AFFORDABLE HOUSING RENTAL APPLICATION

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1 Please call Sally with any AFFORDABLE HOUSING RENTAL APPLICATION This Affordable Housing Rental Application is the first step in seeking to rent an apartment owned and/or managed by Community Concepts, Inc. Property Management Department. Due to State and Federal legislation and regulations, extensive information is required by the agencies involved. This is to assure the government that housing, which might be subsidized by them, is used fairly and to maximum efficiency. Affordable Housing Locations South Paris Norway Housing: 14 High Street: 6 one-bedroom Norway Family Stony Brook Housing 6 one-bedroom 2 two-bedroom & 16 three-bedroom High Street Apartments: 12 three-bedroom Bethel Bethel Station Apartments: 12 three-bedroom Rumford 408 Penobscot Street 4 one-bedroom Farmington Farmington Hills Apartments: 4 two-bedroom & 6 three-bedroom Brownfield Willard Bickett Apartments: 5 two-bedroom & 3 three-bedroom Fryeburg Willard Bickett Apartments: 4 two-bedroom & 8 three-bedroom 399 Main Street: 3 one-bedroom & 1 three-bedroom Lewiston Street: 195 Sabattus Street: 138/140 Horton 4 one-bedroom 2 one-bedroom & 3 two-bedroom Mt Blue Housing: 5 one-bedroom 130 Oxford Street: 1 two-bedroom & 7 three-bedroom 60 Maple Street: 2 two-bedroom, 12 three-bedroom & 2 four-bedroom building) Bates St. Senior Housing: 26 one-bedroom, 4 two-bedroom (This is a smoke-free Mt David Housing: 14 one-bedroom & 1 two-bedroom IMPORTANT: Please be sure to fill out all required information with complete addresses and phone numbers where applicable. Adults 18 years of age or older who will be residing in the apartment must sign and date application. Incomplete applications will be returned for completion and will only be processed once they have been completely filled out. Thank you. Indicates special requirements apply for eligibility Referred to Community Concepts by: Please list the location(s) you are applying for: Please return completed application to: Community Concepts, Inc. Property Management 240 Bates Street Lewiston, ME 04240

2 VERY IMPORTANT PLEASE READ BEFORE PROCEEDING IN order for us to be able to process your application efficiently, you MUST fill in an answer on ALL lines of this application for ALL questions asked. You MUST either fill in the question with the correct information, OR write in N/A if the question is T APPLICABLE to you. It is especially important to fill in the complete phone number and address of your current and/or prior Landlord(s) and character references. We require two years of positive prior landlord verification other than family. Exceptions may apply. All applications will be processed for State and National Sex Offenders Registry and a local police check. Your application will not be accepted as complete if you fail to fill in all the questions as outlined above, and it will be returned to you as incomplete. THIS WILL HOLD UP THE PROCESSING OF YOUR APPLICATION. If you have any questions, or need assistance filling out the application, you may contact us Mondays through Fridays between 8:00 AM and 4:30 PM by calling , and asking to speak with someone in the Property Management Department. Thank you for your cooperation and interest in our Affordable Rental Housing. Property Management - 2 -

3 A. GENERAL INFORMATION Last Name: First Name: MI: Mailing Address: Residence: Street Apt. # City State Zip Telephone Number: Day: Evening: I require a: Do you rent, One Bedroom, Two Bedroom, Three Bedroom Four Bedroom, Handicapped Unit, Other Requirements or own Current monthly rent $ or mortgage payment $ Do you currently hold a Section 8 Housing Choice Voucher? YES If YES, what BR size is the Section 8 Voucher? 0 BR, 1 BR, 2 BR, 3 BR, 4 BR Other Are you currently Homeless or at risk of Homelessness? YES If YES, are you living with friends or relatives? YES If YES, please Explain: B. FAMILY HOUSEHOLD COMPOSITION List ALL persons, including children, who will live in the apartment. Please list Head of Household first: Relation to Last Name First Name MI M/F head of Date of household Birth SSN # H Head Custody status of all minors listed above: Full, Shared Visitation, Joint Custody Do you anticipate any additions to your household in the next twelve months? YES If YES, please Explain: - 3 -

4 Full Time Students: Are ALL of the persons living in your household currently Full Time Students, OR have been Full Time Students within the last calendar year, OR are planning on becoming Full Time Students within the next 12 months? YES (If answered No skip questions a-e) If answered YES you MUST continue with the following questions: (You will need to provide verification of all items to which you answered YES.) a. Are the household members married and currently filing a joint tax return? YES b. Is at least one household member receiving assistance through TANF (the Temporary Aid for Needy Families program)? YES c. Is at least one household member enrolled in a federal, state or local job training program? YES d. Does the household consist of a single parent with a dependent child (or children) and neither the parent nor the child (or children) is claimed as a dependent by anyone else on their tax return? YES The following information is requested by the apartment owner in order to assure that the Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, religion, sex, age, familial status, national origin, or physical or mental 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. PLACE OF BIRTH U. S. CITIZEN RACE ELIGIBILITY (Y/N) * indicate by code below **indicate by code H * Race: WNH=white non-hispanic, WH=white Hispanic, A=American Indian/Alaskan Native, P=Pacific Islander, B=Black ** Eligibility: M=Minor, FTS=Full Time Student, E=Elderly, D/H=Disabled, H=Handicapped - 4 -

5 C. INCOME INFORMATION: List ALL sources of income for all household members. PLEASE LIST GROSS AMOUNTS (BEFORE ANY DEDUCTIONS) Family Member: Employment: Hourly Rate $ Hours Per Week: Weeks per Year: If applicable, Annual Gross Salary: $ Employer: Address: Employment: Hourly Rate $ Hours Per Week: Weeks per Year: If applicable, Annual Gross Salary: $ Employer: Address: Self Employment Monthly Amount $ If applicable, Annual Gross Salary: $ Social Security Benefits Monthly Amount $ Social Security Benefits Monthly Amount $ SSI benefits Monthly Amount $ SSI benefits Monthly Amount $ Maine State Supplement Monthly Amount $ Pension Monthly Amount $ Pension Monthly Amount $ Veterans Benefits Monthly Amount $ Veterans Benefits Monthly Amount $ Unemployment Compensation Monthly Amount $ Unemployment Compensation Monthly Amount $ TANF Monthly Amount $ TANF Monthly Amount $ Child Support Monthly Amount $ Child Support Monthly Amount $ Alimony Monthly Amount $ Alimony Monthly Amount $ Interest Income Monthly Amount $ Interest Income Monthly Amount $ Source of Interest Income Address Other Income Gross Monthly Amount $ Source Address Do you anticipate any changes in this income in the next 12 months? YES If YES, explain: - 5 -

6 D. ASSETS FOR ALL HOUSEHOLD MEMBERS: List ALL sources of assets for all household members (Include children s accounts) Bank Name: Checking Account #: Savings Account #: Name(s) on Account: Bank Name: Checking Account #: Savings Account #: Name(s) on Account: Bank Name: Trust or CD Account # Name(s) on Account: Address: Balance: Balance: Address: Balance: Balance: Address: Balance: Stocks, Bonds, Money Market, Mutual Funds, Annuities or Capitol Gains Name of Broker of Fund or Capitol Gains recipient Address Value as of Today s Date $, Rate of Return %, Annual Dividend, # of Shares Whole and/or Universal Life Insurance Policies Name of Insurance Company: Address: Name of Insured: Type of Policy: Value as of Today s Date $, Rate of Return %, Annual Dividend, # of Shares Real Property Do you own any property? YES If YES, please provide a copy of your tax bill. Type and Location of property: Does your property produce income? YES. If YES, Monthly Amount of Income: $ Mortgage or Outstanding loans Balance: $ What is the current value of the property: $ Is your property for sale? YES. If YES, Name & Address of selling agent: Address of Town Office your tax bill comes from: Tax Map # Lot # Town Have you sold/disposed of any property/assets in the last 2 years? YES If YES, Type of property/asset: Market value when sold/disposed: $ Amount sold/disposed for: $ Date of transaction: - 6 -

7 E. REFERENCE INFORMATION: PLEASE FILL OUT COMPLETELY Have you or anyone in your household ever been a previous tenant in any rental housing owned or managed by Community Concepts, Inc.? YES If YES: Address: Unit #: Date rented: Current Landlord: Landlord Name and Address: Landlord Home Phone #: Business Phone #: Rental Address and Unit #: Monthly Rent Amount $ Date Moved In: Date Moved Out: How long have you lived there? Reason for Moving? Prior Landlord: Landlord Name and Address: Landlord Home Phone #: Business Phone #: Rental Address and Unit #: Monthly Rent Amount $ Date Moved In: Date Moved Out: How long did you live there? Reason for Moving? Prior Landlord: Landlord Name and Address: Landlord Home Phone #: Business Phone #: Rental Address and Unit #: Monthly Rent Amount $ Date Moved In: Date Moved Out: How long did you live there? Reason for Moving? Prior Landlord: Landlord Name and Address: Landlord Home Phone #: Business Phone #: Rental Address and Unit #: Monthly Rent Amount $ Date Moved In: Date Moved Out: How long did you live there? Reason for Moving? - 7 -

8 Character References: (We prefer business/community contacts i.e. employer, teacher, minister, counselor, etc.) (PLEASE RELATIVES) 1. Name: Relationship: Mailing Address: Telephone #: 2. Name: Relationship: Mailing Address: Telephone #: 3. Name: Relationship: Mailing Address: Telephone #: EMERGENCY CONTACTS: Primary Contact: Name: Telephone #: Address: City/State: Zip: Secondary Contact: Name: Telephone #: Address: City/State: Zip: F. VEHICLE AND PET INFORMATION Vehicles: List all cars, trucks, or other vehicles owned. Type of Vehicle: Year/Make: Color: License Plate #: Type of Vehicle: Year/Make: Color: License Plate #: Driver s License Number for Head of Household: Driver s License Number for Household Member 2: PLEASE TE: WE HAVE A STRICT PETS POLICY AT MOST OF OUR PROPERTIES. Pets: DO YOU HAVE ANY PETS: YES If YES: Dogs: * Cats: * Other: * Please indicate Breed, Size and Weight: - 8 -

9 G. ADDITIONAL INFORMATION Have YOU or ANY member of your family listed on this application EVER been charged and/or convicted of ANY Felony crime including drug use, sales and/or possession? YES If YES, you MUST indicate which family member AND describe the type and class of Felony charge(s) and/or conviction(s) Are YOU or ANY member of your family listed on this application required to register as a Sex Offender in the state of Maine or in any state in the United States of America? YES If YES, you MUST describe the type and class of Felony sex offense(s), who on this application must register as a Sex Offender, and in which states they are required to register: Have you or any member of your family been evicted from any housing? YES If YES, please describe who, when, where, and why: Have you ever filed for bankruptcy? YES If YES, please indicate year and describe: If YES, has the case been closed? YES If YES, date closed: You will be required to provide documentation that it has been closed. If, please explain: - 9 -

10 Application Checklist In order to speed up the processing of your request for affordable housing, please remember the following: Did you either provide the correct information for ALL questions on the application, or mark them as N/A if they do not apply? Did you list ALL persons on the application who will be occupying the apartment? Did you provide us with a minimum of your last 2 years of previous landlord rental history and/or any other housing history for ALL adult members on the application? (You MUST provide ALL prior Landlord names, addresses and correct telephone numbers) Did you attach copies of Social Security Cards for ALL persons who will reside in the apartment? Did all household members over 18 years of age supply all information required: Such as: ALL Income of ALL family members; Landlord and character references for all adults on the application; Answer the Felony related questions for All members of the household; Etc. Did ALL adult household members over 18 years of age sign the application and the certification/authorization form? If you are homeless or about to become homeless did you provide us with verification? Did you provide us with your current telephone number and mailing address? Once we have completely reviewed your application, you will be contacted by mail or telephone indicating the status of your Affordable Housing Rental Application. Thank You

11 C E R T I F I C A T I O N / A U T H O R I Z A T I O N =========================================== AUTHORIZATION I/We hereby authorize Community Concepts, Inc., and its staff or authorized representative to contact any persons, agencies, offices, groups or organizations to obtain and verify any information in this application, which may be necessary for housing and/or housing programs administered and/or managed by Community Concepts, Inc. CONDITIONS I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with the management s office and will remain in effect for a long as I reside in any apartment complex managed by Community Concepts, Inc. I/We understand I have a right to review my file and correct any information that I can prove is incorrect. CERTIFICATION I/We hereby certify that I/We do/will not maintain a separate subsidized rental unit in another location. I/We further certify that this will be my/our permanent residence. I/We understand that my/our eligibility for housing will be based on Maine State Housing Authority (MSHA), and/or the Department of Housing and Urban Development (HUD), and/or the Low Income Housing Tax Credit Program (LIHTC) income/occupancy limits and program regulations, and by Community Concepts, Inc. selection criteria. I/We certify that all information in this application is true and complete 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. Head of Household (Signature) Printed Name Date Spouse/Co-Tenant (Signature) Printed Name Date Adult Member (Signature) Printed Name Date

12 OPTIONAL CONFIDENTIAL QUESTIONS: Answering yes to any of the following question MAY assist us in providing affordable housing to you sooner and WILL T have an adverse affect on your possible selection for housing we offer. We may be required to verify all yes answers as applicable depending on the location of the housing. PLEASE INDICATE IF YOU ARE CURRENTLY: HOMELESS? YES Please explain: A VICTIM OF DOMESTIC VIOLENCE? YES If so are you engaged in services with AWAP? YES Other domestic violence recovery agency? YES Name of agency: RECOVERING FROM SUBSTANCE ABUSE? YES If so are you engaged in services with Community Concepts. Inc. Alcohol and Drug treatment Services? YES Other substance abuse agency? YES Name of agency: ENGAGED IN SERVICES WITH COMMUNITY CONCEPTS, INC. YES HEAD START OR EARLY HEAD START PROGRAM? ENGAGED IN SERVICES WITH COMMUNITY CONCEPTS, INC. YES FAMILY SUPPORT PROGRAM? ENGAGED IN SERVICES WITH TRI-COUNTY MENTAL HEALTH? YES OTHER MENTAL HEALTH AGENCY? YES Name of agency: ON A WAITING LIST FOR SECTION 8 HOUSING? YES If so, name of agency or housing authority:

13 U. S. Department of Housing and Urban Development We Do Business in Accordance With the Federal Fair Housing Law (The Fair Housing Amendments Act of 1988) It is illegal to Discriminate Against Any Person Because of Race, Color, Religion, Sex, Handicap, Familial Status, or National Origin ν In the sale or rental of housing or ν In the provision of real estate residential lots brokerage services ν In advertising the sale or rental ν In the appraisal of housing of housing ν In the financing of housing ν Blockbusting is also illegal Anyone who feels he or she has been U.S. Department of Housing and discriminated against may file a complaint of Urban Development housing discrimination: Assistant Secretary for Fair Housing and (Toll Free) Equal Opportunity (TDD) Washington, D.C Previous editions are obsolete form HUD (2/2003)

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