SCDP Thief River Falls Tenant Survey

City of Thief River Falls Tenant Survey
SCDP Rental Rehab Program

Northwest Minnesota Multi-County HRA
PO Box 128 | Mentor, MN 56736
Phone: 218-309-0057
Name of Owner:*
Name of Tenant:*
Rental Building Address:*

Street Address

Apartment Number

CityState / Province

Postal / Zip Code
Data Privacy:

The information being collected is considered private and will not be available to the public. This information will be used only to determine eligibility for the owner to rece funds under the Rental Housing Prgoram. Not supplying the requested information may jeopardize the rehabilitation project.
HOUSING INFORMATION
Initial Start Date of Lease:*
Term of Lease:*
Average Monthly Housing Expenses:
Rent:*
Heat:*
If you do not have heat expenses, put N/A
Gas:*
If you do not have gas expenses, put N/A
Electricity:*
If you do not have electricity expenses, put N/A
Is your household currently receiving rental assistance? (HUD or other assistance)*

YesNo
Tenancy Information*

I have no intention of moving within the next 6-9 monthsI anticipate moving within the next 6-9 months
HOUSEHOLD INFORMATION
Gender of Head of Household:*

MaleFemale
Race/Ethnicity of Head of Household: (select all that apply)*

WhiteBlack or African AmericanAsianAmerican Indian/Alaskan NativeNative Hawaiian/Other Pacific IslanderOther
Does any household member have disabilites?*

YesNo
If yes, please describe the nature of the disabilities:*
INCOME INFORMATION
"Income" means any amount received from the following sources by any member of the househeld age 18 or over.

Please check yes or no for the following:
Public Assistance including: MFIP, SSI, GA, Child Support, and Unemployment Compensation*

YesNo
Salaries including Wages, Commissions, Bonuses, Tips, and Overtime Pay*

YesNo
Estate or Trust Income*

YesNo
Rental Income*

YesNo
Gains from the Sale of Property or Securities*

YesNo
Pensions and annuities including: PERA, Social Security, and Railroad Retirement*

YesNo
Business Profit (for self-employed individuals, including farmers)*

YesNo
Interest and Dividends*

YesNo
Contract for Deed Payments Received*

YesNo
List all occupants, date of birth, annual income, and income sources for any member of the household age 18 or over for the past twelve (12) months.
How many incomes do you have to add?*

14253
Income #1
Name:*
Birth Date:*

MonthDayYear
Date
Annual Income Amount:*
Source of Income:*
attach proof/copies of income at the end of this survey
*Proof/copies include, but are not limited to: Paystubs, Social Security Award Letter, Printout from Social Services for Public Assistance, Pruntout of Child Support Payments, Annuity/Pension Payments, Retirement Payments, etc.

For self-employed individuals, farming, and rental property income, use the appropriate line for "adjusted gross income" from your most recent 1040 IRS Income Tax Return.
Income #2
Name:*
Birth Date:*

MonthDayYear
Date
Annual Income Amount:*
Source of Income:*
attach proof/copies of income at the end of this survey
*Proof/copies include, but are not limited to: Paystubs, Social Security Award Letter, Printout from Social Services for Public Assistance, Pruntout of Child Support Payments, Annuity/Pension Payments, Retirement Payments, etc.

For self-employed individuals, farming, and rental property income, use the appropriate line for "adjusted gross income" from your most recent 1040 IRS Income Tax Return.
Income #3
Name:*
Birth Date:*

MonthDayYear
Date
Annual Income Amount:*
Source of Income:*
attach proof/copies of income at the end of this survey
*Proof/copies include, but are not limited to: Paystubs, Social Security Award Letter, Printout from Social Services for Public Assistance, Pruntout of Child Support Payments, Annuity/Pension Payments, Retirement Payments, etc.

For self-employed individuals, farming, and rental property income, use the appropriate line for "adjusted gross income" from your most recent 1040 IRS Income Tax Return.
Income #4
Name:*
Birth Date:*

MonthDayYear
Date
Annual Income Amount:*
Source of Income:*
attach proof/copies of income at the end of this survey
*Proof/copies include, but are not limited to: Paystubs, Social Security Award Letter, Printout from Social Services for Public Assistance, Pruntout of Child Support Payments, Annuity/Pension Payments, Retirement Payments, etc.

For self-employed individuals, farming, and rental property income, use the appropriate line for "adjusted gross income" from your most recent 1040 IRS Income Tax Return.
Income #5
Name:*
Birth Date:*

MonthDayYear
Date
Annual Income Amount:*
Source of Income:*
attach proof/copies of income at the end of this survey
*Proof/copies include, but are not limited to: Paystubs, Social Security Award Letter, Printout from Social Services for Public Assistance, Pruntout of Child Support Payments, Annuity/Pension Payments, Retirement Payments, etc.

For self-employed individuals, farming, and rental property income, use the appropriate line for "adjusted gross income" from your most recent 1040 IRS Income Tax Return.
Before continuing, please click the following link and read through the information:
- Protect Your Family From Lead in Your Home
LEAD PAINT, GENERAL INFORMATION NOTICE, AND ACKNOWLEDGMENT STATEMENT
I/we hereby certify that I have read and understand the information in the publication "PROTECT YOUR FAMILY FROM LEAD IN YOUR HOME" in the link above. I also understand that I will have the option to download the file at the end of the application and can request a copy be mailed to me at any time.
I/we certify that I read and understood the information in the "GENERAL INFORMATION FOR NON-DISPLACEMENT" letter that I received in the mail.
I/we certify that all statements on this application are true and correct to the best of my/our knowledge
I/we authorize program representatives and contractors with the right to enter the property and my unit to be improved for the purpose of the Rental Rehabilitation program and to take photographs of the property and unit before and after rehabilitation
Signature of Tenant:*

Clear
Date*

MonthDayYear
Date
Is there a co-applicant that needs to sign this form?*

YesNo
Signature of Co-Applicant:*

Clear
Date*

MonthDayYear
Date
Upload proof/copies of income below. If you can't upload them or would like to email them, please send them to kristi@nwmnhra.org

Cancelof
Should be Empty:

HOUSING INFORMATION

HOUSEHOLD INFORMATION

INCOME INFORMATION

Income #1

Income #2

Income #3

Income #4

Income #5

LEAD PAINT, GENERAL INFORMATION NOTICE, AND ACKNOWLEDGMENT STATEMENT