Application for Housing

Application for Housing HELP Philadelphia IV consists of sixty 1-BEDROOM units. Applicant Information Last Name First Name MI Street Address Apt. # City State Zip Code Social Security# Home Phone: Date of Birth / / Work Phone: Cell Phone: Housing Considerations Is the applicant a veteran? YES NO DD214 is required to verify veteran status. Is the applicant disabled? YES NO Will applicant require a handicap accessible unit? YES NO Will other household member require a handicap accessible unit? YES NO Are there any other special housing needs or reasonable accommodations that the household will require: 1) Were you referred by a social services agency? YES NO If YES, what is the name of the agency? Contact Name / Phone #: 2) Do you own a home? YES NO If you answered YES (homeowner), please answer these questions below. Describe type of home / s (check all that apply): Rental property Primary residence Are you in the process of selling your home? YES NO Has your property / home ever entered foreclosure proceedings? YES NO HELP Philadelphia IV Application, 9/23/2014, KM 1

Primary Applicant -- Income Information Employer: Address: From: / / To: / / Occupation: Supervisor s Name: Phone #: Estimated Monthly Income $: Please list ALL other sources of income here: Source of Income SOCIAL SECURITY PENSION Total Gross Monthly Income: Monthly Amount $ Co-Applicant Information, (If applicable) Last Name First Name Middle Initial Street Address Apt. #: City_ State Zip Code Social Security# Date of Birth / / Home Telephone: Work Telephone: Cell #: HELP Philadelphia IV Application, 9/23/2014, KM 2

Please list ALL other sources of income (for co-applicant) here: Source of Income SOCIAL SECURITY PENSION Total Gross Monthly Income: Monthly Amount $ Please list everyone that will be living in the household, including Primary Applicant: # First Name, MI, Last Name Age Sex Relationship to Applicant 1 Receives Income? YES or NO 2 3 Total Household Income: $ / year If any of the household members (listed above) receive income from any source (and the information was not provided under Co-Applicant ), please list below. Prospective Household Member Name: Source of Income SOCIAL SECURITY PENSION Monthly Amount Total Gross Monthly Income: $ HELP Philadelphia IV Application, 9/23/2014, KM 3

Rental History CURRENT LANDLORD NAME: Name of Property (if applicable): Property Owner / Landlord Telephone #: Address:_ Move-In Date: / / Move-Out Date: / / Reason for Leaving: PREVIOUS LANDLORD NAME: Name of Property (if applicable): Property Owner / Landlord Telephone #: Address:_ Move-In Date: / / Move-Out Date: / / Reason for Leaving: Tenant screening (performed by National Tenant Network) includes a credit / criminal background check for all members of the household, over the ages of 18. Tenant screening is performed, ONCE an applicant meets HELP s initial income eligibility standards, AND when a unit becomes available that meets the applicant s housing needs. HELP USA will not ask, nor will they accept, the application fee until these two requirements are met. The HELP Philadelphia IV application fee / cost of the screening is $40 per household member, over the age of 18 years old. This application fee is non-refundable. HELP Philadelphia IV Application, 9/23/2014, KM 4

ALL MEMBERS OF THE HOUSEHOLD AGES 18 YEARS AND OLDER - MUST COMPLETE AND SIGN BELOW IN ORDER FOR APPLICATION TO BE PROCESSED. 1. We certify that all information given in this application and any address thereto is true, complete and accurate. We understand that if any of this information is false, misleading or incomplete, management at its option may cancel the application or, if move-in has occurred, the Rental Agreement without notice. 2. We authorize HELP Philadelphia and its affiliates and agents to make appropriate and periodic inquiries, either directly or through information exchanged now or later with rental and credit screening services, and to contact previous and current landlords, other sources for credit, verification of employment and other information provided herein. 3. If our application is approved, and move-in occurs, we certify that only those persons listed in this application will occupy the apartment and that there are no other persons for whom we have, or expect to have, responsibility to provide housing. 4. We agree to notify management in writing immediately regarding any changes in household telephone numbers, income and/or household composition. 5. We have read and understand the information in this application and we agree to comply with such information. 6. We understand that this application may be placed on a waiting list. We may request samples of the rental agreement. If this application is approved, and move-in occurs, we certify that we will accept and comply with all conditions of occupancy as set forth therein, including specifically all conditions regarding pets, rent, damages and security deposits. 7. We authorize management to obtain one or more consumer reports as defined in the Fair Credit Reporting Act, 15 U.S.C. Section 1681a(d), seeking information on our credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics or mode of living. FAIR CREDIT REPORTING ACT This is to inform you that as part of our procedure for processing your application an investigative report may be made whereby information is obtained through personal interviews with third parties such as family members, business associates, financial sources, friends, neighbors or others who are acquainted with you. This inquiry includes information as to your character, general reputation, personal characteristics, mode of living, income, credit background and police records. All information you or others give us will be held in strict confidence. HELP Philadelphia, and its affiliates, comply with the United States Federal Fair Housing Act of 1968, as amended, and all local and State laws. HELP Philadelphia does not discriminate based on race, color, religion, sex, familial status, or national origin. For more information about fair housing or to make a complaint, please call: The Office of Fair Housing and Equal Opportunity at the Office of U.S. Department of Housing and Urban Development (HUD) at: (215) 656-0647 or (215) 656-3450 (TTD). Please be advised that any information given to this office that is falsified in any way will automatically result in the denial of your application. I/we have read and understand the above. Primary Applicant: Last Name First Name Middle Initial Street Address Apt. # City State Zip Code Social Security# - - Date of Birth / / Applicant Signature: Date: Co-Applicant: Last Name First Name Middle Initial Street Address Apt. # City State Zip Code Social Security# - - Date of Birth / / Co-Applicant Signature:_ Date: HELP Philadelphia IV Application, 9/23/2014, KM 5

Race & Ethnicity Information I DECLINE to provide this information. The section below is OPTIONAL. I AGREE to provide this information. Please complete below. Total # of Household members: Ethnicity: Enter total # members as applicable 1. Hispanic 2. Non-Hispanic Race: Enter total # of members as applicable 1. American Indian or Alaskan Native 4. Asian 2. Black or African American 5. Native Hawaiian or other Pacific Islander 3. White / Caucasian 6. Other: *Information in this section is collected solely to document efforts as a part of HUD s Affirmative Fair Housing Marketing Plan (AFHMP). OMB Approval No.2529-0013. FOR OFFICE USE ONLY: Application Date / Time Received: Staff Initials: Annual Income: Tax Credit Status: % AMI Approved for Unit: YES NO Income Limits: -- Reason for Denial: Does not meet income guidelines Credit / Criminal Background Does not meet tenant selection criteria Please explain: If APPROVED, please check all that apply below. Initial Housing Assignment: Mobility Impaired Unit Project-Based Unit Hearing / Visually Impaired Unit Tax Credit Unit Notes: HELP Philadelphia IV Application, 9/23/2014, KM 6