Dear Applicant s7

Dear Applicant,

Attached please find an application for an apartment at Bent Tree North Apts. In order for you to be considered for occupancy, all information must be completed and a money order for $25.00 made out to Bent Tree North Apts. for the processing fees.

MONEY ORDER ONLY!

Please note that CASH WILL NOT BE ACCEPTED. An application not including the application fee will not be considered. Payment of the fee does not guarantee eligibility.

Please remember to include your CURRENT and previous addresses, names and phone numbers of former landlords or mortgage holders. If you are receiving child support please indicate what county you are receiving this from.

After the completion of the application we ask that you mail your money order, made out to Bent Tree North Apts. to:

Bent Tree North Apartments c/o

Harbor Villa Apartments

P O Box 491
Port Austin, MI 48467

Once application and fee is received we will begin to process your information.

If you have any questions, please feel free to contact our Bent Tree North office at

(989) 635-0051 or (989) 738-5061

Sincerely,

Brandy Martinez, Manager

Prime Properties Management

This institution is an equal opportunity provider and employer.

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at .”

RD Approved

Bent Tree North Apartments

2900 Ayre St

Marlette, MI 48453 www.primemichigan.com

Phone (989)635-0051

Fax (989)635-0052

T.D.D. 711

APPLICATION FOR OCCUPANCY

AUTHORIZATION for Release of Information CONSENT:

I authorize and direct any Federal, State, or local agency, organization, business, or individual to release to and verify my application for participation, and/or maintain my continued assistance under the Section 8, Rental Rehabilitation, Low-Income Public and Indian Housing, Section 515/8 and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the USDA RHS, Rural Development administering and enforcing program rules and policies. I also consent for USDA RHS, Rural Development, or the manager to release information from my file about my rental history to USDA RHS, Rural Development, credit bureaus, collection agencies, or future property owners. This includes records on my payment history, and any other violations of my lease or occupancy policies.

INFORMATION COVERED

I understand that, depending on program policies and requirements, previous or current information regarding my household or me may be needed. Verifications and inquiries that may be requested, include but are not limited to:

Identity and Marital Status Employment, Income, and assets

Medical or Child Care allowances Credit and Criminal Activity

Residences and Rental activity

GROUP OR INDIVIDUAL THAT MAY BE ASKED

The groups of individuals that may be asked to release the above information (depending on program requirements) includes but not limited to:

Previous Landlords (including Public Housing Agencies) Employers Courts and Post Offices

Welfare Agencies Schools and Colleges State Unemployment Agencies

Law Enforcement Agencies Social Security Administration Medical & Childcare Providers

Support and Alimony Providers Retirement Systems Veterans Administration

Utility Companies Bank & Other Financial Institutions Credit Providers and Credit Bureaus

CONDITIONS

I agree that a photocopy of this authorization may be used for the purpose stated above. The original of this authorization is on file in the management office and will stay in effect for a year and one month from the date signed. I understand I have the right to review my file and correct any information that I can prove is incorrect. I certify that the unit applied for will be my household’s primary residence and my household and I will not maintain a separate subsidized rental unit in a different location.

SIGNATURES:

______

Head of Household (Print Name) Date

______

Spouse (Print Name) Date

______

Adult Member (Print Name) Date

______

Adult Member (Print Name) Date

NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, INS FORM 4506, “REQUEST FOR COPY OF TAX FORM” MUST BE PREPARED AND SIGNED SEPARATELY.

This institution is an equal opportunity provider and employer.

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at .”

Office use only Date Rec’d / / 20 Time Rec’d Initials

Preliminary Rental Application

Please note that this is a preliminary application and gives no lease or rent rights.

Community Bent Tree North Apts. Office Phone (989)635-0051 Date ______

Circle Unit Size 1 bedroom 2 bedroom 3 bedroom

Would you or a member of your household benefit from the design features of a barrier free unit? Yes or No

Would you request a disability adjustment to income? Yes or No

Applicant Email Phone

Co Applicant ______Email Phone

Applicant Applicants History Co-Applicant

Current Address: / Current Address:
Date: From / Rent $ / Date: From / Rent $
To: / To:
Reason for moving: / Reason for moving:
Current Landlord / Current Landlord
Address / Address
Phone ( ) / Phone ( / )
Previous Address: / Previous Address:
Date: From / Rent $ / Date: From / Rent $
To: / To:
Reason for moving: / Reason for moving:
Current Landlord / Current Landlord
Address / Address
Phone ( ) / Phone ( / )
Previous Address: / Previous Address:
Date: From / Rent $ / Date: From / Rent $
To: / To:
Reason for moving: / Reason for moving:
Current Landlord / Current Landlord
Address / Address
Phone ( ) / Phone ( / )

If you have resided at additional addresses within the past five (5) years, please attach previous address information on a separate sheet of paper.

The information contained in this application is treated confidentially. No information will be revealed to anyone without express written consent.

Head of Household signature Date Co-Applicant, Spouse/Co-Head signature Date

This institution is an equal opportunity provider and employer.

Please list ALL persons that will occupy the residence.

Name / Maiden / Date of / Relationship to / Social Security Number
First, Middle, Last, / name / birth / head of household / (Print Clearly)
1 / Head of Household
2
3
4
5
6

Do you or any member of your household engaged in current illegal use of illegal distribution of a controlled substance

or have you previously been convicted of the same? Yes or No

Have you ever been evicted? Yes or NO If yes from where

If you answered “Yes” to the above question, have you successfully completed a controlled substance abuse program or are you presently enrolled in such programs? Yes or No

If yes please explain:

Have you ever been convicted of a crime, felony, and or a misdemeanor? Yes or No

If yes please explain:

Number of Vehicles ______

Make/Model Year Color Tag # State

Driver’s license/ID Numbers and state

Applicant Co. Applicant

Person to contact in case of Emergency

Applicant

Name Relationship

Telephone Address City

Co-Applicant

Name Relationship

Telephone Address City

TENANT INCOME CHECKLIST

Complete a separate form for each household member who is age 18 or older, and be prepared to provide ORIGINAL verification (not photocopies) for items checked yes.

Failure to comply could result in the termination of assistance.

NAME

Answer all questions

Yes No

I am self-employed. Money earned $ week / month / year
I have a job and receive money/wages. Wages earned $ week / month / year.
Name of Employer

Address

Phone Fax

I receive tips. If yes, how much per week? $

I am a student.

Name of School: Contact Person: ______

Address Telephone: Fax

I receive cash contributions or gifts including rent or utility payments from persons not living with me.

Name of Source Amount $ wk / mo / yr

Address

Phone Fax

I receive periodic payments from Workers’ Compensation. Amount $

I receive military active duty allotments. Amount $

I receive Veteran’s Administration benefits. Amount $

I receive Social Security. Amount $

I receive Supplemental Security Income (SSI). State Amount $

I receive disability or death benefits other than Social Security.

Name of Source Amount $

Address

Phone Fax

I receive Medicaid.

I receive a cash grant from DHS Amount $

I receive unemployment benefits. Amount $

I receive child support or alimony. If yes, from how many persons do you receive support?
If yes, is child support paid directly to Department of Human Services (DHS)? Yes No
If No….. Friend of the Court County

Address

Phone Fax

Amount: $ Per week / month / year (Circle only one)

05-2010

Yes No

I receive adoption assistance payments. Amount $

I receive periodic payments from a trust, annuity or inheritance.

Source Name

Address

Phone Fax

Amount: $ Per week / month / year (Circle only one)

I receive periodic payments from insurance policies.

Source Name

Address

Phone Fax

Amount: $ Per week / month / year (Circle only one)

I receive periodic payments from retirement funds or pensions.

Source Name

Address

Phone Fax

Amount: $ Per week / month / year (Circle only one)

I receive periodic payments from lottery winnings.

Source Name

Address

Phone Fax

Amount: $ Per week / month / year (Circle only one)

I receive income from rental of real estate or personal property. Describe

I receive income from Indian Trust Land. Amount $

I own real estate. Describe

I own a mobile home. Describe:

I have personal property held for investment purposes Amount $

(Gems, jewelry, coin or stamp collections, etc.)

I have saving accounts at:

Address

Phone Fax

I have checking accounts at

Address

Phone Fax

I have time certificates or certificates of deposit / CDs at:

I have IRA’s or Keogh accounts at:

I have Treasury Bills

I have Stocks

I have Bonds
I have a life insurance policy with a cash surrender value. Amount $
I have a land contract(s).

I have sold, given away, or otherwise transferred ownership of assets within the last two (2) years
List items: Sale amount $

I have income/assets from sources other than those listed above. Type

Yes No

I am elderly (age 62 or older) or disabled and I pay Medicare premiums.

I am elderly (age 62 or older) or disabled I pay medical insurance premiums, other than Medicare.
Name of Insurance Company: Address Phone Fax

I am elderly (age 62 or older) or disabled and I pay medical expenses, which are not reimbursed by

Insurance.

I am elderly (age 62 or older) or disabled and I pay prescription expenses which are not

Reimbursed by insurance

Source Name Address

Phone Fax

I am elderly (age 62 or older) or disabled I pay chore care provider expenses, which are not

Reimbursed by insurance.

Source Name

Address

Phone Fax

Department of Human Services (DHS) pays child care expenses for a child(ren) age 12

or under in order for me to be gainfully employed, or to further my education

If yes, DHS pays: Full Partial payment.

I pay child care expenses for a child(ren) age 12 or under in order for me to be gainfully

Employed, or to further my education.

Name of Child Care Provider:

Address

Phone Fax

I pay handicap care expenses for a disabled family member in order to be gainfully employed.

I pay handicap equipment expenses for a disabled family member.

Describe: ______

I have a family member(s) age 17 or under who has unearned income (example: Social Security).

List their names and type(s) of income:

I have a family member(s) age 17 or under who has assets (example: savings accounts, bonds, etc.).
List their names and type(s) of income:

All adult household members must complete and sign a copy to certify that their information is included and accurately reported. Failure to comply could result in the denial/termination of assistance.