I. Household Composition
Unless assistance is required, this form must be completed by the applicant/tenant.List each person who will reside in the unit along with the relationship to the head of household, date of birth, and social security number. Do not include minors who will be present less than 50% of the time. List FT student status for any member who is currently enrolled, expects to become enrolled, or was previously enrolled for any part of 5 months in the calendar year. Include grades K-12; college; university; technical; trade; and mechanical schools.
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Rows
Household Member Name
Relationship
DOB
Last 4 of SSN
FT Student?
Phone
Email
Address
1
2
3
4
5
6
Are you looking for units built-out for persons with Disabilities?
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Please Select
Yes
No
Below are the Unit Types available. Which Unit Types are you looking for?
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1 Bedroom
2 Bedroom
3 Bedroom
Below are all Unit Types available. Which Unit Types are you looking for?
Please Select
1 Bedroom
2 Bedroom
3 Bedroom
Reasonable Accommodation Request
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Please Select
Live-in personal care attendant (PCA)
Extra room required for disability related medical equipment.
Other
None of the above
Is the anything about your household that you feel it's important for us to understand but there was no space to explain in the application? e.g. you are co-parenting with someone who doesn't live in the household, you are a child's guardian, you are expecting a child.
II. Student Status
Is every member of the household a FT student as defined above?
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Please Select
Yes
No
If NO continue to Section III. If YES please complete the following questions:
Does a student receive assistance under Title IV of the Social Security Act
Please Select
Yes
No
Was a student previously a foster child?
Please Select
Yes
No
Is a student enrolled in a program funded by the Workforce Investment Act or similarfederal/state/local program?
Please Select
Yes
No
Is a student married and eligible to file a joint tax return?
Please Select
Yes
No
Is a student a single parent who is not claimed as a dependent by another individua
Please Select
Yes
No
Are the minors in the household claimed as a dependent by a parent?
Please Select
Yes
No
III. Household Income
Please select all income sources that apply to you and all members your household who are 18 years old or older.
Check all that applies
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1. Salary or pay from job
2. Overtime or shift pay
3. Bonus/commission/etc.
4. Do you have a 2nd job?
5. Seasonal/sporadic work
6. Tips
7. Cash pay
8. Self-employment income
9. Periodic gift income
10. Non-cash contributions
11. Formal child support
12. Is child support awarded but not paid?
13. Informal child support
14. Formal spousal support
15. Is spousal support awarded but not paid?
16. Informal spousal support
17. Social Security
18. SSI
19. TANF, AFDC, etc.
20. Unemployment benefits
21. Severance pay
22. Pension income
23. Retirement acct payments (including RMDs)
24. Investment acct payments
25. Annuity acct payments
26. Trust acct payments
27. Disability/death benefits
28. Real estate rent income
29. Student financial aid
30. Military pay
31. Veterans/VA income
32. Other Income
33. Did you file a tax return last year?
34. Are any income changes expected in the next 12 months?
Please estimate the total yearly household income for ALL household members who are 18 years and older. This is the annual income before any taxes are taken out.Combined Yearly Household Income for everyone 18 years and older.
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Enter a mount
IV. Household Assets
Please select all assets that you and the members of your household possess.
Select all that applies
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1. Checking account
2. 2nd checking account
3. Savings account
4. 2nd Savings account
5. Debit/ Direct Deposit card
6. 2nd Prepaid/ debit card
7. Cash on hand
8. Certificate of Deposit
9. Other bank account
10. Mutual Fund
11. Stocks
12. Portfolio/brokerage
13. IRA/401K/etc.
14. 2nd IRA/401K/etc.
15. Treasury bills/bonds
16. Company retirement acct
17. Annuity
18. Pension
19. Trust(Irrevocable or Revocable)
20. Life insurance (not term)
21. Real estate equity
22. PayPal, Venmo, CashApp
23. Other asset
24. Has anyone received any lumpsum amounts in the past 2 years (i.e. lottery/gambling/inheritance)?
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Please Select
Yes
No
25. Has anyone disposed of any assets for less than fair market value in the past 2 years?
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Please Select
Yes
No
26. What is the combined value of all assets held by all household members over 18 years old?The answer provided here should be the sum of all assets disclosed above. Combined value of all household assets for everyone included in this application.
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Under penalties of perjury, I/wecertify that the information presented on this form is true and accurate to the best ofmy/our knowledge. False, misleading, or incomplete information may result in the termination of this application/lease.
Signature
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Name
*
First Name
Last Name
Email
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date
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Month
-
Day
Year
Date
Submit
Submit
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