Criminal background and eviction will be check within the past 5 years.

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1 Housing Authority of the City of Fort Lauderdale (HACFL) Telephone: (954) Submit your application to: HACFL- Affordable Housing Division 500 West Sunrise Boulevard Fort Lauderdale, FL The following documents will need to be provided with your completed application & fee*: Valid Picture ID for all adult members (Drivers License, government issued ID) Birth Certificate for all members Social Security Cards for all members Marriage / Divorce certificate (if applicable) Income received for all members (1 months) Assets all members (6 months), if applicable- bank statement, Life Insurance, IRA, etc THERE IS A NON-REFUNDABLE APPLICATION FEE OF 25.00* PER ADULT (18 YEARS & OLDER), PAYABLE IN MONEY ORDER ONLY TO: HOUSING AUTHORITY OF THE CITY OF FORT LAUDERDALE (HACFL) IN ORDER TO HOLD A UNIT, YOU MUST PROVIDE HALF (½) OF THE SECURITY DEPOSIT (1 MONTH RENT) IN MONEY ORDER TO: HOUSING AUTHORITY OF THE CITY OF FORT LAUDERDALE (HACFL) NO PET(S) ALLOWED. Your total monthly gross income must be twice (2x) the rent amount Criminal background and eviction will be check within the past 5 years.

2 The Housing Authority of the City of Fort Lauderdale, Florida Affordable Housing Division Application: Initial Renewal If this is an initial application, address of unit applying for: Head of Household Information Home Phone: Current Address: Work Phone: City, State, Zip: Cell Phone: Address: MAIDEN NAME, NICKNAME OR ALIAS (if applicable): LEGAL NAME Last, First, Middle Initial Social Security Number Household Information Date of Birth Relationship To Head HEAD Sex M/F Marital Status Race (see # Below) Ethnicity (see # Below) RACE: (1) Black (2) White (3) American Indian/Alaskan Native (4) Asian or Pacific Islander (5) Multi Racial ETHNICITY: (1) Hispanic (2) Non- Hispanic Current Landlord name, address and phone number: Rental History Have you or any household member ever been evicted? Yes No If yes, how many times and when: Name of Landlord(s): Are you or any household member now living or have ever lived in Public Housing, received Section 8 assistance or any other form of government assistance? Yes No If yes, where and what agency: Do you owe them money? Yes No If yes, how much: Are you related to anyone currently employed by The Housing Authority of the City of Fort Lauderdale or any of its affiliates, including the Affordable Housing Division? Yes No If yes, who are you related to and what is the relationship:

3 Criminal History Have you or any member of your household ever engaged in, been cited, arrested, indicted, convicted, placed on probation/parole, had an adjudication withheld, had charges dropped or nolle prossed in connection with any criminal activity? Yes No If yes, who: When? What was the charge? What was the outcome? Are you or any member of your household required to register as a sex offender or predator? Yes No If yes, who? What was the charge: When? What city and state did the offense occur: Emergency Contact Telephone: Relationship: Beneficiary Telephone: Relationship: THE RESIDENT DESIGNATES THE ABOVE ADULT PERSON AS THE RESIDENT'S BENEFICIARY TO BE RESPONSIBLE FOR REMOVAL OF THE RESIDENT'S PERSONAL PROPERTY IN THE EVENT OF DEATH OR INCAPACITY OF RESIDENT. RESIDENT FURTHER DESIGNATES HIS/HER BENEFICIARY TO BE THE RECIPIENT OF ANY FUNDS DUE TO RESIDENT IN THE EVENT OF RESIDENT'S DEATH OR INCAPACITY. THIS EMERGENCY CONTACT BENEFICIARY NOTICE SUPERCEDES ANY AND ALL PRE-EXISTING EMERGENCY CONTACT BENEFICIARY NOTICES. Household Income Please provide one (1) month of income receiving now and/or expect to receive in the next twelve (12) months for all members of your household. Proof of income such as: Employment Retirement Fund Unemployment Social Security Workmen s Compensation TANF / Food Stamps Self Employment Verification Child Support Tax Return with W-2 attached for the past 2 years Alimony Veterans Benefits Annuity Payments Contribution / Money received from: (i.e. gifts, family members, friends, etc.) Notarized letter ONLY Member Name Type of Income Agency / Contributor Name Income Household Expenses Please provide twelve (12) months of your most recent expenses paid out of pocket. Proof of expenses such as: (Only applicable for Project Based Units) Childcare Prescriptions/Medications Doctor/Dental Hospital Adult care / Nurse Aide Supplemental Insurance Insurance Other Member Name Type of Expense Agency Name Expenses

4 Household Assets Please provide your most recent asset statement. Proof of assets such as: Checking Account Life Insurance Policy Money Market IRA/ Retirement Pension Savings Account Trust Stocks / Bonds / CD Other Member Name Type of Asset Agency Name Value or Balance Vehicle Information Member Name Year, Make, Model Tag Number Vehicle Payment Insurance Payment If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our program and services, please contact the Affordable Housing Manager at 500 West Sunrise Boulevard, Fort Lauderdale, FL or By signing below I understand that there is a non-refundable initial application fee per adult. I further understand that any security deposit given to The Housing Authority of the City of Fort Lauderdale will only be refunded if denied. If I decide to cancel after being approved, security deposit paid will NOT be refunded. I hereby authorize The Housing Authority of the City of Fort Lauderdale to perform background checks, including, but not limited to, income verification, criminal background, and eviction record for the purposes of determining my suitability and eligibility as an initial or continuing tenant. I understand and agree that any initial or renewal lease agreement entered into by the parties is conditional upon the receipt of cleared background checks, income verifications, and eviction records. Said checks and verifications will be performed after this Application has been completed. The Housing Authority of the City of Fort Lauderdale reserves the right to terminate any lease if the background checks are not approved or the income verifications do not meet eligibility requirements. Tenant will be given a 7-Day Notice to Cure the Non Compliance if their background check(s) are not approved. Tenant s lease will be terminated in the event they are unable to cure the noncompliance. WARNING: Title 18, Section 1001 of the United States Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the United States. I/we read and understand all questions asked of me and certify that all information given is true. I/we further understand any false information given will result in denial of my application. Stamp date/time received: Revised 7/26/13

5 Authorization for the Release of Information Organization requesting release of Information (Name, Address, Telephone, & Date): The Housing Authority of the City of Fort Lauderdale Affordable Housing Division 500 West Sunrise Blvd Ft. Lauderdale, FL (954) Purpose The Housing Authority of the City of Fort Lauderdale may use this authorization and the information obtained with it, to administer and enforce program rules and policies. Authorization I authorize the release of any information (including documentation and other materials) pertinent to eligibility for or participation under any of the following program: Affordable Housing Program I authorize the above named organization to obtain information about me or my family that is pertinent to eligibility for participation in assisted housing programs. I authorize the Housing Authority of City of Fort Lauderdale to obtain information on wages or unemployment compensation from State Employment Securities Agencies. Information Covered Inquiries may be made about: Child Care Expenses Credit History Criminal Activity Family Composition Employment, Income, Pension, and Assets Federal, State, Tribal, or Local Benefits Handicapped Assistance Expenses Identity and Marital Status Medical Expenses Social Security Numbers Residences and Rental History Individuals Or Organizations That May Release Information Any individual or organization including any governmental organization may be asked to release information. For example, information may be requested from: Banks and Other Financial Institutions Courts Law Enforcement Agencies Credit Bureaus Employers, Past and Present Landlords Providers of: Alimony Child Care Child Support Credit Handicapped Assistance Medical Care Pensions/Annuities Schools and Colleges U. S. Social Security Administration U. S. Department of Veterans Affairs Utility Companies Welfare Agencies Conditions I agree that photocopies of this authorization may be used for the purposes stated above. If I do not sign this authorization, I also understand that my housing assistance may be denied or terminated. Signature, Original of the is retained Head of Household by the requesting organization. Date Print, Name of Head of Household HOUSING AUTHORITY OF CITY OF Signature, Spouse/Co-Head FORT LAUDERDALE Date Print, Name of Spouse/Co-Head Signature, Other Adult Member of the Household Date Print, Other Adult Member of the Household Signature, Other Adult Member of the Household Date Print, Other Adult Member of the Household