Application for Admission

Date:______________________

Name: __________________________

Address: _________________________    City / State:_________________________

Phone:  Home:_________________  Work: ______________________

FAMILY COMPOSITION   (List all household members who live or will live  in the unit.  Indicate if any member is a full time student or foster child.)
Last name, first, middle initial Sex:
M/F Birth
date Alien
Status Social Security # or
Alien Reg. # Place of birth
1. (head)    
2.    
3.    
4.    

INCOME: ( List all income for household members.  Include full and part time employment, self-employed earnings, welfare, social security, S.S.I., pensions, disability compensation, interest, child care earnings, alimony, child support, annuities, dividends, income from rental property, earned income tax credits, Armed Forces Reserved income, scholarship and or grants, net income from operation of a business, etc.)

Household member Source of income Gross Income
  $                   per
  $                   per
  $                   per
  $                   per

ASSETS:  (Check “yes” or “no” on all of the following lines.  If “yes”, enter the amount or value of the asset and the current income from the asset.)
                                          YES   NO                AMOUNT/VALUE INTEREST RATE/            
Cash on hand over $100  ____    ____    $________________  _________________
Checking Accounts          ____    ____      ________________  _________________
Cash Management Accts.____    ____      ________________  _________________
Savings Accounts            ____    ____      ________________  _________________
Certificate of Deposit       ____    ____      ________________  _________________
Annuities                           ____    ____      ________________  _________________  Money Market Funds        ____    ____      ________________  _________________
IRA Accounts                    ____    ____      ________________  _________________
Stocks/Bonds/Mutual Funds

                                           ____    ____      ________________  _________________
U.S. Savings Bonds         ____    ____      ________________   _________________
    YES     NO      AMOUNT/VALUE   INTEREST RATE/
           DIVIDEND

Contract for deed             ____    ____      ________________   _________________
Real Estate                       ____    ____      ________________   _________________
Business Assets              ____    ____      ________________   _________________

Other (please describe)  ___________________________________________________
________________________________________________________________________   

Have you disposed of any assets for less than Fair Market Value?
In the past two years?      Yes:______     No:_____
If yes, complete the following information:
Date of disposal of asset (s)________________   Amount Received?_____________
Market value at time of disposal $___________________

MEDICAL EXPENSES: (Complete this section only if head of household or spouse is elderly, disabled or handicapped.)
         YES  NO
Do you receive Medicare benefits?     ____  ____
Do you receive medical assistance through welfare?   ____  ____
Do you pay for additional medical insurance?   ____  ____
Are all of your medical expenses covered by insurance or
outside sources?       ____  ____
If “no”, indicate expenses paid by you:
Prescription drugs       ____  ____
Outstanding bills       ____  ____
Other:
___________________ $________________
___________________   ________________

Do you have any expenses for attendant care or special apparatus for a disabled or handicapped household member that is necessary for a household member to be employed? ( Do not consider expenses paid to a family member or reimbursed by outside source.)       YES: ____ NO: ____
Do you pay for childcare for children 12 yrs old or younger while a household member is employed or attending school?    YES: ____ NO: ____

Are any members of your household smokers?   YES:_____    NO : ______

Do you and all household members consent to a criminal background check?  If you choose to answer no to this question it constitutes an automatic rejection of your housing application.  The Board of Directors will review each background check and approve or deny the application at their discretion.

YES: ____ NO: ____n.

Have you ever been convicted of a felony?  Yes___   No ___

Have you ever been known to use another name?

Last place of residence, how long, landlord phone # :

List 3 references, 2 can not be relatives.
Name: ____________________________
Address_______________________   Phone #__________________________
Name: ____________________________
Address_______________________   Phone #__________________________
Name: ____________________________
Address_______________________   Phone #__________________________

 

Applicant (s)’s/ tenant (s)’s statement

I/We certify that the information* given to the Housing and Redevelopment Authority of New Richland on household composition, income, net family assets, and allowances and deductions is accurate 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 also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy.

_________________________________  ________________________
Signature of head of household   Date

_________________________________  ________________________
Signature of other adult household member  Date

If you believe you have been discriminated against, you may call the Fair Housing and Equal Opportunity National Toll-free Hot Line at 1-800-669-9777 or 1-800-927-9275 (TTY).

*After verification by this Housing Agency, the information will be submitted to the Department of Housing and Urban Development on Form HUD_50058 (Tenant Data Summary), a computer-generated facsimile of the form or on magnetic tape.  See the Federal Privacy Act Statement for more information about its use.