Rental Application w/Background Information

Rental Application
Please Indicate which Apartment Complex you are interested in *

Downtown - 1620 Broadway, Scottsbluff Northfield - 2350 Five Rocks Road, Gering Eastwood Apartments - 1413 E Overland
Unit Size *

Studio 1 Bedroom 2 Bedroom
Today's Date

Month Day Year
Date
Move In Date *

Month Day Year
Date

Applicant and Co-Applicant Info (If NO Co-Applicant type NA) *

	Name
Applicant
Co-Applicant

Current Phone *

Area Code Phone Number
Other Phone

Area Code Phone Number
E-mail

Part I - Personal Information
Birth Date *

Month Day Year
Social Security #
Drivers License # or ID *
Current Marital Status (Check One) *

Single Married Divorced Separated

Part II - Rental History
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Move in Date *

Month Day Year
Move Out Date *

Month Day Year
Current Monthly Rent *
Current Landlord or Company Name *
Current Landlord Phone # *

Area Code Phone Number
Previous Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Previous Date *

Month Day Year
Previous Out Date *

Month Day Year
Amount Paid Monthly *
Previous Landlord or Company Name *
Previous Landlord Phone # *

Area Code Phone Number
Reason for Leaving *
If "other" please explain:

Part III - Family Composition
Directions to Applicant:

Please complete the table below for each member of your household, whether or not those members are related. Include all members who you anticipate will live with you at least 50% of the time during the next 12 months. (A full time student is anyone who is enrolled for at least five calendar months for the number of hours or courses which are considered full-time attendance by that institution. The five calendar months need not be consecutive. By definition, all tenants of elementary or high school age are considered full time students.)

Names of ALL people to Occupy Unit: *

	Name	Date of Birth	Gender	Relationship
1.
2.
3.
4.

Do you expect any changes in the household composition in the next 12 months? *

Yes No
If yes, please explain why
Do you of any other adult members of the household anticipate a change to the current income information within the next 12 months (i.e. seeking employment, expecting child support/alimony, expecting a promotion, etc.)? *

Yes No
If yes, please explain why

Part IV - Household Income

Directions to Applicant: For questions (3) through (22), indicate the amount of anticipated income for all household members named in the table on page 1 (for minors, unearned income amounts only), during the 12 month period beginning this date. If you are uncertain which types of income must be included or may be excluded, please ask the management personnel for assistance. If no income is received, put 0. *

	Income
(3.) Gross Annual Wages or Salaries (include overtime, tips, bonuses, commissions, and payments received in cash)
(4.) Child Support (include child support you are entitled to but may not receive)
(5.) Alimony (include alimony you are entitled to but may not receive)
(6.) Social Security
(7.) Supplemental Security Income (SSI)
(8.) Public Assistance (ADC, TANF, and/or Aid to Families with Dependent Children (AFDC)
(9.) Veterans Administration Benefits
(10.) Pensions and/or Annuities
(11.) Unemployment Compensation
(12.) Disability, Death Benefits, and/or Life Insurance Dividends
(13.) Worker's Compensation
(14.) Severance Pay
(15.) Net Income from a Business (Self employment, Inc rental prop., land contracts, or other forms of real estate)
(16.) Income from Assets
(17.) Regular Contributions and/or Gifts from Person not residing in unit
(18.) Lottery Winnings or Inheritances (Paid as an annuity)
(19.) All regular pay paid to members of the Armed Forces (Military Pay)
(20.) Education Grants, Scholarships, or Other Student Benefits
(21.) Long Term Medical Care Insurance Payments in excess of $180/day)
(22.) Other Income
TOTAL
Total Gross Annual Income from Previous Year (from Tax Return)

Part V - Asset Income

CURRENT ASSETS - List all assets currently held by all household members and the case value of each. The Cash Value is the Market Value of the asset minus reasonable costs incurred, or would be incurred if selling or converting the asset to cash. Please complete if YOU or ANYONE in Your Household Have: *

	Institution	Cash Value
(25.) A Saving Account?
(26.) A Checking Account?
(27.) Certificates of Deposit?
(28.) Money Market Account?
(29.) A Safety Deposit Box?
(30.) Trust Account?
(31.) Any Stocks or Securities?
(32.) Any Treasury Bills?
(33.) A Retirement Fund? (Includes IRA's, Keogh Accounts)
(34.) Mutual Funds?
(35.) Savings Bonds?
(36.) Have any Whole or Universal Life Insurance Policies?
(37.) Have any Personal Property held as an Investment (this includes: paintings, artwork, collector or show cars, jewelry, coin or stamp collections, antiques, etc.)?

(38.) Do you own equity in real estate, rental property, land contracts/contract for deeds or other real estate holdings or other capital investments (this includes your personal residence, mobile homes, vacant land, farms, vacation homes, or commercial property?

Yes No
If you answered yes on question #38, please tell us the type of property, location or property, appraised market value, mortgage or outstanding loans & balance due, amount of annual insurance premium, and amount of more recent tax bill.
(39.) Have you sold or disposed of any property in the last 2 years?

Yes No
If you answered yes on question #39, please tell us type of property, market value when sold or disposed, amount sold or disposed for, and date of transaction.
(40.) Have you received any Lump Sum Receipts? (Include inheritances, capital gains, lottery winnings, insurance settlements and other claims)?

Yes No
If you answered yes on question #40, please let us know when you received the lump sum, the cash value, and where the funds are held?
(41.) Have you disposed of any other assets in the last 2 years (Example: given money away to relatives, set up Irrevocable Trust Accounts)?

Yes No
If you answered yes on question #41, please describe the asset, date of disposition, and amount disposed.
(42.) Do you have any other assets not listed above (excluding personal property)?

Yes No
If you answered yes on question #42, please list below:

Part VI - Employment History
(43.) Applicants Current or Most Recent Employer *
Current Employer Address: *
Current Employer Business Phone *
Length of Employment *
Current Position / Title *
Current Salary *
Select One: *
(44.) Applicants Previous Employer *
Previous Employer Address: *
Previous Employer Business Phone *
Length of Employment with previous Employer *
Previous Position / Title *
Previous Salary *
Payroll Frequency Select One: *
Reason for Leaving Position *
(45.) Co-Applicant's Current Employer:
Co-Applicants Current Employer Address:
Co-Applicants Current Employer Business Phone
Co-Applicants Length of Employment with current employer
Co-Applicants Current Position / Title
Co-Applicants Current Salary
Select One:
(46.) Co-Applicant's Previous Employer:
Co-Applicants Previous Employer Address:
Co-Applicants Previous Employer Business Phone
Co-Applicants Length of Employment with previous employer
Co-Applicants previous Position / Title
Co-Applicants previous Salary
Select One:
Reason for Leaving Position

Part VII - Credit References

Please list your credit reference below: *

	Name	Address & Phone	Monthly Payment
(47.)
(48.)
(49.)

Part VIII - Other Information
(50.) Do you have full custody of your child(ren)? Explain the custody arrangements:
(51.) Would you or any members of your household benefit from a handicapped-accessible unit? If your answer is yes, please explain
(52.) Will your household be receiving a Section 8 rental assistance in the next 12 months? *

Yes No
If you answered yes to #52, please explain.
(53.) Will your household be eligible or are you applying to receive Section 8 rental assistance in the next 12 months?

Yes No
If you answered yes to #53, please explain *
(54.) Will this be your only place of residence?

Yes No
If you answered no to #54, please explain: *

(55.) What is the condition of your current housing?

	Condition
Standard
Unsafe or Unhealthy
Living with Parents
No indoor plumbing/kitchen
Currently without housing

Part IX - Special Needs
(56.) Does anyone in your household have special needs? *

Yes No
If you answered no to #56, please explain: *
(57.) Are special living arrangements required? *

Yes No
If you answered no to #57, please explain: *

Part X - In Case of Emergency

To be completed by applicant: *

	Name/Relationship	Address	Phone
Primary Contact
Contact
Contact

Part XI - Resident's Statement
(59.) Do you have a legal right to be in the United States: (Check one that applies) *

Yes, because I am a United States Citizen Yes, because I have valid documentation from the Bureau of Citizenship and Immigration Services (formerly The Immigration and Naturalization Service) No
If you answered "YES" because you are a non-US citizen with valid documentation, you must provide documentation and complete paperwork required by the Department of Housing and Urban Development, so we can verify that you are a non-citizen with eligible immigration status.
(60.) Please check your Race/National Origin: The Federal Government requests the following information. You are not required to furnish this information, but are encouraged to do so.

I do not with to furnish this information White, not of Hispanic Origin Black, not of Hispanic Origin Hispanic Asian or Pacific Islander

Part XI - Final Submit
I /We certify that the application contained herein is true and correct. Falsification of information will constitute the breach of all contracts. I/We hereby acknowledge and agree that the Program Administrator may contact all persons listed on this application, and I/we have no objections in checking my/our application for the purposes of verification and credit-processing. I understand that this application is for purposes of consideration for the Western Nebraska Housing Opportunities Rental and Twin Cities Development.
Applicant Signature: *

Clear
Date

Month Day Year
Date
Co-Applicant Signature:

Clear
Date

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Rental Application

Directions to Applicant:

If you answered "YES" because you are a non-US citizen with valid documentation, you must provide documentation and complete paperwork required by the Department of Housing and Urban Development, so we can verify that you are a non-citizen with eligible immigration status.