LUTHER TOWERS / VILLAGE TENANT APPLICATION

LUTHER TOWERS / VILLAGE TENANT APPLICATION
I/We are applying for residence in the following apartment(s) (You may choose any or all. We recommend all.)*

Luther Towers ILuther Towers IILuther Towers IIILuther Towers IVLuther Village ILuther Village II
Will you accept an efficiency apartment?*

YesNo
Name (Head of Household)

First NameMiddle NameLast Name
What's your gender?

MaleFemale
Present Address
City
State
Zip
Years of Residence
Telephone
Social Security
Date of Birth

MonthDayYear
Date
Name (Second Occupant)

First NameMiddle NameLast Name
What's your gender?

MaleFemale
Social Security
Date of Birth

MonthDayYear
Date
Relationship to Head of Household
REQUEST FOR ACCOMMODATION
Does any applicant have special needs?

YesNo
Other requirements: (Reference Paragraph 7 of attached Tenant Selection Plan: “Reasonable Accommodation”)
ESTIMATED MONTHLY INCOME (RESIDENT 1):
Interest on Checking
Interest on Savings
Interest on M.M.
Interest on C.D.
Dividends on Stock
Interest on Bonds
Sub Total
Social Security*
*if Medicare is deducted from your entitlement you must add it back in.
SSI
Pensions
Annuities
VA Benefits
Salary/Wages
Tax Credits
Other Income
Total Income
ESTIMATED MONTHLY INCOME (RESIDENT 2):
Interest on Checking
Interest on Savings
Interest on M.M.
Interest on C.D.
Dividends on Stock
Interest on Bonds
Sub Total
Social Security*
*if Medicare is deducted from your entitlement you must add it back in.
SSI
Pensions
Annuities
VA Benefits
Salary/Wages
Tax Credits
Other Income
Total Income
VALUE OF ASSETS OWNED (RESIDENT 1)
Checking Account Balance
Saving Account(s)
Money Market Account
Certificate(s) of Deposit
Stocks/Mutual funds
Bonds
Real Estate (Market Value)
Other Assets
Sub Total
Subtract Mortgage Balance
Total Assets
VALUE OF ASSETS OWNED (RESIDENT 2)
Checking Account Balance
Saving Account(s)
Money Market Account
Certificate(s) of Deposit
Stocks/Mutual funds
Bonds
Real Estate (Market Value)
Other Assets
Sub Total
Subtract Mortgage Balance
Total Assets
Have you given away any assets in the past twenty-four (24) hours?

YesNo
Person to contact if for some reason Applicant cannot be reached.
Name
Address
Telephone
Place of residence for the last five yeras
Year you moved in to your present place?
Year your moved out of your present place?
Landlord Name
Address
Telephone
Year you moved in to your previous place?
Year you moved out of your previous place?
Previous Landlord Name
Previous Address
Telephone
Year you moved in to your previous place?
Year you moved out of your previous place?
Previous Landlord Name
Previous Address
Telephone
Year you moved in to your previous place?
Year you moved out of your previous place?
Previous Landlord Name
Previous Address
Telephone
The Information Requested Below is for Federal Reporting Only and is Voluntary.
Race: (Select One)

American Indian/Alaska NativeNative Hawaiian/Pacific IslanderAsianWhiteBlack/African AmericanElect Not to Answer
Ethnicity: (Select One)

Hispanic or LatinoNon HispanicElect Not to Answer
Have you ever been convicted of a felony?

YesNo
If “Yes” What Year?
Identify Felony
Have you ever been convicted or required to register for a sex offense?

YesNo
If “Yes” What year and state?
Have you ever been convicted of theft, shoplifting, or a crime where you served time and/or probation?

YesNo
Identify Crime and Date(s)
Have you ever been convicted of a violent crime with/without the use of a deadly weapon?

YesNo
Identify Crime and Date(s)
Have you ever been evicted?

YesNo
If "Yes" What Year?
Reason for Eviction
Check all state or US territories that you have resided in.

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingGuamPuerto RicoAmerican Samoa
List any countries that you have resided in since you were 21
Signature (Head of Household)

Clear
DATE

MonthDayYear
Date
Signature (Spouse/Second Occupant)

Clear
DATE

MonthDayYear
Date
EAH SECTION 214 DECLARATION FORM
First Name
Middle Name
Last Name
Relationship to head of household
Sex
Date of Birth

MonthDayYear
Date
Social Security Number
Alien Registration Number
Admission Number
(If applicable - from INS Form I-94, Departure Record))
Nationality
(Country to which you owe legal allegiance - may or may not be country of birth.)
DECLARATION

INSTRUCTIONS: Complete the declaration below by reviewing all three boxes and signing the ONE box that applies. A separate Declaration must be signed for each member of the assisted household.
I, blanks hereby declare, under penalty of perjury, that:
I am a citizen or national of the United States of America

Clear
If you sign this box, no further information is required
If signing on behalf of a child who lives in your assisted unit and for who you are responsible.

Yes, I'm signing on behalf of a child who lives with me
Signature Date

MonthDayYear
Date
I am a non-citizen with eligible immigration status, as described on reverse.

Clear
If you sign this box, you must go on to complete the reverse side including the Verification Consent
If signing on behalf of a child who lives in your assisted unit and for who you are responsible.

Yes, I'm signing on behalf of a child who lives with me
Signature Date

MonthDayYear
Date
REQUEST FOR AN EXTENSION
I hereby certify that I am a non-citizen with eligible immigration status, as noted in block 2 above, and as described on reverse, but the evidence needed to support my claim in temporarily unavailable. Therefore, I am requesting additional time to obtain the necessary evidence. I further certify that diligent and prompt efforts will be undertaken to obtain this evidence.

Clear
If you sign this box, you must go on to complete the reverse side including the Verification Consent
If signing on behalf of a child who lives in your assisted unit and for who you are responsible.

Yes, I'm signing on behalf of a child who lives with me
Signature Date

MonthDayYear
Date
I am not contending eligible immigration status and I understand that I am not eligible for financial housing assistance.

Clear
If you sign this box, you must go on to complete the reverse side including the Verification Consent
If signing on behalf of a child who lives in your assisted unit and for who you are responsible.

Yes, I'm signing on behalf of a child who lives with me
Signature Date

MonthDayYear
Date
PENALTIES FOR MISUSING THIS CONSENT: 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 restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. 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 disclosure 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** Violations of these provisions are cited as violations of 42 U.S.C. Section **408 (a) (6), (7) and (8**
If you checked box 2 on the front side of this page, and are claiming to be a non-citizen with eligible immigration status, one of the following boxes MUST be checked:

1. A non-citizen lawfully admitted for permanent residence, as defined by section 101(a)(20) of the Immigration and Nationality Act (INA) as an immigrant, as defined by section 101 (a)(15) of the INA (8 USC 1001 (a)(20) and 1101 (a)(15), respectively). [immigrants] (This category includes a non citizen admitted under section 210 or 210A of the INA (8 USC1160 or 1161), [special agricultural worker], who has been granted lawful resident status);2. A non-citizen who entered the U.S. before 1-1-1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under Section 249 of the INA (8 USC 1259);3. A non-citizen who is lawfully present in the U.S. pursuant to an admission under section 207 of the INA (8 USC 1157) [refugee status]; pursuant to the granting of asylum which has not been terminated under section 208 of the INA (8 USC 1158) [asylum status]; or as a result of being granted conditional entry under section 203 (a)(7) of the INA (8 USC 1153 (a)(7) before 4-1-1980, because of persecution on account of race, religion, or political opinion or because of being uprooted by a catastrophic national calamity;4. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under section 212 (d)(5) of the INA (8 USC 1182 (d)(5)) [parole status];5. A non-citizen who is lawfully in the U.S. as a result of the Attorney General’s withholding deportation under section 243 (h) of the INA (8USC 1253 (h)) [threat to life] or freedom; or6. A non-citizen lawfully admitted for temporary or permanent residence under section 245 A of the INA (8 USC 1255a) [amnesty granted under INA 245 A]
If you checked one of the above boxes you must submit one of the following documents:

1. Form I-551, Alien Registration Receipt Card (for permanent resident aliens);2. Form I-94, Arrival-Departure record, with one of the following annotations: a.“Admitted as Refugee Pursuant to Section 207” b.“Section 208” or “Asylum” c.“Section 243(h)” or “Deportation stayed by Attorney General” d.“Paroled pursuant to Section 212(d5) of the INA3. If Form I-94, Arrival-Departure Record, is not annotated, then accompanied by one of the following documents: a.A final court decision granting asylum (but only if no appeal is taken); b. director grant asylum (if application filed before 10-1-1990); c.A court decision granting withholding of deportation; or d. A letter from an INS asylum officer granting asylum (if application is filed on or after 10-1-1990)4. Form I-688, Temporary Resident Card, which must be annotated “Provision of Law 274a.12(11)” or “Provision of Law 247a.12”;5. Form I-688B, Employment Authorization Card, which must be annotated “Provision of Law 274a.12(11)” or “Provision of Law 247a.12”;6. A receipt issued by the INS indicating that an application for issuance of a replacement document in one of the above-listed categories has been made and the applicant’s entitlement to the document has been verified.;7. Form I-152, Alien Registration Receipt Card.
VERIFICATION CONSENT
CONSENT: I, blanks hereby consent to the following:

1. The use of the attached evidence to verify my eligible immigration status to enable me to receive financial assistance for housing;

2. The release of such evidence of eligible immigration status by the project owner without responsibility for the further use or transmission of the evidence by the entity receiving it, to; (a) HUD, as required by HUD; and (b) The INS for the purposes of verification of the immigration status of the individual.

NOTIFICATION: Evidence of eligible immigration status shall be released only to the INS for purposes of establishing eligibility for financial assistance and not for any other purpose. HUD is not responsible for the further use or transmission of the evidence or other information by the INS.
Signature

Clear
If signing on behalf of a child who lives in your assisted unit and for who you are responsible.

Yes, I'm signing on behalf of a child who lives with me
Date

MonthDayYear
Date
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)
example@example.com
Relationship to Applicant
Reason for Contact: (Check all that apply)

EmergencyAssist with Recertification ProcessUnable to contact youChange in lease termsTermination of rental assistanceChange in house rulesEviction from unitLate payment of rentOther
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.

I choose not to provide contact information.
Signature of Applicant

Clear
Date

MonthDayYear
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.
APPLICATION FOR AN APARTMENT - PAGE FOUR
Applicant/Resident*
Email Address (if applicable)
example@example.com
Date

MonthDayYear
Date
Property Name
ENROLLMENT IN SCHOOL
1. Are you a student at an institution of higher education?*

YesNo
* Institutes of higher education include post-secondary vocational institutions; "proprietary institutions of higher education" which prepare students for "gainful employment in a recognized occupation", and accredited post-secondary colleges and universities. If you are not sure, please mark "yes" and we will verify it.
If you answered yes, the owner agent is required to determine your eligibility as a student. You
may refer to the resident selection plan for additional information regarding student eligibility.
Please complete the following questions:
2. Are you a full-time student?

YesNo
3. Will you be living with your parents?

YesNo
4. Are your parents receiving or eligible to receive Section 8 assistance?

YesNo
5. Are you claimed as a dependent on your parent's tax return?

YesNo
6. Are you a graduate or professional student?

YesNo
7. Are you at least 24 years of age?

YesNo
8. Are you a veteran of the United States military?

YesNo
9. Are you married?

YesNo
10. Do you have a dependent child?

YesNo
11. Do you have dependents other than a child or spouse?

YesNo
12. Have you been independent of your parents for at least one year?

YesNo
13. Do you feel you qualify as a disabled student who was receiving Section 8 Assistance as of November 30, 2005?

YesNo
14. Are you receiving any financial assistance to pay for your education?

YesNo
A. If so - Please list all sources of financial assistance including the school, any providers of scholarships or grants, parents, associations, etc.
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 restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. 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 disclosure 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).
Print Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

LUTHER TOWERS / VILLAGE TENANT APPLICATION

REQUEST FOR ACCOMMODATION

ESTIMATED MONTHLY INCOME (RESIDENT 1):

ESTIMATED MONTHLY INCOME (RESIDENT 2):

VALUE OF ASSETS OWNED (RESIDENT 1)

VALUE OF ASSETS OWNED (RESIDENT 2)

Person to contact if for some reason Applicant cannot be reached.

Place of residence for the last five yeras

EAH SECTION 214 DECLARATION FORM

DECLARATION

REQUEST FOR AN EXTENSION

VERIFICATION CONSENT

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

APPLICATION FOR AN APARTMENT - PAGE FOUR

ENROLLMENT IN SCHOOL