Affordable Housing Applicant Questionnaire

Affordable Housing Applicant Questionnaire Property Name: Madison Mark of Interview: Desired Apartment: Desired Lease s: Unit Type: Rent Special: Rent: $ Non-Refundable Pet Fee: $ Security Deposit: $ Please fill out the following application with pen only (please print). Any errors can be corrected by placing a single line through the mistake. DO NOT USE WHITEOUT ON THIS APPLICATION! I. Household Information: List each household member that will occupy the apartment. Any non-related household members must fill out separate rental applications. This application MUST include income / asset information for anyone who will be 18 years or older during the next 12 months. Disclosure of an applicant s social security number is voluntary and housing may not be denied solely on the applicants decision to withhold their social security number. Name First, Middle Initial, Last Relationship to Head of Household Head of Household M/F Social Security Number of Birth Month,, Year Current Address: Home Phone: ( ) Cell Phone: ( ) Email: 1. Do you expect any additions to the household within the next twelve months? Name & Relationship: 2. Do you have full custody of your child(ren)? Explanation of custody arrangements: YES NO 1

3. Are any household members temporarily absent? Who? For How Long? 4. Are any household members permanently absent? Who? 5. Have you ever filed for bankruptcy? Is bankruptcy discharged? 6. Have you ever been convicted of a felony or a violent crime? 7. Have you ever been evicted from an apartment for any reason? 8. Do you wish to receive a written explanation of a denial of tenancy? II. Housing References: List the past TWO YEARS of housing references. (If additional space is required, use the back of this page.) 1. Present Address: City: State: Zip: From: To: (Month/Year) Rent Amount: $ Landlord: Landlord s Address: Landlord s Phone Number ( ) Reason for Leaving: Rent Own (Check One) 2. Former Address: City: State: Zip: From: To: (Month/Year) Rent Amount: $ Landlord: Landlord s Address: Landlord s Phone Number ( ) Reason for Leaving: Rent Own (Check One) III. Employment / Income Sources (please list the last two years of employment/income sources) 1. Current Employer or Income Source Monthly Gross Income $ Start Contact Person Fax Number Phone Number 2. Current Employer or Income Source Monthly Gross Income $ Start Contact Person Fax Number Phone Number 3. Previous Employer / Income Source Monthly Gross Income $ Contact Person Employment s Phone Number 4. Previous Employer / Income Source Monthly Gross Income $ Contact Person Employment s Phone Number IV. Emergency Contact Information (this information will be used if needed before, during and after your tenancy for emergency situations) 2

Name/Address Phone: ( ) Relationship to Head of Household: V. Asset Information: Include all assets held and the corresponding annual interest rate, dividends or any other income derived from the asset. An asset is defined as any lump sum amount that you hold and have access to. Include the value of the asset and corresponding income from the asset in the space provided. Include ALL assets held by ALL household members listed on this application, including minors. Check either YES or NO to each question. Do YOU or ANYONE listed on this application have: 1. Checking or savings accounts? (EMC #09) Household Member Type of Account Institution Name & Phone # Account # Amount 2. CDs, money market accounts or treasury bills? (EMC # 09) Household Member Type of Account Institution Name & Phone # Account # Amount 3. Trust funds? (EMC # 09) Household Member Type of Account Institution Name & Phone # Account # Amount 4. Stocks, bonds or mutual funds? (SH #103) Household Member Type of Account Institution Name & Phone # Account # Amount 5. Pensions, IRAs, KEOGH, 401Ks or other retirement accounts? (SH #103) Household Member Type of Account Institution Name & Phone # Account # Amount 6. Cash on hand over $500? Household Member(s): Amount: YES NO 3

7. Real estate including a primary residence, farm, vacant land, vacation home, rental property, commercial space, or other real estate investments? (SH #104) Household Member Address of Property Fair Market Value Balance Owed on Mortgage 8. Payments under a land contract? (If yes, attach copy of amortization schedule.) 9. Personal property held as an investment? (paintings, coin/stamp collections, artwork, etc.) Household Member Type of Investment Value 10. A safe deposit box? Household Member(s): Contents: Monetary Value of Contents: 11. Assets held jointly with a person who is not a household member? Household Member Name of Asset Jointly Held Asset Held Jointly With 12. Whole life insurance policy? (Term life insurance policies are not included) (SH #103) Household Member Source & Phone # Policy # Cash Value 13. Received any lump sum payments in the last 24 months? (settlements, inheritance, lottery, etc.) Household Member Type of Lump Sum Amount Where is Money Now 14. Have you or any household member disposed of or given away any asset(s) for LESS than fair market value within the past 2 years? (EMC #11) Household Member: Amount: VI. Income Information: Include all income anticipated for the next 12 months (include income for minors turning 18 in the next 12 months). 4

1. Employment wages or salaries? (EMC #01) (Includes overtime, tips, bonuses, commissions and payments received in cash) Household Member Employer Name, Phone/Fax #, Contact Person Amount 2. Self-employment? (copies of last two years tax returns required) (EMC #02) Household Member Name of Company Amount 3. Regular pay as a member of the Armed Forces, including housing allowance? (EMC #03) Household Member Branch of Service, Phone Number Amount 4. Unemployment benefits or workman s compensation? (EMC #04) Household Member Source, Phone Number Amount 5. Public Assistance, General Relief or W-2? (EMC #05) Household Member Source, Phone Number Amount 6. Child support or alimony? (Any COURT ORDERED amounts collected or uncollected) (EMC #06) Household Member Payor s Name, County, Phone Number Amount 7. Court ordered child support or alimony not paid, but have made reasonable efforts to collect by filing with the courts or agencies responsible for enforcing payment. 8. Social Security, SSI or any other payments from the Social Security Administration? (EMC #07) (Please do separate line items for Federal and State payments) Household Member Source Amount 9. Pensions, annuities or other retirement benefits? (SH#100) Household Member Name of Company, Phone Number, Contact Amount 10. Veteran s benefits? (SH#101) Household Member Source and Phone # Amount YES NO 11. Severance payments? (SH #102) Household Member Name of Company, Phone #, Contact Name Amount 5

12. Settlements? (Such as insurance settlements) (SH #102) Household Member Source, Phone Number Amount 13. Disability, death benefits or life insurance dividends? (SH #102) Household Member Name of Company, Phone #, Contact Name Amount 14. Regular gifts or payments from anyone outside of the household? (SH #102) (This includes anyone supplementing your income or paying any of your bills.) Household Member Source, Phone Number Amount 15. Lottery winnings or inheritances? (SH #102) Household Member Source, Phone Number Amount 16. Payments from rental property or other forms of real estate? (EMC #08) Household Member Source, Phone Number Amount 17. Any other income sources or types not listed? (SH #102) Household Member Source, Phone Number Amount 18. Grants or Scholarships for attending an educational facility (financial aid in the form of a loan not applicable) paid to you or directly to the institution? (SH #12) Household Member Source, Phone Number Amount VII. Zero Income Verification: Are YOU or is ANY OTHER ADULT member of your household: 1. Claiming zero income? If so, who? (SH #105) VIII. Live-In Care Attendant: 1. Will you or anyone in your household require a live-in care attendant? (EMC #15) (Proof from doctor is required) Name of Live-in Care Attendant and Relationship if any: IX. Student Information: (EMC #12) 6

1. Are you or any member of your household attending school or plan on attending school within the next 12 months (include minors and primary school): List each student List name of school attending or planning to attend Phone Number for School(s): 2. Are you, or have you attended classes at an educational institution during at least five months of the year in which this rental application is being submitted? List each student List name of school(s) s of enrollment IF YES TO #1 OR #2 ABOVE, PLEASE CONTINUE WITH THE FOLLOWING QUESTIONS: a. Are you married and filing a joint tax return? (If yes, attach signed copy of last year s Federal Income Tax Return) b. Are you receiving assistance under Title IV of the Social Security Act (also known as Aid and Services to Needy Families with Children and Child-Welfare Services)? c. Are you enrolled in a job training program receiving assistance under the Job Training Partnership Act or under other similar Federal, State or local laws? d. Are you a single parent with child(ren) and neither you nor the child(ren) are dependents on anyone else s tax return? (If yes, attach signed copy of last year s Federal Income Tax Return) e. Will you be living with someone who is not a full-time student? If so, who? X. Marital Status Information: 1. Are you currently separated, but not divorced from your spouse? IF YES, CONTINUE WITH THE FOLLOWING QUESTIONS: a. Are you legally separated from your spouse? (If yes, attached copy of current legal separation agreement.) b. Have you pursued legal action? If not, list reason: c. Do you currently receive any monetary support from your spouse? If yes, list monthly amount received: XI. Section 8 Rental Assistance: 1. Will your household be receiving Section 8 rental assistance at time of move-in? Name of Agency and Contact Person: 2. Will your household be eligible or are you applying to receive Section 8 rental assistance in the next 12 months? 7

All questions that were answered YES will be verified through the appropriate third-party source. It will be your responsibility to provide management with all necessary information to properly process your application and verify your eligibility. This will include names, addresses, telephone and fax numbers, account numbers where applicable and any other information required to expedite this process. XII. Signature Clause: I/We understand that management is relying on this information to prove my/our household s eligibility for the Low Income Housing Tax Credit Program. I/We certify that all information and answers to the above questions are true and complete to the best of my/our knowledge. I/We consent to release the necessary information to determine my/our eligibility. I/We understand that providing false information or making false statements is grounds for denial of my/our application as well as forfeiture of all application fees and deposits as liquid damages for time and expense, as well as termination of my/our right of occupancy. I/We also understand that such action may result in criminal penalties. I/We authorize my/our consent to have management verify the information contained in this application for purposes of proving my/our eligibility for occupancy. I/We will provide all necessary information and expedite this process in any way possible. I/We understand that occupancy is contingent on meeting management s resident selection criteria and the Low-Income Housing Tax Credit Program requirements. I agree that I was informed of my right to view the photographs documenting any damage, waste or neglect charged to the previous tenant for the apartment in which I am applying. Initials All ADULT household members must sign below: Signature of Applicant Signature of Applicant Signature of Applicant Signature of Applicant Signature of Property Manager/Leasing Agent 8

Authorization Release of Information PROPERTY ADDRESS: 132 E. Wilson Street : Apt. No.: Madison, WI 53703 Development Name: Madison Mark Applicant/Resident Name(s): TELEPHONE NUMBER: 608.268.1384 FAX NUMBER: 608.258.9434 I/We,, hereby authorize the release of any information requested by the above named property. I/We understand and agree that photocopies of this authorization may be used for the purposes stated below. Signature Social Security # (optional) Signature Social Security # (optional) Terms and Conditions By my/our signature above, I/we hereby indicate my/our desire to lease an apartment from Stone House Development, Inc. I/We do also hereby consent to and authorize any representative of Stone House Development, Inc. or the above mentioned development to obtain, verify and exchange information or any reports concerning me/us as are maintained by, but not limited to: City, County, State, Federal law Enforcement Agencies, Credit Reporting Agencies, present and/or past employers, present and/or past residences. I/We understand that any information obtained may be considered by Stone House Development, Inc. at their sole discretion, as a factor in any decision they make with respect to the apartment for which I am making application. Furthermore, I/We authorize Stone House Development, Inc. or the above mentioned development to obtain information regarding my/our income, assets, and household status for purposes of determining my/our eligibility for participation in the Low Income Housing Tax Credit Program. I understand that any information obtained may be considered by Stone House Development, Inc. at their sole discretion, as a factor in any decision they make with respect to the apartment for which I am applying. Furthermore, I/we hereby release and hold harmless the above named organization, its subsidiaries or managing agents, including but not limited to their officers, directors, employees, agents, Law Enforcement Agencies, Credit Reporting Agencies, present and/or past employers, present and/or past residences, its officers and employers that shall provide information to the above named organization, its subsidiaries or managing agents from and against any and all claims, demands, suits or expenses arising from or related to the content, validity or handling of said reports. This release for information will expire thirteen (13) months from the date of signature. 9

Asset Certification for Combined Household Assets Less Than $5000 Applicant/Resident Name(s): Property Name: Madison Mark Apt. No.: : If the combined assets of your household (include ALL household members, including minors) assets are less than $5,000 on the date of your application, please complete the information below. COMPLETE ONLY ONE FORM PER HOUSEHOLD. 1. I/We do not have any assets at this time (If this statement does not apply to you, please leave blank and skip to question #2. If you check this statement, please skip to question #3) 2. The undersigned hereby swears to the following: (Complete all information in both columns. If an asset type does not apply to you, please enter 0.) ASSET TYPE CASH VALUE ESTIMATED ANNUAL INCOME FROM ASSETS Checking/ Savings Account $ $ CD/Money Market/Treasury Bills $ $ Trust/Retirement/ Pension Funds $ $ Stock/Bonds/Mutual Funds $ $ Cash on Hand/Safety Deposit Box $ $ Equity in Real Estate/Land Contracts $ $ Personal Property**held as an investment $ $ Whole Life Insurance (exclude term life) $ $ Lump Sum Payments $ $ Assets disposed of or given away for less than $ $ Fair Market Value (see below) Other $ $ TOTAL $ $ Assets include cash held in savings and/or checking accounts, trust funds, equity in real estate and other capital investments, stocks, bonds, Treasury bills, certificates of deposit, money market funds, IRA accounts, retirement and pension funds, lump sum receipts (i.e. lottery winnings, insurance settlements, etc.) ** Personal property held as an investment (i.e. gem or coin collections, paintings, antique cars, etc.). It does not include necessary personal property such as furniture, automobiles, and clothing. 3. Have you disposed of any assets (given money/assets away) for less than they are worth in the past two years? YES NO Under penalties of perjury, I (we) certify that the information presented in this certification is true and accurate to the best of my (our) knowledge. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information may result in the termination of the lease agreement. Signature of Applicant/Resident Signature of Applicant/Resident 10

Application Fee Agreement Applicant Name(s): Property Name: Madison Mark Apt #: An application fee in the amount of $20.00 per adult household applicant has been collected with this application. All application fees must be submitted in a personal check, money order, or cashiers check. We will not accept cash. The purpose of the application fee is: 1) To check the credit report of each adult household applicant 2) To hold your desired apartment through the application process If accepted for the apartment, the application fee will become a credit on your rental account. You may deduct your first payment for rent/security deposit by this amount. If you are denied for your apartment for ANY reason, or if you cancel your application during the screening process, your application fee will be kept for the cost of the credit report(s) which is $20.00 per adult applicant. Upon your request, we will give you a copy of your credit report. Agreed: Applicant Signature Applicant Signature Resident Manager 11

Resident Selection Criteria Thank you for your interest in our apartment community. The purpose of this resident selection criteria form is to make you aware of our screening procedures. It is our declared policy of that all persons shall have an equal opportunity for housing regardless of sex, race, color, sexual orientation, disability, religion, national origin, marital status, family status, lawful source of income, age or ancestry, sexual orientation, physical appearance, political beliefs, military discharge and arrest/conviction record. Applications will be processed in the order of which they are received and can take 1 to 4 weeks to be fully processed. If you are denied for any reason you do have the right to reapply or appeal the decision (please see our How to Appeal a Denial in Tenancy section for more details). Your application will be denied if one or more of the following pertain to you: 1) You have provided false or misleading information on your rental application. Information omitted from the rental application will be considered false information. 2) You have not provided us with a written application for residency and/or paid the application fee in the form of a personal check, money order or cashiers check. 3) You do not meet our occupancy limits of no more than 2 persons per bedroom. 4) If applying for low-to-moderate income housing, you do not meet the income and program/student requirements according to the HUD and/or Section 42 guidelines. 5) You have been evicted from an apartment within the past three years. If you were evicted for nonpayment of rent, you will be given the opportunity to prove that your financial situation has changed and we will take that information into consideration. 6) Your conviction record presents a reasonable fear for safety of residents or employees unless more than two years have passed since you were placed on probation, paroled, released from incarceration, or paid the fine. These convictions will include (if found to be substantial in regards to housing): a. Felony drug convictions b. A conviction reportable under the Sex Offender Registry Program with the conviction date being within the last 8 years. (Wisconsin State Statutes 973.048: If a court imposes a sentence or places a person on probation for any violation, or for the solicitation, conspiracy, or attempt to commit any violation, under ch. 940, 944, or 948 or ss. 942.08 or 943.01 to 943.15, the court may require the person to comply with the reporting requirements under s. 301.45 if the court determines that the underlying conduct was sexually motivated, as defined in s. 980.01 (5), and that it would be in the interest of public protection to have the person report under s. 301.45.) 12

c. One or more convictions involving murder, child abuse, sexual assault, aggravated assault or assault with a deadly weapon, if found to be substantial in regards to housing. d. Two or more convictions of disturbance to neighbors, injury to persons, destruction of property (including arson, vandalism, theft, burglary, criminal trespass, disorderly conduct) if found to be substantial in regards to housing. 7) No household members are age 18 or older. 8) You have a pending bankruptcy or a bankruptcy that has not been discharged prior to your lease effective date. 9) You are currently in a lease with another landlord in which you are financially responsible for and your income is not large enough to support both rent expenses unless your landlord is releasing you from your lease obligations. 10) You do not have a monthly net income greater than your monthly expenses unless you have assets that are readily available to use as a form of rental payment. All verifiable lawful sources of income are allowed. If you are on Section 8 housing assistance only your portion of rent is considered when calculating your monthly rent expense. We require your income to be at least 1.5 times the amount of your portion of rent unless you can prove you have been able to pay the same amount of rent at a prior leased location for at least one year. 11) At least one adult household member does not meet our imposed scoring system on other reference checks such as housing history, income requirements and credit history. If one adult household member is automatically denied for any reasons listed above, the entire household application will be denied. I agree that I have read the above mentioned Resident Selection Criteria and understand that the Landlord will be checking all references to ensure all criteria has been met. I also understand that I may request a copy of all lease forms and addendums prior to signing said lease/addendums upon my application for residency being approved. Landlord may offer other options such as cosigner, full month security deposit, etc. to cover any selection requirement deficiencies except for those that are automatic denials. If denied for tenancy I may reapply, request a standard follow-up meeting to discuss the denial or follow the appeal process. In the case that my application is denied and the decision is overturned because of an appeal, I understand that the apartment will not be held for me during the appeal process and I will be placed on the waiting list if one exists. Waiting list applications are processed on a first come, first serve basis. Applicant Signature Applicant Signature Applicant Signature 13