Conway Village Application

Form
Applicant Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
How long Have you been at this address?
Current Landlord
Social Security Number
Landlord Phone
Please enter a valid phone number.Format: (000) 000-0000.
Landlord Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Length of Employment at current or last job
Name of Supervisor
Have you ever been convicted of a felony?

YesNo
If Yes Felony conviction, when did this occur?
Reason for Moving?
Drivers License #
State Issued
How Many Vehicles do you have
What is the Make, Model and Year of Vehicle
License plate
Are you or Will you be a student anytime during the next 12 months?

Yes Full timeYes Part TimeNO
Previous Address last 5 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Landlord Name and Phone
Dates living there
Previous Address last 5 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Landlord Name and Phone
Dates Living there
Previous Address last 5 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Landlord Name and Phone
Dates Living there
Previous Address last 5 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Landlord Name and Phone
Dates Living there
Previous Address last 5 years

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior Landlord Name and Phone
Dates Living there
Co-Applicant Name

First NameLast Name
Other Occupants #1

First NameLast Name
Other Occupants Social Security Number
Other Occupant Date of Birth

MonthDayYear
Date
Occupant Relationship

ChildRoommateFamily memberOther
Occupant: Are you or Will you be a student anytime during the next 12 months?

Yes Full timeYes Part TimeNO
Other Occupants #2

First NameLast Name
Other Occupants Social Security Number
Other Occupant Date of Birth

MonthDayYear
Date
Occupant Relationship

ChildRoommateFamily memberOther
Occupant: Are you or Will you be a student anytime during the next 12 months?

Yes Full timeYes Part TimeNO
Other Occupants #3

First NameLast Name
Other Occupants Social Security Number
Other Occupant Date of Birth

MonthDayYear
Date
Occupant Relationship

ChildRoommateFamily memberOther
Occupant: Are you or Will you be a student anytime during the next 12 months?

Yes Full timeYes Part TimeNO
Other Occupants #4

First NameLast Name
Other Occupants Social Security Number
Other Occupant Date of Birth

MonthDayYear
Date
Occupant Relationship

ChildRoommateFamily memberOther
Occupant: Are you or Will you be a student anytime during the next 12 months?

Yes Full timeYes Part TimeNO
Other Occupants #5

First NameLast Name
Other Occupants Social Security Number
Other Occupant Date of Birth

MonthDayYear
Date
Occupant Relationship

ChildRoommateFamily memberOther
Occupant: Are you or Will you be a student anytime during the next 12 months?

Yes Full timeYes Part TimeNO
Emergency Contact

First NameLast Name
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact relationship

RoommateFamily memberOtherEmployerFriendSpouse
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Doctor Name

First NameLast Name
Doctor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Hospital Name
Do you have a checking account

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have a Saving account

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have a Certificate of Deposit account

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have a Money Market account

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any stocks or Bonds?

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any treasury Bills?

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any IRA/Keough Accounts?

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any treasury Bills?

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any company retirement account?

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any pension Fund account?

YesNo
If Yes, List estimated Value and Interest rate on account
Do you have any trust accounts?

YesNo
Est Amount
Do you have any trust accounts if Yes is it irrevocable?

YesNo
Est Amount
Do you have any cash held in safety deposit boxes, etc?

YesNo
Est Amount
Do you have a house?

YesNo
Est Amount
Do you have any rental proprety?

YesNo
Est Amount
Do you have any other investments?

YesNo
Est Amount
Do you have any lump sum payments inheritances?

YesNo
Est Amount
Do you have any lump sum payments lottery winnings?

YesNo
Est Amount
Do you have any lump sum payments insurance settlements?

YesNo
Est Amount
Do you have any lump sum payments workers compensation?

YesNo
Est Amount
Do you have any lump sum payments social security disability settlements?

YesNo
Est Amount
Do you have any lump sum payments unemployment compensation settlements?

YesNo
Est Amount
Do you have any lump sum payments VA disability settlements?

YesNo
Est Amount
Do you have any lump sum payments severance Pay?

YesNo
Est Amount
Do you have any lump sum payments capital gains?

YesNo
Est Amount
Do you have any lump sum payments educational grants or scholarships?

YesNo
Est Amount
Do you have any lump sum payments other?

YesNo
Est Amount
Have you disposed of any assets for the less than fair market value in the past two (2) years?

YesNo
Est Amount
Income: Do you receive any of the following: Wages, Salary etc thru employment?

YesNo
Est Amount
Income: Do you receive any of the following: income from a business or profession?

YesNo
Est Amount
Income: Do you receive any of the following: income from social security?

YesNo
Est Amount
Income: Do you receive any of the following: income from SSI?

YesNo
Est Amount
Income: Do you receive any of the following: income from AFDC or other public assistance?

YesNo
Est Amount
Income: Do you receive any of the following: income from alimony?

YesNo
Est Amount
Income: Do you receive any of the following: Child support payments?

YesNo
Est Amount
Income: Do you receive any of the following: unemployment compensation?

YesNo
Est Amount
Income: Do you receive any of the following: workman's compensation?

YesNo
Est Amount
Income: Do you receive any of the following: severance pay?

YesNo
Est Amount
Income: Do you receive any of the following: retirement income?

YesNo
Est Amount
Income: Do you receive any of the following: annuities income?

YesNo
Est Amount
Income: Do you receive any of the following: insurance policies income?

YesNo
Est Amount
Income: Do you receive any of the following: disability or death benefits (other than Social security of SSI?

YesNo
Est Amount
Income: Do you receive any of the following: income from rental property?

YesNo
Est Amount
Income: Do you receive any of the following: income from other?

YesNo
Est Amount
Income: Do you receive any regular monetary gifts or non-cash contributions from persons outside the household for: Rent?

YesNo
Est Amount
Income: Do you receive any regular monetary gifts or non-cash contributions from persons outside the household for: utilities?

YesNo
Est Amount
Income: Do you receive any regular monetary gifts or non-cash contributions from persons outside the household for: groceries?

YesNo
Est Amount
Income: Do you receive any regular monetary gifts or non-cash contributions from persons outside the household for: clothing?

YesNo
Est Amount
Income: Do you receive any regular monetary gifts or non-cash contributions from persons outside the household for: misc household supplies?

YesNo
Est Amount
Income: Do you receive any regular monetary gifts or non-cash contributions from persons outside the household for: other?

YesNo
Est Amount
do you pay any child care expenses for children age 12 or younger that enables a family member to go to work or school?

YesNo
Est Amount
Do you have any handicapped assistance expenses which enable a family member (including the handicapped members) to work?

YesNo
Est Amount
Persons which meet the definition of disabled or handicapped qualify for a $400 deduction to there annual income when determining rent contribution and certain other deductions. If after reading the definition (listing in rental application) you feel that you qualify and would like to request this adjustment to you income, please indicate below

Yes, i feel that i meet the definition of handicapped and/or disabled as defined above and would there like to request the $400 adjustment to incomeNo, I feel i do not qualify based on the definition in the rental application and therefore do not request the $400 adjustment to income
if you have indicated your desire to request this adjustment then we will need to sufficient information (documentation) to confirm your qualifications for the handicapped/disabled status. failure to provide this information may result in the denial of these deductions. Would you like to request a handicapped designed unit?

YesNo
Would you like to request reasonable accommodation/modification to the unit?

YesNo
If yes what would you like to request?
Are you moving due to a presidential declared disaster area?

YesNo
Are you a veteran?

YesNo
For congregate housing only, would you like to request a specific service or services?

YesNo
If yes what would you like to request?
Are you currently under the care of a physician, optometrist, ENT, etc? where you are having to pay for bills not covered by medical insurance?

YesNo
Name of physician

First NameLast Name
Address of Physician

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently having to take medication that is not covered by medical insurance?

YesNo
Name of Pharmacy
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Pharmacy
Please enter a valid phone number.Format: (000) 000-0000.
are you currently paying for hospital bills not covered by medical insurance?

YesNo
Name of Hospital
Hospital Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Hospital
Please enter a valid phone number.Format: (000) 000-0000.
total amount owed $
What is the estimated amount that you will spend over the next 12 months to reduce the amount owed?
Do you pay medical insurance premiums?

YesNo
Name of Insurance Company?
Address of Insurance company

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Insurance Company
Please enter a valid phone number.Format: (000) 000-0000.
Monthly premium amount
Signature For Application
Date

MonthDayYear
Date
How did you hear about our community

Internet 1Drive byFlyerNewspaperPhonebookResidentOther
Date of move in desired?

MonthDayYear
Date
Please List any comments below
Phone Number Physician
Please enter a valid phone number.Format: (000) 000-0000.
Sex of Applicant

MaleFemale
Race
Hispanic of Latino?

YesNo
Marital Status

YesNoSeparated
Tenant release and consent. I/we understand that previous or current information regarding me/we may be needed. Verification and inquiries that may be requested include but are not limited to: personal identity, employment, income, assets, medical or child care allowance. I/We understand that this is authorization cannot be used to obtain information about me/us that is not pertinent to my eligibility for and continued participation as a qualified tenant. Please refer to hard copy of application for additional details
Date signed

MonthDayYear
Date
Have you been evicted from a federally assisted site for drug related criminal activity within the past 3 years?

YesNo
Do you currently use illegal drugs or abuse alcohol?

YesNo
are you currently subject to a lifetime registration requirement under a state sex offender registration program?

YesNo
Have you been convicted of any drug related crime within the past 5 years?

YesNo
Have you been convicted of any felony within the past 5 years?

YesNo
Have you been convicted of any crime involving fraud or dishonesty within the past 5 years?

YesNo
Have you been convicted of any crime involving violence within the past 5 years?

YesNo
Are you currently charged with any of the below criminal activities?

YesNo
Please list all states you have lived and/or held a drivers License in?
Have you ever been known by another name? if so what name?
I understand that the above information is required to determine by eligibility for residency. I certify that my answers to the above questions are true and complete to the best of my knowledge. I understand that making false statements on this form is grounds for rejection or termination of my lease. I authorize Conway Village apartments to verify the above information and i consent to the release of the necessary information to determine my eligibility. I hereby authorize law enforement agencies to release criminal records and or sec offender registration information to Conway village apartment to a public authority or to an agency contracted by Conway village to conduct criminal background checks.
Date

MonthDayYear
Date
You have right by law to include as part of your application for housing, the name, address, phone number and other relevant information of a family member or friend, social, health, advocacy or other organization. this contact information is for the purposes 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 providing any special care or services you may request. 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.

YesNo
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
relationship to applicant
reasons for contact

emergencyunable to contact youtermination of rental assistanceeviction from unitlate payment of rentassist with recertification processchange in lease termschange in house rulesother
Signature for supplement to application for federally assisted housing
Date

MonthDayYear
Date
please upload document or picture of social security card, birth certificate & 6 months of bank statements for all your accounts below
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
File Upload

Cancelof
Should be Empty:

Form