Application for Occupancy s1

APPLICATION FOR OCCUPANCY

IMPACT SEVEN, INC.

Date:

PART 1 Office Use Only

STATEMENT REQUIRED BY THE PRIVACY ACT

The Farmers Home Administration (FmHA) and Department of Housing and Urban Development (HUD) are authorized by Title V of the Housing Act of 1937 as amended (42 U.S.C. 1437 et seq.) to solicit the information requested on this form. Disclosure of the information requested is voluntary. However, failure to disclose certain items of information may result in a delay in the processing of your eligibility or rejection, except that it is unlawful for FmHA and HUD to deny eligibility because of the refusal to disclose the Social Security Account Number.

The principal purposes for collecting the requested information are to determine eligibility for occupancy in the FmHA, HUD financed rental project and to determine the amount of tenant contribution for rent. The information collected on this form may be released to appropriate Federal, State, and Local Agencies when relevant to civil, criminal or regulatory proceedings.

NAME OF PROJECT Eldon Marple Manor

Complete all applicable information for Tenant; Spouse/Co-Tenant. Complete parts 1, 2, 3 & 4 and attach an additional sheet if more space is needed.

RETURN TO: Impact Seven, Inc.

147 Lake Almena Drive

Almena, WI 54805

Where did you hear of the housing program? Newspaper Radio Poster Word of Mouth

Mr. Mrs. Ms. Preferred Moving Date:

Applicant

Full Name Birth Date Age Sex Race Social Security #

Spouse/Co-Tenant

Full Name Birth Date Age Sex Race Social Security #

Current Address

(Mailing Address) City Zip Code

Telephone Number (Home) (Work )______

Do you own your own home? rent other Specify: ______

Other Members of Household (That will be living in the unit)

Name Birth Date Age Sex Race Social Security #

Are any household members considered a student at an institution of higher education? Yes No

If you answer "yes" to question above, you are required to fill a student certification to see whether you qualify (will be supplied from our Management Office).

Please list your nearest relative

Name Address Phone

Who should we contact in case of an emergency?

Name Address Phone

“The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through HUD that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age, and disability 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.

PART 2

INCOME AND EXPENSE INFORMATION

1. SALARY/WAGES - List gross amount (before deductions) of wages and salaries; overtime pay; commissions; fees; tips; bonuses. Indicate Source (Include names, phone # & addresses of source)

$ annually from

2. NET INCOME FROM business or professional or rental of real or personal property. (Include names, phone # & addresses of source)

$ annually from

3. SOCIAL SECURITY OR SSI PAYMENTS

$ per month Social Security for

$ SSI payments per month for

4. PENSIONS; ANNUITIES; RETIREMENT FUNDS; IRA ACCOUNTS (Include names, phone # & addresses of source)

$ annually from

5. ALL OTHER INCOME: Include from ALL OTHER SOURCES, such as Unemployment; Disability Compensation; Workman’s Compensation; Severance Pay; Alimony; Child Support; Regular recurring contributions or gifts of money; VA Benefits; Armed Forces; Public Assistance; AFDC; Welfare; or any other Source. (Include names, phone # & addresses) If income is from Child Support or Alimony, a copy of the court order MUST be attached to this application. Further documentation may be requested. (Include names, phone # & addresses of source)

$ annually from

6. CHILD CARE EXPENSE - List amount paid by family for the care of minor children under 13 years of age when such care is necessary to enable a family member to further education or to be gainfully employed. (Include names, phone # & addresses of source)

$ annually to

7. MEDICAL EXPENSES (Elderly, Handicapped, or Disabled Families Only) - Include total anticipated medical expenses to be incurred over next twelve-month period not covered by insurance. May include expenses for: dental; prescription medicines; medical insurance premiums; eyeglasses; hearing aids/batteries; cost of live-in resident assistant; monthly payments required on accumulated major medical bills including that portion of spouse's or child's nursing home paid from tenant family income(s). (Include names, phone # & addresses of source)

$ annually to

8. HANDICAP EXPENSES - List amounts paid by family for care of a handicapped member of the family which make it possible for the head or spouse to work. (Include names, phone # & addresses of source)

$ annually to

PART 3

ASSET INFORMATION - List all information for Tenant; Spouse; Co-Tenant REP PAYEE ACCOUNTS MUST BE REPORTED (Include names, phone # & addresses of source)

Cash on hand - List amount on hand at present time $

Bank or Credit Union - Checking

Account # Bank

Address

Balance in Account at Present Time $ Account # Bank

Address

Balance in Account at Present Time $

Savings Accounts (Including IRA's, Money Markets and CD's)

Account # Bank

Address

Balance in Account at Present Time $ Account # Bank

Address

Balance in Account at Present Time $

Stocks and/or Bonds

Type Number Owned Value $

Life Insurance and/or Funeral Trusts

Policy #______Company Name______Value $______

Address

Policy #______Company Name______Value $______

Address

Real estate owned at present time or sold within last 2-year period:

Market Value: $ If sold within last 2 year period, list amount sold for $

Is there a mortgage on this property? Yes No Amount of Mortgage: $______

Mortgage with (provide bank/company name, address & phone number):

Property sold under land contract

Original amount of Land Contract $

Outstanding balance at present time $

Terms of Land Contract:

$ Per Month $ Per Year Annual Interest Rate %

I certify that: I have I have not

disposed of any assets for less than fair market value during the past two years. If yes, list below. (Include cash, savings, stocks, bonds, CDs, personal property, real estate, etc., given, donated or sold below market value to organizations and/or family members and/or others.) ______

______

PART 4

REFERENCES - Please list your present landlord and previous landlords up to past 10 years. (Include names, phone # & addresses)

Landlord Name, Phone # & Complete Address Phone

Rented from , 20____ to , 20____

Landlord Name, Phone # & Complete Address Phone

Rented from , 20____ to , 20____

Landlord Name, Phone # & Complete Address Phone

Rented from , 19____ to , 19____

Please list two personal (nonfamily) and credit references; addresses and telephone numbers.

Name Address Phone

SPECIAL NEEDS HOUSING

Under the HUD 202 & 811 programs, owners provide housing for persons who meet the eligibility criteria for a targeted population. Only one adult household member must be a member of the targeted population to occupy a development reserved for a targeted population. (All household members must also meet the program eligibility criteria.) Please indicate with an "X" for any or all of the following targeted population developments in which the household is interested and believes it is eligible to reside in.

Elderly (age 62+) Chronically Mentally Ill Physically disabled Developmentally Disabled

Name and address of a qualified neutral third party who will be able to provide verification of your eligibility for special needs housing. (Example: physician, therapist, social worker, etc.)

Name Title

Address

City State Zip Telephone Number

Do you believe you would qualify for a preference for a fully accessible unit for a person with a disability? Yes No

Do you believe you would qualify for a preference for a unit for a vision-impaired household member? Yes No

Do you believe you would qualify for a preference for a unit for a hearing-impaired household member? Yes No

Do you need a second bedroom because of a need for a live-in attendant? Yes No

NOTE: In addition to the above, if any person in the household, because of one or more disabilities, needs a reasonable accommodation(s) to our policies or procedures, or a reasonable modification(s) to the apartment or premises, please complete the Tenant/Applicant Request for Accommodation and/or Modification.

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Do you have a pet? Yes No If yes, what type and how many? (Cat, dog, etc.?) ______

Breed: ______Approximate Weight: ______

Is any member of the household engaged in the current illegal use of a controlled substance? Yes No

APPLICANT CERTIFICATION - Applicant(s)’s/Tenants(s)'s Statement - I/We certify that the information given to Impact Seven, Inc. on household composition, income, net family assets, all allowances and deductions, and references, is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are grounds for denial of occupancy and/or termination of housing assistance and termination of tenancy.

Signature of Head of Household Date

Signature of Spouse or Other Adult Date

Authorization for Release of Information

Consent:

I authorize and direct any Federal, State, or Local Agency, organization, business, or individual to release to Impact Seven, Inc. any information or materials needed to complete and verify any application for participation, and/or maintain my continued assistance under Section 8, Section 202, Section 811, FHA 515, or IRS Section 42, housing programs. I understand and agree that this authorization of the information obtained with its use may be given to and used by the Wisconsin Housing Economic Development Association (WHEDA), Rural Development (RD), and/or The Office of Housing and Urban Development (HUD) in administering and enforcing program rules and 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 & Marital Status Credit and Criminal Activity

Medical or Child Care Expenses Residence & Rental Activity

Employment, Income & Assets

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in the housing assistance program.

Group or Individuals that may be asked:

The groups or individuals that may be asked to release the information (depending on program requirements) include but are not limited to:

Previous Landlords (including State Unemployment Agencies

Public Housing Agencies) Social Security Administration

Courts Post Offices Wisconsin State SSI Office

Schools & Colleges Medical & Child Care Expenses

Law Enforcement Agencies Veterans Administration

Past & Present Employers Retirement Systems

Welfare Agencies Banks & Other Financial Institutions

Child Support & Alimony Providers Credit Providers & Credit Bureaus

Utility Companies Doctors or Counselors (to determine

disability eligibility)

Computer Matching Notice and Consent:

I understand and agree that WHEDA, RD, or HUD may conduct computer-matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. WHEDA, RD, or HUD may in the course of its duties exchange such automated information with other Federal, State, or Local Agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the US Postal Service; the Social Security Administration; and State welfare and food stamp agencies.

Conditions:

I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in effect for one year from the date signed.

Head of Household:

Print Name Signature Date

Spouse or Co-Tenant:

Print Name Signature Date

REQUEST FOR A REASONABLE ACCOMMODATION

NAME: ______PHONE: (______) ______

ADDRESS: ______

1. The following member of my household has a disability as defined below:

(a physical or mental impairment that substantially limits one or more major life activities; a record of having such an impairment; or being regarded as having such an impairment.)

Name: ______

2. As a result of his/her disability the following change or changes so that (the person listed) can live here as easily or

successfully as the other residents. Check the kind of change(s) you need.

A change in my apartment or other part of the housing complex.

A change in the following rule, policy or procedure. (Note: You may ask for changes in how you meet the terms of the lease, but everyone must continue to meet the terms of the lease.)

3. I need this reasonable accommodation so that I can:

______

4. You may verify that I have a disability and need for this request by contacting:

Name: ______

Address: ______

Phone: ______

5. If you asked for a change to your apartment or to the housing complex, please use this space to

list any company or organization that might help us locate or build anything special that you may

need. (If you do not know of any, we will try to obtain this information.)

______

I give you permission to contact the above individual for purposes of verifying that I, or a family member, has a disability and needs the reasonable accommodation requested above. I understand that the information you obtain will be kept completely confidential and used solely to determine if you will provide an accommodation.

______

Signature of Person Needing Accommodation Date