PALM LAKE VILLAGE. Application Fee is $25.00 Please make money order/cashier check payable to P.L.V.H.C.

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1 PALM LAKE VILLAGE 1515 County Road One Dunedin, Florida (727) Monday through Friday 8:00 am to 5:00 pm (Office closed last Friday of each month for in-service day) Application Fee is $25.00 Please make money order/cashier check payable to P.L.V.H.C. You must be 55+ years of age; pass a rental credit check; background check & have a minimum monthly income of $ Convenient to Malls, Post Office, Banks & Beaches Serviced by PSTA Bus Line Laundry Facilities included on property One Small Pet is allowed with Restrictions (20 lbs or less; $25.00 Non-refundable Pet Fee & $50.00 Deposit) One Bedroom $ per month $ security deposit (658 sq ft of living space 195 sq ft screened patio area) Two Bedroom $ per month $ security deposit (780 sq ft of living space 213 sq ft screened patio area) Monthly rent includes Water, sewer, garbage, lawn care & pest control. Tenant pays for Electric, telephone & cable. Revised 10-10

2 PINELLAS COUNTY HOUSING AUTHORITY The Dean S. Robinson Administration Building Ulmerton Road, Largo, Florida Telephone (727) Palm Lake Village Housing Corporation 1515 County Road 1, Dunedin, FL APPLICATION INSTRUCTIONS PLEASE READ CAREFULLY INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED OR PROCESSED THIS IS NOT A SECTION 8 OR PUBLIC HOUSING APPLICATION AND CANNOT BE USED FOR THE HOUSING ASSISTANCE PAYMENTS PROGRAMS. 1. This application is valid for all properties owned by the Palm Lake Village Housing Corporation. 2. To be qualified for admission an applicant must: a) Meet the HUD requirements on citizenship or immigration status. b) Provide documentation of Social Security numbers for all family members, or certify that they do not have Social Security numbers. c) Meet or exceed the Applicant Selection Criteria. d) Pay any monies owed any Federally Funded Housing Payments Program. e) Not have had a lease terminated by any Federally Assistant Housing Payments Program in the past 12 months. f) Be able and willing to comply with the Palm Lake Village Housing Corporation lease. g) Not be engaged in any criminal activity that threatens the life, health, safety, possessions, or right to peaceful enjoyment of other residents and not be engaged in any drug-related criminal activity. 3. As part of the approved suitability procedures, the Palm Lake Village Housing Corporation will conduct a criminal background check on all adults who will be members of the household. THE PALM LAKE VILLAGE HOUSING CORPORATION IS AN EQUAL HOUSING PROVIDER The Palm Lake Village Housing Corporation is operated by the Pinellas County Housing Authority

3 PALM LAKE VILLAGE APPLICATION PROCESS Please take a moment to answer the questions and read the information for the application. Please bring a photo ID and your social security card with you when dropping off application; we will make a photocopy. Application Fee is $25.00 (non-refundable) and must be in the form of a money order/cashier check payable to: P.L.V.H.C. DO NOT SIGN Application until in front of Notary or Palm Lake Office Staff. 1. Do you have a pet? Yes or No If yes, provide type & weight 2. Do you have a lease now? Yes or No If yes, when does it end 3. Do you need a 30-day notice? Yes or No. 4. Could you move in 2 weeks or less notice? Yes or No 5. Do you have a preference of middle or end unit? Yes or No. (This could cause a longer wait time for an apartment) 6. Please bring in your proof of income, Social Security Award letter, Pension, Alimony, Last three pay stubs; if you work, or any income that you may have. Must have actually documentation. 7. Please bring in your last three current bank statements. Once application is received, we will mail to you any information that is required to process application. It is your responsibility to keep your phone number and address current with us. Please mail any new address or phone number to our office. We will not take any information over the phone. Wait list status can be checked on at the end of every month.

4 APPLICATION FOR LEASE THE PALM LAKE VILLAGE HOUSING CORPORATION COMPLETE BOTH PAGES Applicant-Last Name First Name Middle Initial Co-Applicant-Last Name First Name Middle Initial Present Address Apt. No. City State Zip Code Telephone # ( ) FOR STATISTICAL PURPOSES ONLY RACE: White/Caucasian Black/African-American Asian/Pacific Islander Native American/Alaskan Native ETHNICITY: Hispanic/Latino Non-Hispanic/Non-Latino How long at present address? Years Months Monthly Rent $ Utilities $ Is rent payment current? If not explain A. Present Landlord/Apt Manager Name Telephone # Address City State Zip Code B. Previous Address City State Zip Code How long? Years Months C. Have you ever been evicted? Yes No if yes, Reason. A yes answer will not automatically disqualify you for housing. D. Have you ever lived in Public Housing or any federally subsidized program? If so, which City/Housing Authority/Program Name. Dates From to Address Do you owe any money to the Agency? E. Do you require a reasonable accommodation? If so, please explain E. FAMILY COMPOSITION: Beginning with yourself, list all persons who will live in the apartment/house including live-in attendants who are necessary for the care of a family member? You must fill out each box for each person. Your application cannot be processed without complete information. 1 Last Name First Name Social Security # Relationship to Head Sex Date of Birth Place of Birth F. Will any other people be living with you or joining your family? Yes No G. FAMILY INCOME: List the source and the amount of all money received for the last 12 months for each member of the household including yourself. Be sure to include earning from employment, VA benefits, Welfare, TANF, General Assistance, Social Security, SSI, Disability, Unemployment, and Workers Compensation. Person Source Amount Frequency H. If working, employer is Name Address Telephone #

5 I. Assets. Do you have a savings account, checking account, stocks, bonds, etc. Yes No Enter amount $ Type of Asset(s) J. Drivers License or Florida I.D. # Applicant Co-Applicant K. Automobile (applicant) Year Make Model Tag# (Co-applicant) Year Make Model Tag# L. Arrests/convictions. Have you or anyone in the family who is applying for an apartment been charged, arrested or convicted of a crime? Yes No If yes, please explain the nature of the problem and who in the household was involved. A yes answer will not automatically disqualify you from housing. Is anyone in your household currently on parole probation? Yes No If yes, please explain Name of probation officer Phone # M. Other 1. Are you currently residing in any properly of the Pinellas County Housing Authority? Yes No If yes, please tell us who is the lease holder s name and the Address 2. In case of applicant emergency, notify Phone # Address City State Zip Code In the event of serious illness or death of applicant(s) the above person IS/IS NOT authorized to enter the apartment and remove all contents. 3. If the above contact IS NOT please give the name of who will be an authorized person to enter. Name Phone # Address City State Zip Code 4. In the event of serious illness, contact the following physician Phone # 5. Please list type and description of ALL PETS maintained by the applicant I/we certify that the statements on this application are true to the best of my/our knowledge and belief and understand that inquires must be made to verify them. I/we authorize the release of information to the Pinellas County Housing Authority by my/our employer(s), the Department of public service, the Social Security Office, and/or other business or government entities. I/we understand that any false or omitted statements made on this application will cause me/us to be declined for tenancy. Applicant Signature Co-Applicant Signature Date Date Warning: 18 U.S.C provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000 or imprisoned for not more than five years or both. Chapter of Florida Statues make it a crime, punishable by fine of $50.00 to $ or imprisonment for up to five (5) years, or both, if a housing applicant or tenant deliberately makes false statements about his or her income or fail to disclose material fact affecting income and rent. STATE OF COUNTY OF The forgoing instrument was acknowledged before me this day of, 20 by (Name(s) of person acknowledging) Who is personally known to me and/or produced (Type of identification) (Print notary name) (Notary Signature)

6 Please Print Pinellas County Housing Authority CONSENT FOR CONSUMER REPORT DATE: CLIENT NAME: CO-APPLICANT/SPOUSE: I hereby authorize the Pinellas County Housing Authority permission to obtain a consumer report or other information it deems necessary, for the purpose of evaluating my application. I understand that the inquiries may, but is not limited to, credit history, civil and criminal information, records of arrest, rental history, and/or any other necessary information. I hereby expressly release Pinellas County Housing Authority, any procurer or furnisher of information, from any liability what-so-ever in the use, procurement, or furnishing of such information, and understand that my application information may be provided to various local, state and/or federal government agencies, including without limitation, various law enforcement agencies. I understand that should I lease an apartment, Pinellas County Housing Authority, and it s agent, shall have a continuing right to review my consumer report information, rental application, payment history, and occupancy history for account review purposes and for improving application methods. I understand that the information obtained will be used in determining my eligibility for all Subsidized Housing Programs and that the information will be kept confidential within state and/or federal guidelines. I have read and understand the above. Signatures Client: Date: Co-applicant/Spouse: Date: Witnessed By: Date: (Pinellas County Housing Authority Representative) STATE OF OR COUNTY OF The forgoing instrument was acknowledged before me this day of, 20 by (Name(s) of person acknowledging) Who is personally known to me and/or produced (Type of identification) Print Notary Name (Notary Signature)

7 SCREENING REQUIRED INFORMATION All information MUST be complete. Failure to do so will Delay and or Reject your screening process. PLEASE PRINT DO NOT USE NICK NAMES ONE PAGE FOR EVERY APPLICANT 1. LAST FIRST MIDDLE MAIDEN NAME OTHER NAMES USED SOCIAL SEC # DOB PHONE # MUST SHOW 3 YEARS OF PAST ADDRESS HISTORY (use back of form if needed) 2. PRESENT ADDRESS APT CITY COUNTY STATE HOW LONG? YEARS MONTHS LANDLORD NAME PHONE # ADDRESS 3. PREVIOUS ADDRESS APT CITY COUNTY STATE HOW LONG? YEARS MONTHS LANDLORD NAME PHONE # ADDRESS 5. EMPLOYER NAME Rate of Pay $ PER # HOURS PER PAY CYCLE TIPS/COMMISSION WEEKLY/BI-WEEKLY/MONTHLY 6. OTHER SOURCE OF INCOME FROM (SS, SSI SSD, PENSION, ANNUITIES, WORKERS COMP, UNEMPLOYMENT, CONTRIBUTIONS, ETC.) SIGNATURE DATE INTERVIEWED BY COMPLEX STATE OF COUNTY OF The forgoing instrument was acknowledged before me this PRINT NOTARY NAME day of, 20 by (Name(s) of person acknowledging) Who is personally known to me and/or produced (Type of identification) NOTARY SIGNATURE

8 FOR SECOND APPLICANT SCREENING REQUIRED INFORMATION All information MUST be complete. Failure to do so will Delay and or Reject your screening process. PLEASE PRINT DO NOT USE NICK NAMES ONE PAGE FOR EVERY APPLICANT 1. LAST FIRST MIDDLE MAIDEN NAME OTHER NAMES USED SOCIAL SEC # DOB PHONE # MUST SHOW 3 YEARS OF PAST ADDRESS HISTORY (use back of form if needed) 2. PRESENT ADDRESS APT CITY COUNTY STATE HOW LONG? YEARS MONTHS LANDLORD NAME PHONE # ADDRESS 3. PREVIOUS ADDRESS APT CITY COUNTY STATE HOW LONG? YEARS MONTHS LANDLORD NAME PHONE # ADDRESS 5. EMPLOYER NAME Rate of Pay $ PER # HOURS PER PAY CYCLE TIPS/COMMISSION WEEKLY/BI-WEEKLY/MONTHLY 6. OTHER SOURCE OF INCOME FROM (SS, SSI SSD, PENSION, ANNUITIES, WORKERS COMP, UNEMPLOYMENT, CONTRIBUTIONS, ETC.) SIGNATURE DATE INTERVIEWED BY COMPLEX STATE OF COUNTY OF The forgoing instrument was acknowledged before me this PRINT NOTARY NAME day of, 20 by (Name(s) of person acknowledging) Who is personally known to me and/or produced (Type of identification) NOTARY SIGNATURE

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