Application Cover Letter. Dear Prospective Tenant:

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1 3620 Phillips Parkway St. Louis Park, MN TEL FAX RE: Application Cover Letter Dear Prospective Tenant: Thank you for considering HUD Subsidized Housing at Sholom! You are receiving this letter because you have expressed interested in one of our three vibrant communities: Menorah Plaza: 4925 Minnetonka Boulevard, St. Louis Park, MN Menorah West: 3600 Phillips Parkway, St. Louis Park, MN Harry and Jeanette Weinberg Apartments: 760 Perlman Street, St. Paul, MN As HUD-supported Housing with Services buildings, our three communities offer various floor plans designed to meet your needs, 24/7 on-site Sholom Home Care health services and housekeeping services to assist you with daily living, a complete offering of cultural programs and social activities, optional kosher meal programs and socialized dining, and on-site therapy clinics. Our communities are in close proximity to public transportation and community businesses and resources. Attached you will find an application folder for your review. To be considered for our building, you must complete all forms and return to us as soon as possible to ensure you meet age and income requirements. Missing information may delay the processing of your application. Applicants who meet the necessary requirements will be notified by our admissions staff of available apartments and/or that you have been added to our waiting list(s). When your name reaches the top of our waiting list, admissions staff will contact you to schedule an appointment. If you have any questions regarding the application process and/or our services offered, please contact me, Jane Feldman, Tenant Services Coordinator, at (952) Sincerely, Jane Feldman Tenant Services Coordinator Rossy and Richard Shaller Family Sholom East Campus, St. Paul Shirley Chapman Sholom Home East Bentson Family Assisted Living Residence Jay and Rose Phillips Center for Memory Care Harry & Jeanette Weinberg Apartments David Feinberg Vitality & Aquatics Center Roitenberg Family Adult Day Center Sholom Home Care Sholom Johnson Hospice Agency Twin Cities Metro Area Norman and Lisette Ackerberg Family Sholom West Campus, St. Louis Park Sholom Home West Knollwood Place Apartments Roitenberg Family Assisted Living Residence Leo and Doris Hodroff Pavilion for Memory Care Menorah West Menorah Plaza

2 Sholom HUD-subsidized Housing Application Form All members of the household shall be listed on the application; completed in its entirety, signed and dated by the head of household (Applicant 1) and co-head(s) of household (Applicant 2), and all other household members. Staff will assist any applicant who might have trouble completing the application form to ensure all interested parties are able to apply for housing. Incomplete, unsigned applications and failure to respond to written communication will halt processing. Completed applications and questions can be directed to the Tenant Services Coordinator: ; and/or 4925 Minnetonka Boulevard, St. Louis Park, MN Menorah Plaza is a 151 unit federally subsidized apartment building established in 1981 under the Section 202 program to provide affordable housing for low-income persons 62 years of age and older, or a non-elderly person 55 years of age and older with physician-verified disabilities (handicapped persons). Menorah West is a 45 unit federally subsidized apartment building established in 1986 under the Section 202 program to provide affordable housing for very low-income persons 62 years of age and older. Weinberg is a 45 unit federally subsidized apartment building established in 2008 under the Section 202 program to provide affordable housing for extremely low-income persons 62 years of age and older. Rents are based on 30% of a person s adjusted gross income. Check the location(s) you are applying and apartment type(s) that best meet your needs: Menorah Plaza Apartments, 4925 Minnetonka Boulevard, St. Louis Park, MN Regular 1BR Regular 2BR Accessible 1BR Accessible 2BR Customized Assisted Living 1BR Customized Assisted Living 2BR Weinberg Apartments, 760 Perlman Street, St. Paul, MN Regular and Accessible 1BR Menorah West Apartments, 3600 Phillips Parkway, St. Louis Park, MN Regular 1BR Accessible 1BR Sholom HUD-subsidized Housing Application Form Page 1

3 Office use only: : Time: Method: Initials: I. Applicant Information Head of Household (Applicant 1) Name: Current/Present Address and APT#: Telephone: Birthdate: Social Security: Car Make, Model, and License Plate: Co-head of Household (Applicant 2) Name: Current/Present Address and APT# (if different): City, State, and Zip Code (if different): Telephone: Birthdate: Social Security: Car Make, Model, and License Plate: In the event we are unable to contact you, please provide secondary contact information: Name: Current/Present Address and APT#: Telephone: Address: II. Current Landlord Information (within the last 36 months): Name of Residence: Name of Landlord: Address and APT#: s of Residence: Telephone: Fax: III. Citizenship Requirement (only for Menorah West and Menorah Plaza applicants) Assistance in subsidized housing is restricted to (1) U.S. Citizens or Nationals; and (2) Non-citizens who have eligible immigration status. Each family member, regardless of age, must answer: Yes, I am a United States citizen. Yes, I have valid documentation from the Bureau of Citizenship and Immigration Services (formerly the Immigration and Naturalization Service). Applicant must provide documentation and complete paperwork required by HUD to verify you as a non-citizen with eligible immigration status. No, I am not a United States citizen. Sholom HUD-subsidized Housing Application Form Page 2

4 IV. Verification of Financial Information Are you presently employed? Head of Household (Applicant 1): Yes No Co-head of Household (Applicant 2): Yes No List the name and cash value ($) of all assets fully or partially owned: Applicant 1 Applicant 2 Cash on Hand: / Savings Bonds: / Property: / Interest/Dividends: / Annuities: / Stocks: / Other: / List all monthly income received: Applicant 1 Applicant 2 Employment: / Social Security: / Supplemental Security Income: / Minnesota Supplemental Aid: / Pension: / Alimony: / Family Contributions: / Disability Benefits: / Other Monthly Income: / Other Annual Income: / List all bank accounts (checking, savings, certificate of deposit (CD), money market, individual retirement account(s) (IRA), etc. Use additional pages if necessary. Name of Financial Institution and Type of Account: / Address: Name of Financial Institution and Type of Account: / Address: Have you given away or disposed of any assets during the past two (2) years? Yes No If yes, indicate amount, recipient, and reason for disposal: Sholom HUD-subsidized Housing Application Form Page 3

5 Do you receive monetary gifts or non-cash contributions (food, clothing, etc.) regularly? Yes No If yes, please explain: V. Medical Expenses Applicant 1 Applicant 2 Medicare: / Health Insurance: / Medical Assistance Spend Down: / Other: / VI. Certification Release and Disclosure (Background Check, Criminal and Sex Offender) Yes No Have you ever used or been known by any other name? If Yes, please list: List all states you have ever lived in or held a driver s license (include DL numbers): I/We certify/understand: (1) the information provided here is true and complete to the best of my/our knowledge, (2) it is my/our responsibility to report changes in income and/or assets as soon as they occur, (3) that if selected to receive assistance, the unit I/we occupy will be my/our only residence, (4) that information collected is to determine eligibility for assistance, (5) false statements/information is punishment under federal law. I/We authorize Sholom St. Paul Senior Housing, Inc. (d/b/a) Harry & Jeanette Weinberg Apartments; Knollwood Community Housing Corp (d/b/a) Menorah West; and/or Menorah Plaza Housing Corp (d/b/a) Menorah Plaza to verify all information provided on this application and to contact previous or current landlords or other sources for verification and credit information which may be released to appropriate Federal, State or local agencies. Signature Head of Household (Applicant 1) Signature Co-head of Household (Applicant 2) Signature Sholom Owner/Manager Designated Representative Sholom HUD-subsidized Housing Application Form Page 4

6 Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing OMB Control # Exp. (11/30/2015) Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form. Check this box if you choose not to provide the contact information. Applicant Name: Mailing Address: Telephone No: Name of Additional Contact Person or Organization: Cell Phone No: Address: Telephone No: Address (if applicable): Cell Phone No: Relationship to Applicant: Reason for Contact: (Check all that apply) Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent Assist with Recertification Process Change in lease terms Change in house rules Other: Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you. Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law. Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law , approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of Signature of Applicant The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C ). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C ) imposed on HUD the obligation to require housing providers participating in HUD s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law , authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions. Form HUD (05/09)

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