LUTHER VILLAGE III
Tenant Application
Name (Head of Household)
*
First Name
Middle Initial
Last Name
Male or Female?
*
Male
Female
Present Address
Years of Residence
City
State
Zip
Telephone
Format: (000) 000-0000.
Social Security
*
Date of Birth
*
/
Month
/
Day
Year
Date
Name (Second Occupant)
First Name
Middle Initial
Last Name
Male or Female?
Male
Female
Social Security
Date of Birth
/
Month
/
Day
Year
Date
Relationship to Head of Household
ESTIMATED ANNUAL INCOME (RESIDENT 1)
Social Security Income
SSI
Pensions
Annuities
VA Benefits
Salary/Wages
Tax Credits
Asset Income
Total Income
ESTIMATED ANNUAL INCOME (RESIDENT 2)
Social Security Income
SSI
Pensions
Annuities
VA Benefits
Salary/Wages
Tax Credits
Total Income
VALUE OF ASSETS OWNED
Checking & Savings
Money Market
Certificates of Deposit
Stock/Mutual Funds
Bonds
Real Estate
(Market Value less mortgage balance)
Total
Fill in 5% of the total "Estimated Annual Income"
This is 5% of the total amount you filled in the previous section titled "Estimated Annual Income"
Person to contact if for some reason Applicant cannot be reached:
Name
Address
Telephone
Format: (000) 000-0000.
Place of residence for the last five years
What year did you move into your present address?
What year did you move out of your present address?
Present Landlord Name
First Name
Last Name
Present Landlord Address
Present Landlord Telephone
Format: (000) 000-0000.
What year did you move in to your previous address?
What year did you move out of your previous address?
Previous Landlord Name
First Name
Last Name
Previous Landlord Address
Previous Landlord Telephone
Format: (000) 000-0000.
What year did you move in to of your previous address?
What year did you move out of your previous address?
Previous Landlord Name
First Name
Last Name
Previous Landlord Address
Previous Landlord Telephone
Format: (000) 000-0000.
Have you ever been evicted?
Yes
No
If “Yes” What Year?
Reason for eviction
Have you ever been convicted of a felony?
Yes
No
If “Yes” What year and state?
Identify Felony
Have you ever been convicted or required to register for a sex offense?
Yes
No
If “Yes” What year and state?
Have you ever been convicted of theft, shoplifting, or crime where you served time and/or probation?
Yes
No
Identify Crime and date(s)
Have you ever been convicted of a violent crime with/without the use of a deadly weapon?
Yes
No
Identify Crime and date(s)
The Information Requested Below is Voluntary.
RACE : (Select One)
Asian
White
Black/African American
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
ETHNICITY : (Select One)
Hispanic or Latino
Non-Hispanic
SIGNATURE (Head of Household)
*
DATE
/
Month
/
Day
Year
Date
SIGNATURE (Spouse/Second Occupant)
*
DATE
/
Month
/
Day
Year
Date
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