An Application must be filled out for each adult (18 and older) or one application per married couple. (Except in Wyoming, one application per household is permitted)

The application must be signed and the following must be included for the application to be accepted:

• $25 Application Fee –Money Order ONLY (Application fee is per adult or married couple)
• Copies of picture identification on all occupants over the age of 18.
• Copies of Social Security card for all occupants.

Once received, the application will be dated and reviewed for completeness.  A pre-eligibility determination will be made based upon the information contained in the application.

Eligibility will be determined based upon the following factors:

• The applicant(s) meet the income criteria.
• References (i.e. employer, current & former landlords) will be contacted to verify employment, length of time on the job and verify rental payment history.
• A Credit & Criminal background check will be obtained and reviewed.

Applicant(s) will be notified in writing within ten (10) days of receipt of the application as to the acceptance or denial of this application.  If no unit is available at the time of acceptance, applicant’s name will be placed on the waiting list.

Somerset Pacific is committed to the non-discrimination provision in the Fair Housing Act and Section 504 of the Americans with Disabilities Act.  If you require assistance in the form of readers, interpreters, large print or any other way to enable you to fully participate in our housing program, please let us know and we will assist you to the fullest extent feasible.

NOTE TO APPLICANT: In order for us to determine your eligibility or continued eligibility, you must provide all information included in this questionnaire.  This information is considered confidential and will only be used as necessary in determining your eligibility for the Section 42 LIHTC program / RD program.  

Providing false information may result in loss of your housing

 
VOLUNTARY HUD TENANT DATA COLLECTION
Race
1 = White
2 =  Black or African American
3 = American Indian or Alaska Native
4 = Asian
5 =  Native Hawaiian or Other Pacific Islander
6 = Other
7 =  N/A or do not wish to answer

*General Instructions: This section is to be completed by applicants and residents in housing assisted by the Department of Housing and Urban Development. Owner and agents are required to offer the applicant/resident the option to complete this section. There is no penalty for persons who do not wish to complete this form. However, the owner or agent will place a note in the tenant file stating the applicant//resident refused to complete the form. Parents or guardians are to complete the form for children under the age of 18. The Office of Housing has been given permission to use this section for gathering race and ethnic data in assisted housing programs. 

Current Landlord

Prior Landlord

In case of emergency notify

I/We certify that if selected to move into this project, the unit occupied will be my/our only residence.   I/We understand that the above information is being collected to determine eligibility for income restricted income units.  Federal regulations require that in order for a household to be eligible for this type of housing, the income of the household, as well as their assets must not exceed certain established limits.  I/We authorize the Agent to verify all information provided on this application and to contact previous or current landlords or other sources for credit and verification information which may be released to appropriate federal, state or local agencies.   I/we certify that the statements made in this application are true and complete to the best of my/our knowledge and belief.  I/we understand that false statements or information are punishable under federal law.    I/We understand I/We must pay a security deposit for this apartment prior to occupancy.   edit this text...

I/We hereby authorize all persons or companies in the categories listed below to release without liability, information regarding employment, income, and/or assets to said property above for purposes of verifying information on my/our housing rental application.

TERMS AND CONDITIONS

I/We understand that current or previous information regarding me/us may be needed. Verifications and inquiries that may be requested include, but are not limited to: personal identity, employment, income, assets, student status, medical or child care allowances, and utility information. I/We understand that this authorization cannot be used to obtain any information about me/us that is not pertinent to my eligibility for and continued residency participation as a Qualified Resident.

The groups or individuals that may be asked to release the above information include, but are not limited to:

• Credit Bureaus
• Past and Present Employers
• State Unemployment Agencies
• Current and Previous Landlords
• Public Housing Agencies
• Support and Alimony Providers
• Welfare Agencies
• Educational Institutions
• Social Security Administration
• Child Care Providers
• Veterans Administration
• Retirement Systems
• Banks and Financial Institutions
• Utility Provider

“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 and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosure or improper use 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 willingly 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 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).**

The net family assets (as defined in 24 CFR 813.102) above do not exceed $5,000 and the annual income from these assets as       determined above is included in the total gross annual income.

Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge.  The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.

*Cash Value is the market value of the asset minus reasonable costs incurred in selling or converting the asset to cash. Such reasonable costs include:

penalties for withdrawing funds before maturity;
broker/legal fees for the sale or conversion of assets; and
settlement costs for real estate transactions.

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge.   The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.

SECTION: I

Please complete the following information:  List all members that will be living in this household & provide date of birth, social security #, eligible or not eligible to receive PFD and date of AK residency for each household member.

If all household members listed above were Eligible, & you answered "YES", received the PFD then you have completed this statement.  Please sign & date in section III below.

If any household members listed above were Ineligible & you answered "NO", did not receive the PFD, please write the household member line number listed above, under appropriate reason in Section II below.

Section: II

Please complete the following information:  List all members that will be living in this household & provide date of birth, social security #, eligible or not eligible to receive PFD and date of AK residency for each household member.

All Household members that answered "NO", to receiving the PFD may be required to provide additional documentation as proof of non-receipt.

Section: III

I/We certify that the above information is true and correct. Under penalty of perjury, I certify the above representations to be true and accurate to the best of my knowledge.