Madsen Properties, Inc.

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1 Madsen Properties, Inc State Highway 78, Suite 1 Battle Lake, MN Dear Applicant, Thank you for your interest in our affordable apartments. The application you downloaded must be completed by prospective tenants for Rural Development financed housing. You do not need to fill in the verified spaces on the application form. Be sure to include three references and please have each adult household member sign the two required areas. As soon as we receive the completed application your name will be placed on the Waiting List. Each person in the household 18 years of age and over including a caregiver and/or attendant will be required to submit a non-refundable $20.00 fee (Money Order payable to Madsen Properties, Inc.) to cover criminal and credit checks; this fee is to be submitted with the application. Some determining factors for occupancy will be completeness of the application, favorable review of credit and landlord references, criminal background check, income limits and availability of an appropriate unit. The assignment of rental assistance upon move-in is subject to eligibility and availability either through the apartment project or through the local city or county HRA. A Smoke-Free policy has been implemented in our apartment buildings. No smoking or open flame is allowed in apartments, public areas or grounds of the building. Please do not hesitate to call our office with any questions you may have. Our phone number is If you wish to view an apartment please call our office to arrange an appointment. We look forward to hearing from you. Sincerely, MADSEN PROPERTIES, INC. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W, Washington, D.C , or call (800) (voice), or (202) (TDD).

2 FOR OFFICE USE ONLY. DATE/TIME RECEIVED An applicant may be interviewed only after a completed Application is received. Completed Applications are processed in the order of date and time received. You may contact the rental office for assistance in completing this form. Maiden, Alias or Applicant Former names First Middle (full) Last APPLICATION FOR OCCUPANCY AT: MAIL TO: MADSEN PROPERTIES, INC State Hwy 78, Suite 1 Phone: Battle Lake, MN Or: Address Phone # Date of Birth_ Age Sex Social Security # Drivers License State Maiden, Alias or Co-Applicant Former names First Middle (full) Last Address Phone # Date of Birth_ Age Sex Social Security # Drivers License State Additional Household Members: First name Middle (full) Last name Date of Birth Age Sex Social Security # Is anyone in this household a full-time student? Yes No Name(s) Name and address of Educational Institution(s) Are you applying for a handicap/disability adjustment to income? Yes No Do you need the features of a fully accessible unit? Yes No If yes, we will need a letter from your doctor stating you need a fully accessible unit. Do you need a unit with special features for accessibility? Yes No If yes, explain any special features you are requesting_ Will you have a care giver/attendant living with you? Yes No If yes, a criminal background check is required for each care giver/attendant. BACKGROUND HISTORY Have you or any household member ever been evicted from any type of housing or found ineligible for rent assistance due to violence or drug related criminal activity? Yes No Have you or any household member ever been convicted of or pleaded guilty or no contest to a felony or misdemeanor (Whether or not resulting in a conviction)? Yes No Have you or any household member ever been convicted or pleaded guilty or no contest to a misdemeanor involving sexual misconduct (whether or not resulting in a conviction)? Yes No Are you or any household member a registered sex offender? Yes No Are you currently a user of an illegal controlled substance? Yes No Have you ever been convicted of a drug violation (use, attempted use, possession, manufacture, sale or distribution)? Yes No Have you successfully completed a controlled substance abuse recovery program (or are you presently enrolled in such a program)? Yes No LANDLORD REFERENCES List all the places you have lived in the past five (5) years. Failure to complete this section may disqualify your application. Have you owned your own home for the past 5 years? Yes No (If no, please complete the following) Present Landlord Phone Number Landlord Complete Mailing Address Address of Property rented Dates Rented Current rent Utilities? Reason for moving Previous Landlord Phone Number Landlord Complete Mailing Address Address of Property rented Dates Rented Current rent Utilities? Reason for moving Please list additional landlords on a separate piece of paper.

3 Have you resided in Minnesota for the past ten (10) years? Yes No if no, give previous address of residence. PERSONAL REFERENCES (Other than family members and landlord references) Name Complete mailing address Phone number 1) 2) 3) INCOME INFORMATION Social Security Benefit (Monthly Net) x Amount deducted for Medicare (Monthly) x SSI Benefit and /or Grant (Monthly) x 12 Source:... Pensions (Monthly Gross) x 12 Source:.. Veterans Benefit (Monthly) x Employer Wages (Monthly Gross) x 12 Income from Rental of Real Estate (circle Monthly or Annual)... Interest Portion of Payment on Contract for Deed (Annual)... Interest Earned on Interest earning Checking Accounts (Annual)... Interest Earned on Savings Accounts (Annual)... Interest Earned on Certificates of Deposit (Annual)... Interest Earned on IRA (Annual)... VERIFIED Column: Office use only Tenant s Estimate VERIFIED Interest or Dividends Earned on Stocks (Annual)... Interest Earned on IRA or Annuities... TOTAL ANNUAL INCOME... Have you disposed of any assets in the last 2 years? No. ASSET INFORMATION: VERIFIED Column: Office use only Equity in Real Estate (Market Value Listed on Current Tax Statement)... Average Checking Account Balance. List Bank(s)... Savings Account. (Total Value) List Banks(s)... Certificates of Deposit (Total Value). List Bank(s)... IRA - Company/Bank(s)... Stocks (Total Value). Company... Bonds (Cash Value)... Annuities (Total Value). Company... Other:... MEDICAL EXPENSES: VERIFIED Column: Office use only Tenant s Estimate VERIFIED Amount deducted for Medicare (Monthly, Same as line 2)... Supplemental Insurance (Annual)... Company Name Prescriptions (not covered by Insurance) taken on a regular basis (Annual)... Any other Medical Expenses (not covered by Insurance) (Annual)... Such as Hospital, Clinic, Dental, Glasses, Hearing Aid, etc

4 OTHER INFORMATION List car, truck or other vehicle owned. Parking will be provided for one vehicle. Type of vehicle: Year/Make: Color License Plate Number: Registered To: Do you own any Pets? Yes No If yes, describe Note: There is an additional $ damage deposit for a pet. Landlord reserves the right to limit size/type of pet allowed. In case of emergency notify: Address: Phone Number: APPLICANT PLEASE NOTE: Each person in your household 18 years of age and over including your care giver and or attendant will be required to submit a non-refundable $17.00 fee (money order payable to Madsen Properties, Inc.) to cover criminal and credit checks. This fee is to be returned with the application. Processing of an application normally takes 14 working days. Approved applicants will have their name placed on the waiting list. No further contact will be made until your name comes to the top of the list and a vacancy occurs that meets your needs. In order to keep our records up to date; please notify us of any change of address or phone number. When you are contacted regarding a vacancy we are required to verify your income and assets. You will be sent the necessary forms and instructions at that time. Applicants determined ineligible will be notified in writing of the specific reasons for rejection. Should your application be approved, two forms of identification will be required with a minimum of one being a photo ID. The Tenant Selection Criteria is available upon request. CERTIFICATION I/we further certify that this will be my/our permanent residence. I/we understand that I/we must pay a security deposit for this apartment. I/we understand that my eligibility for housing will be based on tenant selection criteria. I/we certify that all information in this application is true to the best of my/our knowledge and I/we understand that false statements or information are punishable by law and will lead to cancellation of this application or termination of tenancy after occupancy. AUTHORIZATION I/we do hereby authorize MADSEN PROPERTIES, INC., and its staff or authorized representatives to investigate my criminal history, residential, employment and income history, bank and credit history. The source of information may come from but not limited to: Any Government agency, previous landlord, law enforcement, offices, companies, groups, organizations, credit bureaus, banks and other depository institutions: current and former employers; federal or state records including state employment security agency records; county or state criminal records as follows or other sources as required to obtain information or materials about myself, co-tenants, dependents and or care giver/attendants which are necessary to complete my/our application for housing and to verify all information listed on this application. It is understood that a photocopy or facsimile copy of this form will serve as authorization. This application and or authorization continues in effect for 12 (twelve) months from signature date. SIGNATURE(s): Date Signature Applicant Date Signature Co-Applicant FAMILY HOUSEHOLD COMPOSITION: The information solicited on this application is requested by the apartment owner in order to assure the Federal Government, acting through the USDA-Rural Development, Rural housing Service, that Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial status, age, and handicap are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race/national origin and sex of the individual applicants on the basis of visual observation or surname. Racial Categories: American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Other. Ethnic Categories: Hispanic or Latino Not Hispanic or Latino Other. Madsen Properties, Inc. is an equal opportunity provider and employer. Forms tenant 1/10

5 TO: Madsen Properties, Inc State Highway 78, Suite 1 Battle Lake, MN AUTHORIZATION TO RELEASE INFORMATION RE: / Phone/Fax SS# DOB I, and/or another adult in my household, authorize you to provide to Madsen Properties, Inc. (MPINC) for verification purposes the following applicable information: Past and present employment and income records. Bank account, investments, and any other asset balances. Past and present out of pocket medical expenses. I understand that under current Privacy Acts MPINC is authorized to access my financial records, income verification and medical expense information held by such institutions in connection with the consideration or administration of assistance to me. I also understand that financial records, income verification and medical expense information involving my housing eligibility will be available to MPINC without further notice or authorization, but will not be disclosed or released by MPINC to another Government agency or department or used for another purpose without my consent except as required or permitted by law. This authorization is valid for twelve months from date of signature. The information MPINC obtains is only to be used to determine eligibility or level of benefits for housing under a program of USDA/RD. I understand that disclosure of this information is voluntary. However, failure to disclose certain items requested, including my social security number, may result in a delay in processing the certification and loss of financial eligibility for housing assistance. A copy of this authorization may be accepted as an original. Your prompt reply is appreciated. Signature (Applicant or Adult Household Member) Signature (Applicant or Adult Household Member) Date Date In accordance with Federal law and U.S. Department of Agriculture policy, Madsen Properties, Inc. is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all programs). To file a complaint of discrimination, write USDA Director, Office of Civil Rights, 1400 Independence Avenue S.W., Washington, D.C , or call (800) (voice), or (202) (TDD) AUTHORIZATION TO RELEASE INFO REVISED.doc

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