Fillable HUD Rental Application Revised 5.27.2021

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HUD Rental Application Revised 5.27.2021

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Revised 5/27/2021
- 1 -
Applicant:
Name: __________________________________________________________________________
Current Address: __________________________________________________________________
City, State, Zip Code: __________________________________ Work Phone: ________________
Home Phone: ___________________ Social Security # _______________________________
Date Of Birth: ___________________ Bedroom Size Requested: ________________________
Marital Status: ____ single ____ married ____ divorced ____ separated ____ widow
Co-Applicant:
Name: ___________________________________________________________________________
Current Address: ___________________________________________________________________
City, State, Zip Code: __________________________________ Work Phone: _________________
Home Phone: _________________ Social Security # ______________ Date of Birth: ____________
Marital Status: ____ single ____ married ____ divorced ____ separated ____ widow
HOUSEHOLD COMPOSITION AND CHARACTERISTICS
1. List the Head of Household and all other members who will be living in the unit. Give the Relations of each family member to the
head. Disclosure of SSN is not required for individuals age 62 or older and receiving assistance as of January 31, 2010 (must provide
information on where assistance is being received). SSN is not required for applicants not contending eligible immigration status.
Name
Relationship
Birth Date
Age
Sex
Social
Security
Student
select which
applies
Citizenship
Status
select which applies
Head of Household
NO FT PT
Citizen NonCitizen
NO FT PT
Citizen NonCitizen
NO FT PT
Citizen NonCitizen
NO FT PT
Citizen NonCitizen
NO FT PT
Citizen NonCitizen
NO FT PT Citizen NonCitizen
NO FT PT
Citizen NonCitizen
NO FT PT
Citizen NonCitizen
2. Do you expect a change in your household composition within the next 12 months? Yes No
If yes, please explain: ____________________________________________________________
STUDENT STATUS:
Is the head of household a student at an institute of higher education?
If yes: Is applicant unmarried?
If yes: Is Applicant a veteran?
If yes: Does applicant have a dependent child?
If yes: Is applicant disabled?
Yes No
Yes No
Yes No
Yes No
Yes No
Revised 5/27/2021
- 2 -
INCOME INFORMATION
Please answer each of the following questions. For each “yes,” provide details in the charts below.
Does any member of your household:
1. Work Full time, part time, or seasonally .. ....................... ....................... [ ]Yes [ ]No $________________
2. Work for someone who pays him or her cash .................. ....................... [ ]Yes [ ]No $________________
3. Expect a leave of absence from work due to lay off ........ ....................... [ ]Yes [ ]No $________________
medical, maternity, or military leave.
4. Now receive or expect to receive unemployment benefits .................... [ ]Yes [ ]No $_______________
5. Now receive or expect to receive child support. .............. ....................... [ ]Yes [ ]No $________________
6. Entitled to child support that he/she is not now receiving ....................... [ ]Yes [ ]No $________________
7. Now receive or expect to receive alimony ....................... ....................... [ ]Yes [ ]No $________________
8. Have an entitlement to receive alimony that is not
currently being received ......................... ....................... ....................... [ ]Yes [ ]No $________________
9. Now receive or expect to receive public assistance (TANF) .................... [ ]Yes [ ]No $________________
10. Now receive or expect to receive Social Security or disability ............... [ ]Yes [ ]No $________________
11. Now receive or expect to receive income from a pension/annuity ......... [ ]Yes [ ]No $________________
12. Now receive or expect to receive regular contributions from
organizations or individuals not living in the unit .......... ....................... [ ]Yes [ ]No $________________
13. Receive income/dividends from assets including checking, savings,
certificates of deposit, stocks, bonds, rental property .... ....................... [ ]Yes [ ]No $________________
14. Own real estate or any asset for which you receive income ................... [ ]Yes [ ]No $________________
15. Now receive military pay ........................ ....................... ....................... [ ]Yes [ ]No $________________
16. Now receive workers compensation ........ ....................... ....................... [ ]Yes [ ]No $________________
17. Now receive veterans administration benefits ................. ....................... [ ]Yes [ ]No $________________
18. Do you have income from any source not mentioned above .................. [ ]Yes [ ]No $________________
If yes, please explain: ________________________________________________________________
Employed full time Employed part time self – employed
Non-employed Unemployed
Employment:
Applicant:
Select all applicable:
Current
Employer___________________________ Position__________________ Date Hired____________
Address_____________________________ Supervisor_________________ Phone________________
Current Wages: $___________________ per: hour week month year (select one)
Do you expect to earn substantial overtime? ( ) Yes ( ) No If so, how much? ___________________
Co-Applicant:
Select all applicable: Employed full time Employed part time self – employed
Non-employed Unemployed
Current
Employer___________________________ Position__________________ Date Hired____________
Address_____________________________ Supervisor_________________
Phone________________ Current Wages: $___________________ per: hour week month year (select one)
Do you expect to earn substantial overtime? ( ) Yes ( ) No If so, how much? ___________________
_____________________________________________________________________________________________
Revised 5/27/2021
- 3 -
ASSET INFORMATION
Please answer each of the following questions.
Do any household members have any of the following? If yes, indicate the value.
Checking Account (average 6mon balance) ............... [ ]Yes .. [ ]No $________________
Savings Account ......................................... ............... [ ]Yes .. [ ]No $________________
Certificates of Deposit ................................ ............... [ ]Yes ...[ ]No $________________
Stocks or Bonds .......................................... ............... [ ]Yes .. [ ]No $________________
IRA/s or Retirement Funds ......................... ............... [ ]Yes .. [ ]No $________________
Mutual Funds .............................................. ............... [ ]Yes .. [ ]No $________________
Trust Accounts............................................ ............... [ ]Yes .. [ ]No $________________
Whole or Universal Life Insurance (not Term) .......... [ ]Yes .. [ ]No $________________
Personal Property held as an investment .... ............... [ ]Yes .. [ ]No $________________
Real Estate .................................................. ............... [ ]Yes .. [ ]No $________________
Any Assets not listed above ....................... ............... [ ]Yes .. [ ]No $________________
Have you disposed of any assets in the
previous 24 months for less than fair market value? .. [ ]Yes .. [ ]No
List all information for any asset noted above (including Checking, Savings, IRAs, Keogh accounts, and Certificates
of Deposit) of all household members.
BANK NAME or
INSTITUTION
TYPE OF
ACCOUNT
ACCOUNT
NUMBER
BALANCE
PREVIOUS RENTAL HISTORY
Name and Address of Your Present Landlord:
_____________________________________
_____________________________________
_____________________________________
Name and address of your Former Landlord:
_____________________________________
_____________________________________
_____________________________________
Do you: Rent Own Other _______________
Telephone No._________________________________
How Long Have You Lived There? ________________
Reason for Leaving. ____________________________
Telephone No._________________________________
How Long Did You Live There? ________________
Reason for Leaving. ____________________________
Please list all states in which you or any household member has resided:___________________________________
Revised 5/27/2021
- 4 -
RD and HUD PROPERTIES ONLY EXPENSES
Yes No Do you have expenses for child care of a child aged 12 or younger?
If yes, provide the name, address, and telephone number and cost of the care provider:
_______________________________________________________________________________
Yes No Do you or any household member meet the following definition of disabled person?
1. A person who:
a. Has a disability, as defined in 42 U.S.C. 423;
1) Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous
period of not less than 12 months; or
2) In the case of an individual who has attained the age of 55 and is blind, inability by reason of such blindness to engage
in substantial gainful activity requiring skills or abilities comparable to those of any gainful activity in which he/she
has previously engaged with some regularity and over a substantial period of time. For the purposes of this definition,
the term blindness, as defined in section 416(i)(1) of this title, means central vision acuity of 20/200 or less in the
better eye with use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that
the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for the
purposes of this paragraph as having a central visual acuity of 20/200 or less.
b. Is determined, pursuant to HUD regulations, to have a physical, mental, or emotional impairment that:
1) Is expected to be of long-continued and indefinite duration;
2) Substantially impedes his or her ability to live independently; and
3) Is of such nature that the ability to live independently could be improved by more suitable housing conditions; or
c. Has a developmental disability, as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights Act (42
U.S.C. 6001(8)), i.e., a person with a severe chronic disability that
1) Is attributable to a mental or physical impairment or combination of mental and physical impairments;
2) Is manifested before the person attains age 22;
3) Is likely to continue indefinitely;
4) Results in substantial functional limitation in three or more of the following areas of major life activity:
a) Self-care,
b) Receptive and expressive language,
c) Learning,
d) Mobility,
e) Self-direction,
f) Capacity for independent living, and
g) Economic self-sufficiency; and
5) Reflects the person’s need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or
other services that are of lifelong or extended duration and are individually planned and coordinated.
If yes to above:
Yes No Do you pay a care attendant or for any equipment for any disabled household member(s) necessary to
permit that person or someone else in the household to work?
If you pay a care attendant, provide their name, address and telephone number and cost:
_________________________________________________________________________________
Yes No Do you have Medicare? If yes, what is your monthly premium? _____________________________
Yes No Do you have any other medical insurance? If yes, provide name and address of carrier, policy
number, and premium amount: _______________________________________________________
_________________________________________________________________________________
What medical expenses do you expect to incur in the next twelve months?
_____________________________________________________________________________________________
If you use the same pharmacy regularly, please provide the name and address: ______________________________
_____________________________________________________________________________________________
Revised 5/27/2021
- 5 -
OTHER INFORMATION:
Driver's License #: __________________________ State: _______________________ Expires: ___________________________
Vehicle Model: ______________________________ Year: _______________ License Plate #:_________________________
ADDITIONAL QUESTIONS:
1. Have you or any household member filed for Bankruptcy? ................. … ......................... [ ] Yes [ ] No
2. Have you or any household member been evicted from Tenancy? ....... …… ................. [ ] Yes [ ] No
3. Have you or any household member been evicted from Federally Funded Housing for a lease
violation including drug use or a crime? ............................................... .............................. [ ] Yes [ ] No
If yes, when: ___________________________________________________
4. Have you or any household member been convicted of a Felony or Misdemeanor? ……… [ ] Yes [ ] No
If yes, explain: __________________________________________________
5. Are you or any household member subject to lifetime sex offender registration ................. …. [ ] Yes [ ] No
6. Are you or any household member enlisted in the U.S. Military or a veteran …… ............ ………………. [ ] Yes [ ] No
7. Are you or any household member currently receiving housing assistance from HUD or a PHA … [ ] Yes [ ] No
8. Do you or any household member have any special housing needs? .... .............................. … [ ] Yes [ ] No
If yes, explain: _____________________________________________________
9. Do you have any relatives that work for Community Housing Partners? ....................... [ ] Yes [ ] No
If yes, explain:
10. Will you be bringing a pet? .................................................................. ............................. [ ] Yes [ ] No
If yes, what type? __________________________________________________________________________________
Emergency Contact: Nearest Living Relative: _____________________________ __________________________ ________________
Name Phone Relationship
MARKETING INFORMATION:
How did you hear about this community? _________________________________________________________________________
I hereby apply to lease the above described premises on substantially the terms set forth herein. As an inducement to Community Housing Partners, Agent
for the owner of the property, to accept this application, I warrant that all statements contained herein are true. I have been advised and understand that
residency at this community entails certain income restrictions and that residency is subject to qualification. I hereby authorize Landlord to procure a
consumer report as defined in the Fair Credit Reporting Act, 15 U.S.C. 1881 a (d) seeking information on the credit worthiness, credit standing, credit
capacity, character, general reputation, personal characteristics, or mode of living. I agree that in addition to execution of a Lease Agreement that I will
execute a tenant certification attesting to the information contained herein which certification will be made under the penalty of perjury.
By execution of this application, I hereby authorize Community Housing Partners. to make such investigations into my credit history as they may deem
appropriate. I understand that such investigations typically include (but are not limited to) verification of employment and salary, rental history and
consumer credit reports. By signing below, the applicant gives permission to procure a criminal background check and understands the results of such
background check could affect the approval of this application. The undersigned do hereby acknowledge disclosure that the licensee, Community Housing
Partners represents the Landlord in a real estate transaction.
RESIDENT’S DUTY TO PROVIDE TRUTHFUL & COMPLETE INFORMATION
WARNING: 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, the PHA and any owner (or any employee of HUD, the PHA or
the owner) may be subject to penalties for unauthorized disclosures or improper uses 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 willfully 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, the PHA or the owner responsible for the unauthorized disclosure or
improper use. Penalty provisions for misusing the social security numbers 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).
Resident acknowledges that federal law and the IRS require Resident to answer all questions about income and student status truthfully and completely at
Resident’s initial certification and at each annual recertification. This information is essential for determining Resident’s eligibility to occupy the Unit.
Resident understands that (s) he must give truthful and complete income and student status information at all times. Resident understands that compliance
with this paragraph is a condition of Resident’s occupancy of the Unit. If Owner discovers, at any time the Lease Term, that Resident purposely gave false
or incomplete income or student status information, Owner may evict Resident from the Unit.
Resident’s Acknowledgement: ___________________ (Initial here)
A
pplicant: ______________________________________________________________ Date: ____________________
Co-A
pplicant: ___________________________________________________________ Date: ____________________
Received by: _____________________________________ Date Received: _________________ Time : _____________________
We are an equal housing opportunity provider. We do not
discriminate on the basis of race, color, sex, national origin,
religion, disability or familial status (having children under age
18), or any other legally protected characteristic. We do not
interfere, threaten, or coerce person in the exercise of their
fair housing rights. We do not retaliate against persons who
have asserted their rights or person who have assisted
someone in asserting their rights.
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HUD Rental Application Revised 5.27.2021

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Completed 22 September 2021

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