PATHWAY TO RECOVERY RENTAL APPLICATION 1

Transcription

1 PATHWAY TO RECOVERY RENTAL APPLICATION 1 Applicant: Date Driver License # Address Birthdate Social Sec # City State Zip Home Work Co-Applicant: Date Driver License # Address Birthdate Social Sec # City State Zip Home Work Contact in case of Emergency (Name Relationship) Your initials authorize Pathway to contact this person in case of Emergency. Applicant Referral Source ( Transitional housing or semi-independent living program) Program (Residential/Housing Program) Contact Person (Staff Member) Length of Stay Phone HOUSEHOLD INCOME (PROOF OF INCOME MUST BE ATTACHED) Applicant Employer Hire Date Position Gross Employment Income: $ X = $ X 52 $ / 12 = (Per Hour) (Hours per week) (Weekly Gross) (Yearly Gross) (Monthly Gross) My initials authorize Pathway to contact my employer to verify the information listed above. Past Employer Dates to Position Co-Applicant Employer Hire Date Position Gross Employment Income: $ X = $ X 52 $ / 12 = (Per Hour) (Hours per week) (Weekly Gross) (Yearly Gross) (Monthly Gross) My initials authorize Pathway to contact my employer to verify the information listed above. Past Employer Dates to Position OTHER INCOME Type of Income Month $ Year $ Other Income sources not yet reported Month $ Year $ TOTAL HOUSEHOLD INCOME OF ALL SOURCES: HOUSEHOLD SIZE:

2 Vehicle How many Vehicles do you own including company cars? List the vehicle to be parked in your parking space. Make/Model Year Color Tag Number State Occupants Name Relationship Date of Birth Social Security # Move in Date Requested move in date: Requested Unit Address 2 Pets (Pets are only allowed in certain units with staff approval. Pet charges include a $100 non-refundable pet deposit. Number of pets? Weight (s) Legal Date of last arrest or incarceration: Probation Officer Name List any additional pending legal issues: Type(s)/Description(s) If yes, Name of contact person and a Phone number. Please attach picture and proof of current shots Charge(s) My initials authorize Pathway to contact person listed to verify information given above. Medical: (List ALL current medications--failure to do is equivalent to falsifying information). Legally prescribed Addictive or Controlled Substances must be kept locked in the office at Pathway-I and taken under staff supervision. Any such medications must be approved by staff and are only permissible during emergency or short term circumstances. Non compliance violates substance-free housing requirements. Current Medications Physician(s) Counselor(s) Psychiatrist (s) Mental Health Center Diagnosis My initials authorize Pathway to contact person(s) listed in case of emergency or to verify information. Recovery Sobriety date? Sponsor: Longest length of sobriety When Relapse substance(s) or Drug(s) of choice in order of preference(s) 1 st 2 nd 3 rd My initials authorize Pathway to contact person listed above in case of relapse. Applicant Signature: Co-Applicant Signature: Staff Signature:

3 Pathway II, III, IV, V or VI Eligibility Confirmation Form 3, has applied for residency at one of Pathway s affordable (Applicant Name) substance-free housing program. You can help to facilitate their transition and confirm compliance with our requirements for residency by providing the following information. The applicant understands that his or her signature below allows the referral source to provide the following information to Pathway. Applicant Signature: HOMELESS STATUS (Transitional housing or semi-independent living program) Program Contact Person (Residential/Housing Program) (Staff Member) Length of Stay Phone DISCHARGE STATUS Which of the following best describes applicant s most recent discharge? Successful Unsuccessful (Discharge reason) How long was applicant clean and sober at time of discharge? EMPLOYMENT HISTORY Is applicant considered disabled (unable to work)? Yes (skip next question) No Did applicant maintain consistent employment throughout residency? Yes No Current Employer: Length of time at current job: RENT PAYMENT HISTORY Was applicant responsible for rent? Yes No If not, who was? Rent Charge $ per month Number of months applicant paid this amount Did applicant leave an unpaid balance? No Yes, amount: Which of the following best describes applicant s rent payment history? Always paid in advance Usually paid in advance Always paid by due date Usually paid by due date Always had to be reminded Usually had to be reminded Always paid late Usually paid late GENERAL INFORMATION Would you recommend this applicant for residency? Yes No Would you rent to this applicant again? Yes No Did applicant damage any property or exhibit self-destructive behavior during residency? Yes No Staff Signature:

4 4 Landlord Verification of Income & Employment by Employer Applicant Name AUTHORIZATION: Federal Regulations require verification of employment and income for all members of households applying for participation in HOME funded projects. We ask for your cooperation in supplying this information. This information will be used only to determine benefit level eligibility of each household. Your prompt return of the requested information will be appreciated and will help us to expedite this applicant s request Company: Supervisor: Address: Phone: Start Annual Gross Salary: $ Date of Last Increase: Employer Information Pay Rate (Please enter gross amounts based on current wages RELEASE OF INFORMATION: I hereby authorize the release of the requested information. Signature of Applicant Date Total Annual Wages Base pay for last 12 months: $ Overtime pay for last 12 months: $ Projected pay for next 12 months: $ Total Annual Wages: $ Additional Notes: Hourly Amount $ Weekly Amount $ Monthly Amount $ Average Hours/Weeks Hours per week worked Weeks per year worked Overtime pay rate: $ per hour Expected average # of hours of overtime to be worked the next 12 months: Other Compensation not included above (specify for commissions, bonuses, tips, etc): For: ; Amount $ Frequency: Does employee receive vacation pay? No Yes, # of days: X Employer Signature & Title Printed Name Date WARNING: Title 18, Section 1001 of the US 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. ATTACH AT LEAST 3 CURRENT CHECK STUBS X

5 1 PATHWAY ADMISSION & EVICTION CRITERIA ADMISSION CRITERIA Any homeless person who is an alcohol and/or drug abuser attempting to maintain sobriety, in need of substance free, affordable housing, meeting the following criteria may apply: Must be at least 18 years old Must verify completion of previous program such as transitional or halfway house PW-II PW-III PW-IV PW-V PW-VI Must verify continuous sobriety (drugs and alcohol) 3 months 6 months Must verify psychiatric stability and compliance with mental health treatment plan 3 months 6 months Must verify consistent employment income or; disability income. 3 months 6 months Must sign and comply with lease agreement 6 months 1 year EVICTION CRITERIA 1. Violation of any terms listed in lease agreement or property rules, or falsifying information. 2. Evidence of drug or alcohol use by tenant or tenant s guests. 3. Failure or refusal to participate in random drug screen as requested by staff. 4. Failure to pay rent and or security deposit in a timely manner. 5. Destruction of property by tenant or tenant s guests. 6. Possession of illegal substance, or firearms by tenant or tenant s guests. 7. Arrest or incarceration. I have read the information listed above, and understand that evidence of violation can result in eviction. Leaseholder Signature: Co-Leaseholder Signature: Pathway Staff Signature:

6 2 Pathway II & Pathway III ABSOLUTE RULES 1. Pay your rent on time. 2. No drugs or alcohol used or allowed on premises by tenants or guests. 3. No business is to be conducted on property, as insurance only allows for personal use of premises 4. Absolutely No sex relations allowed in the house. 5. Absolutely No physical or verbal aggression on the property. 6. No smoking in bed. 7. Do not enter another resident s room without permission. 8. No long distance phone calls or other billable services (automatic callback, directory assistance, etc) 9. Leave emergency number with Manager if you will be out overnight. 10. Turn in an aftercare report each week. 11. Report any lost or stolen keys to the Manager immediately. 12. Always lock up when you leave. 13. No pets 14. Report any problems to the Manager. Visitors: Minors can visit only with a parent present due to the liability of consenting to medical treatment if medical care became necessary. No visitors allowed in bedrooms. Resident is responsible for their visitors and must be present at all times. No overnight visitors without pre-approval from staff and residents. *Special exceptions can be made for sponsors, out of town guests or special circumstances with staff approval. Visitors Schedule: Mon Thurs: 7 p.m.-10 p.m. Fri. - Sat.11 a.m. to midnight (quiet after 10 p.m.) Sun: 11 a.m.-10 p.m. General Relationship Guidelines Constant visits from a resident s significant other can interfere and detract from the privacy of others. If this becomes an issue, it will be addressed based on each resident s personal recovery issues. Relationships have been known to increase the chances of relapse. While dating is not prohibited as a general rule, we believe your recovery should be your primary focus and building supportive relationships, rather than romantic ones should take priority. Please do not take advantage of daily visitation with a significant other and keep in mind the comfort and privacy of other residents. RESPECTIVE RULES 1. If you take it out, put is back. If you mess it up, clean it up. If you break it, replace it. If you do not own it, do not bother it. 2. Keep your assigned area clean and chores completed 3. Turn on porch light at night. Turn off in the morning. 4. Save electricity, turn off when not in use. 5. Write down phone messages with date, time, name and number. 6. Tell manager if room temperature needs adjusting. 7. Respect privacy; do not enter private rooms without an invitation. 8. You are responsible for anyone you let in the house. 9. Keep noise to a minimum after hours. 10. Keep all prescribed medications in your room. 11. Report concerns on your weekly aftercare report. 12. Do not leave laundry unattended overnight. 13. Do not leave food in your room. 14. Empty ashtrays daily in metal container. Put all ashtrays in kitchen when not in use. 15. Report any property damage immediately. Statement of Understanding: Considering the limitations and demands that group living presents, rules are designed for everyone to be as comfortable. You are responsible for learning the rules and asking for help if you are unable to understand them. Excessive or repetitive rule violations will result in termination as stated in your lease agreement. In sobriety, we must learn to change our behaviors and attitudes to meet the conditions around us, rather than expecting our environment to adjust to our personal demands. Our primary purpose is to provide an atmosphere of recovery, respect, and courtesy for all residents. Resident Signature Date

7 3 Pathway IV, V, & VI ABSOLUTE RULES 1. Read your lease. 2. Pay your rent in full on time. There is a $35 late fee starting the 6 th of the month. 3. If your rent is going to be late, you must Ivy or Gary immediately. 4. No drugs or alcohol used or allowed on premises by tenants or guests. 5. Anyone on property is subject to random drug and alcohol screening at any time. 6. Guests who refuse testing may not return to property. 7. Tenants are responsible for their guests. 8. Report any lost or stolen keys or remotes immediately. There is a$35 replacement or lockout fee. 9. Do not loan your keys or gate remote to anyone else. 10. No business is to be conducted on property, as insurance only allows for personal use of premises 11. Absolutely No physical or verbal aggression on the property. 12. Be respectful of the utilities. Do not open windows with furnace on or air conditioner running. Turn out lights when you are not home. 13. No grills or outside cooking equipment. 14. Do not leave guests unattended in your unit. 15. If a guest stays over beyond two nights, you must have special permission. 16. Do not disturb other tenants with loud music 17. Always lock up when you leave. 18. Make sure drive through gate is shut when you leave. 19. Make sure walk through gate is locked when you leave. 20. No pets without special permission in particular units 21. Report any problems to the office. 22. Do not leave laundry unattended overnight. 23. Put trash in dumpster. 24. Keep balconies clean. 25. Report any property damage immediately. 26. Window treatments should have white backing for uniformity. You may put white blinds up. 27. Submit monthly progress report with rent payment. 28. Attend at least one meeting a week at Pathway and a minimum of at least 2 more elsewhere. 29. Report loss of job or income immediately. 30. Statement of Understanding: Rules are designed for everyone to live comfortably. You are responsible for learning the rules and asking for help if you are unable to understand them. You are also responsible for protecting your home from drugs or alcohol use by tenants or guests. If you suspect someone has violated this requirement, please contact the office immediately. Excessive or repetitive rule violations will result in termination as stated in your lease agreement. In sobriety, we must learn to change our behaviors and attitudes to meet the conditions around us, rather than expecting our environment to adjust to our personal demands. Our primary purpose is to provide an atmosphere of recovery, respect, and courtesy for all residents. My signature confirms that I understand the information above. Tenant Signature Date Make copy for tenant to take.