Please complete this form and the attachments and forward to the Leasing Department at the address provided.
WAITING LIST REQUESTS
NAME: ______
If I qualify, I wish to be placed on the following waiting lists: (it is to your advantage to choose more than one list)
_N/A_ COVENANT PLACE I - ONE BEDROOM (Must be 62 years of age or older to qualify)
Affordable Rate (HUD Section 8 Rent Subsidy) TEMPORARILY CLOSED
______COVENANT PLACE I - ONE BEDROOM (Must be 62 years of age or older to qualify)
Market Rate
______COVENANT HOUSE II - ONE BEDROOM (Must be 62 years of age or older to qualify)
(HUD Section 8 Rent Subsidy)
______CHAI APARTMENTS - ONE BEDROOM (Must be 62 years of age or older to qualify)
(HUD Section 8 Rent Subsidy)
______CHAI APARTMENTS - ONE BEDROOM FOR PERSONS WITH DISABILITIES
(Must be 18 years of age or older to qualify) (HUD Section 8 Rent Subsidy)
______
Date Signature
04/04/2016
ELIGIBILITY QUESTIONNAIRE FOR COVENANT PLACE
INCOME LIMITS
The Department of Housing and Urban Development annually sets the Income-Eligibility Limits. For 2016 the Income Limits are as follows:
Affordable Market
· One Person: $24,650 $39,400
· Two People: $28,150 $45,000
Based on the information you provide in this eligibility questionnaire, we will make a preliminary determination of your eligibility.
PROSPECTIVE RESIDENT INFORMATION
Name of Prospective Resident(s): (List Head of Household first)
#1______#2______
(Last) (First) (M.I.) (Last) (First) (M.I.)
Current Address:
______
(Street)
______
(City) (State) (Zip)
Telephone: Home: ______Work: ______
Marital Status: Single _____ Married _____ Separated _____ Widowed _____ Divorced _____
Is any member of the household a student? Yes _____ No _____ If yes, who: ______
Gender of prospective resident(s): #1______#2______Decline to report ______
Date of Birth (each prospective resident): #1______2______
Will the prospective resident(s) listed above be the sole occupant(s) of the unit for which you are applying? Yes ______No ______
If no, what are the names and addresses of other proposed occupants?
______
______
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TRANSLATION ASSISTANCE
Will you require assistance communicating with Covenant Place management during the leasing process? This may include interpreter services and/or written materials translated into languages other than English. Yes_____ No______
If you answered YES, you will need assistance communicating between English and what other language? ______
Will you require sign language assistance? Yes______No______
SPECIAL NEEDS
Do you have any special needs regarding your potential tenancy at Covenant Place? Please describe any needs or accommodations you may require.
______
______
______
FINANCIAL AND RESOURCE DATA
The Department of Housing & Urban Development and Covenant Place Apartments require that you provide a summary of your GROSS income, assets, and liabilities so that Covenant Place management can determine whether you meet the income requirements of this facility. Please completely fill in the applicable areas below for all prospective residents. Use a separate sheet of paper if necessary.
REGULAR GROSS INCOME: ANNUAL AMOUNT
(Enter N/A if not applicable)
Salary / Wages #1 ______$______
#2 ______$______
Social Security #1______$______
#2______$______
Supplemental
Security Income #1______$______
#2______$______
04/04/2016
Pension #1______$______
#2______$______
Annuities #1______$______
#2______$______
Rental Property
Income ______$______
Trust Income #1______$______
#2______$______
Other Income ______$______
______
Regular Gross Income Subtotal $______
(Add this amount to the Assets Subtotal amount on next page.)
ASSETS: TOTAL FACE ANNUAL
VALUE INTEREST
Savings Accounts ______$______$______
______$______$______
Checking Accounts ______$______$______
______$______$______
Certificates of Deposit or Money Markets
______$______$______
______$______$______
Stocks ______$______$______
______$______$______
Bonds ______$______$______
Value of Home ______$______$______
(Address)
______
Assets Sub Total: $______$______
Regular Gross Income Total: $______$______
(From previous page)
TOTAL = $______$______
Have you or any members of your household, transferred, disposed of or given away any assets for less than fair market value during the past two years?
______Yes ______No
If yes, describe the assets you disposed of, who received them and the date the transaction(s)
occurred:______
______
LIABILITIES:
Home Mortgage $______
Medical Expenses (non-reimbursed) $______
Other (Please specify) $______
Current Monthly Rent $______
STATUS
Do you have the legal right to be in the United States?
(Please answer for both prospective residents)
#1___ #2___ Yes, because I am a United States Citizen
#1___ #2___ Yes, because I have valid documentation from the Bureau of Citizenship and Immigration Services (formerly the Immigration and Naturalization Service).*
#1___ #2___ No
*If you answered “Yes” because you are a non-US Citizen with valid documentation, you must provide documentation and complete paperwork required by the Department of Housing and Urban Development so we can verify that you are a non-citizen with eligible immigration status.
I (We) understand that the above information is required to determine my (our) eligibility for residency. I (We) certify and warrant that that the information I (we) have provided is a complete, true and accurate statement of my (our) total income and that all of the information contained herein is true and correct to the best of my (our) knowledge. I (We) further understand that any deviation between the above figures and my (our) actual financial status can affect my (our) eligibility for admission. I (We) understand that making false statements about the information in this form is grounds for rejection or termination of my (our) lease.
I (We) understand that this Eligibility Questionnaire is not binding upon Covenant Place or Community Housing Management Corp. (CHMC) and authorize them to obtain any information from any source they deem appropriate regarding the statements in this eligibility questionnaire and agree that this eligibility questionnaire shall remain the property of Covenant Place or CHMC, whether or not this rental is approved.
Title 18, section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosure or improper uses of information collected based on the consent form. Use of the information colleted based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning a prospective resident or participant may be subject to a misdemeanor and fined not more than $5,000. Any prospective resident or participant affected by negligent disclosure of information may bring a civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing Social Security numbers are contained in the Social Security Act at 42 USC 408 (f), (g), and (h).
I (We) understand that the information provided in this eligibility questionnaire will be kept in the strictest of confidence.
I (We) understand that Covenant Place does not provide nursing care, personal care or any supervision services for residents. Residents themselves must arrange and pay for any services required to meet their needs.
______
Prospective Resident’s Signature & Date Prospective Resident’s Signature & Date
04/04/2016
6 / Covenant Place Eligibility Questionnaire