion

-I/W

e c

ertify

tha

t the

info

rma

tion

in S

ectio

ns C

, D, a

nd

E o

f this

form

are

true

an

d c

om

ple

te to

the

be

st o

f my/o

ur

kn

ow

led

ge

an

d b

elie

f. I/We

un

de

rsta

nd

tha

t I/we

ca

n b

e fin

ed

up

to $

10

,00

0, o

r imp

riso

ne

d u

p to

five

ye

ars

, or lo

se

the

su

bsid

y H

UD

pa

ys

an

d h

ave

my/o

ur re

nt in

cre

ase

d, if I/w

e fu

rnis

h fa

lse

or in

co

mp

lete

info

rma

tion

.

Ce

rtifica

tion

Su

mm

ary

from

Pa

ge

2

Na

me

of P

roje

ct

Un

it Nu

mb

er

Effe

ctiv

e D

ate

C

ertific

atio

n T

yp

e

He

ad

of H

ou

se

ho

ld

To

tal T

en

an

t Pa

ym

en

t A

ssis

tan

ce

Pa

ym

en

t Te

na

nt R

en

t

Te

na

nt S

ign

atu

res

H

ea

d o

f Ho

use

ho

ld

Da

te

Oth

er A

du

ltO

the

rA

du

ltD

ate

Da

te

Sp

ou

se

/ Co

-He

ad

D

ate

O

the

r Ad

ult

Da

te

Oth

er A

du

lt D

ate

O

the

r Ad

ult

Da

te

Oth

er A

du

lt D

ate

O

the

r Ad

ult

Da

te

Oth

er A

du

lt D

ate

O

the

r Ad

ult

Da

te

Oth

er A

du

lt D

ate

O

the

r Ad

ult

Da

te

Oth

er A

du

lt D

ate

O

the

r Ad

ult

Da

te

Ow

ne

r/Ag

en

t Sig

na

ture

O

wn

er/A

ge

nt

Da

te

Check th

is b

ox if T

enant is

unable

to s

ign fo

r a le

gitim

ate

reason

An

ticip

ate

d V

ou

ch

er D

ate

Pre

vio

us v

ers

ion

s o

f this

form

are

ob

so

lete

. P

ag

e1

of

__

fo

rm H

UD

-50

05

9 (0

4/2

00

5)

Th

is fo

rm a

lso

rep

lace

s H

UD

-50

05

9-D

, -E, -F

, & -G

. H

B 4

35

0.3

Re

v 1

NO

T for Submission to the Federal G

overnment

Landlord's Official R

ecord of Certification

Enterprise INCO

ME VERIFICATIO

N (EIV

)

EIV&You

Are you applying for or

What is EIV?

EIV

is a web-based com

puter system containing em

ployment

and income inform

ation on individuals participating in HU

D’s

rental assistance programs. This inform

ation assists HU

D in

making sure “the right benefi ts go to the right persons”.

What incom

e information is in EIV

and where does it com

e from?

The Social S

ecurity Adm

inistration:•

Social S

ecurity (SS

) benefi ts•

Supplem

ental Security Incom

e (SS

I) benefi ts

JULY 2009

Wh

at if I disag

ree with

the E

IV

inform

ation?

If you do not agree with the em

ployment and/or

income inform

ation in EIV, you m

ust tell your property ow

ner or manager. Your property ow

ner or manager

will contact the incom

e source directly to obtain verifi cation of the em

ployment and/or incom

e you disagree w

ith. Once the property ow

ner or manager

receives the information from

the income source, you

will be notifi ed in w

riting of the results.

Wh

at if I did

not rep

ort incom

e p

reviously an

d it is n

ow b

eing

rep

orted in

EIV

?

If the EIV

report discloses income from

a prior period that you did not report, you have tw

o options: 1) you can agree w

ith the EIV

report if it is correct, or 2) you can dispute the report if you believe it is incorrect. The property ow

ner or manager w

ill then conduct a w

ritten third party verifi cation with the

reporting source of income. If the source confi rm

s this incom

e is accurate, you will be required to repay

any overpaid rental assistance as far back as fi ve (5) years and you m

ay be subject to penalties if it is determ

ined that you deliberately tried to conceal your incom

e.

Wh

at if the in

formation

in E

IV is

not ab

out m

e?

EIV

has the capability to uncover cases of potential identity theft; som

eone could be using your social security num

ber. If this is discovered, you must

notify the Social S

ecurity Adm

inistration by calling them

toll-free at 1-800-772-1213. Further information

on identity theft is available on the Social S

ecurity A

dministration w

ebsite at: http://ww

w.ssa.gov/

pubs/10064.html.

Wh

o do I con

tact if my in

come

or rental assistan

ce is not b

eing

calcu

lated correctly?

First, contact your property owner or m

anager for an explanation.

If you need further assistance, you may contact the

contract administrator for the property you live in;

and if it is not resolved to your satisfaction, you m

ay contact HU

D. For

help locating the HU

D

offi ce nearest you, which

can also provide you contact inform

ation for the contract adm

inistrator, please call the M

ultifamily

Housing C

learinghouse at: 1-800-685-8470.

Wh

ere can I ob

tain m

ore in

formation

on E

IV an

d th

e in

come verification

process?

Your property owner or m

anager can provide you w

ith additional information on E

IV and the incom

e verifi cation process. They can also refer you to the appropriate contract adm

inistrator or your local H

UD

offi ce for additional information.

If you have access to a computer, you can read

more about E

IV and the incom

e verifi cation process on H

UD

’s Multifam

ily EIV

homepage at:

ww

w.hud.gov/offi ces/hsg/m

fh/rhiip/eiv/eivhome.

cfm.

Penalties for providing false information

Providing false inform

ation is fraud. Penalties for

those who com

mit fraud could include eviction,

repayment of overpaid assistance received, fi nes

up to $10,000, imprisonm

ent for up to 5 years, prohibition from

receiving any future rental assistance and/or state and local governm

ent penalties.

Protect yourself, follow H

UD

reporting requirem

ents

When com

pleting applications and recertifi cations, you m

ust include all sources of income you or any

mem

ber of your household receives. Som

e sources include:

• Incom

e from w

ages•

Welfare paym

ents•

Unem

ployment benefi ts

• S

ocial Security (S

S) or S

upplemental S

ecurity Incom

e (SS

I) benefi ts•

Veteran benefi ts•

Pensions, retirem

ent, etc.•

Income from

assets•

Monies received on behalf of a child such as:

- Child support

- AFD

C paym

ents- S

ocial security for children, etc.

If you have any questions on whether m

oney received should be counted as incom

e, ask your property ow

ner or manager.

When changes occur in your household incom

e or fam

ily composition,

imm

ediately contact your property ow

ner or manager to

determine if this w

ill affect your rental assistance.

Your property owner or

manager is required to provide

you with a copy of the fact sheet “H

ow Your R

ent Is D

etermined” w

hich includes a listing of what is

included or excluded from incom

e.

Christopher Community Applicant Survey

Thank you for taking the time to respond to this survey. Your participation will help Christopher Community (CCI) serve our region's housing needs by helping with future development planning. All surveys will be confidential as you are not required to sign your name on the survey. Please return the filled out survey the CCI office or building manager.

1. What is your current housing situation?

Shelter / Homeless Own HomeRenting Living with family or friendsOther

Comments about your current housing:

2. Reason you want to move:

End of lease Home saleEviction Seeking more affordable housingOther

Comments about reason for move:

3. When do you want to move?

Immediate / ASAP Next month2 or more months from nowOther

Comments about when you want to move:

4. How did you find out about CCI Housing (or this building)? {Choose all that apply}

Word of mouth Professional referralAdvertisement (list where in Comments) Know current residentDrove by Christopher Community WebsiteOther

Comments about how you found out about CCI Housing:

5. What made you interested in CCI Housing and specifically this building? {Choose allthat apply}

Area of Town Accessibility features AffordabilityAccess to transportation Other

Comments about your interest in CCI Housing:

6. What type of housing amenities are you looking for? {Choose all that apply} ThisSurvey is to help CCI with future development planning. Not all items are currently available.

Community Meal Service Washer/Dryer hook-upTenant Activities / Recreation Assistance with Finding ServicesAccess to Community Transportation Weekly Shopping BusOff-street Parking Walk-in ShowerDishwasher Wi-fiCableOther

Comments about amenities:

Thank you!

Documents

Application for Admission - Christopher Community · All applicants will be screened in order to determine their capability of fulfilling 5