Application for Riverview Towers / Low Income Application for Public Housing

Applicant Name: ______

Address:______City: ______State:____Zip:_____

Home Phone: ______Cell Phone: ______Work Phone: ______

Name of person and telephone where a message can be received:

Name of Contact Person: ______Phone Number: ______

Do you, your spouse or co-head, currently live or work within the City of Lapeer? ______If “yes” you must enclose one of the following items with your name and current address indicating your address or current employer within the City of Lapeer: a copy of your lease, driver’s license, state ID card, paystub or letter from your employer, utility bill or voter’s registration along with this application.

This preference must be verified for priority placement on the waiting list.

Family Information: Complete the following information for all persons who plan to live within the unit.
Head of Household’s Last Name First Name Middle Initial Social Security# Age Sex
Date of Birth Birthplace U.S. Citizen? Disabled? Ethnicity (required for statistical reporting)
/ / Hispanic or Latino ____ Non-Hispanic or Latino ____
Race (check one or more)
American Indian/Native Alaskan __ Asian __ Black/African __ Native Hawaiian/Other Pacfici Islander __ White __
Co-head or Spouse’s Last Name First Name Middle Initial Social Security# Age Sex
Date of Birth Birthplace U.S. Citizen? Disabled? Ethnicity (required for statistical reporting)
/ / Hispanic or Latino ____ Non-Hispanic or Latino ____
Race (check one or more)
American Indian/Native Alaskan __ Asian __ Black/African __ Native Hawaiian/Other Pacfici Islander __ White __

If you require a unit that provides physical accessibility (Uniform Federal Accessibility Standards) please submit a Verification of Disability And/Or Special Medical Needs with your application. The form is available from the Riverview Tower’s Office Manager’s office.

Income Information: Complete the following information for all persons who plan to live within the unit.

Does your household have any income? _____ If “yes” enter all of the income of all persons who will be living in the unit. Examples of income include full or part-time employment, self employment, Public Assistance, Social Security, SSI, pensions, disability benefits, unemployment benefits, interest income, alimony, child support, annuities, dividends, income from rental property, Armed Forces, Reserves or National Guard.

Name of Person with Income / Source of Income / Gross Amount / Per Week Month
Name of Person with Income / Source of Income / Gross Amount / Per Week Month
Name of Person with Income / Source of Income / Gross Amount / Per Week Month
Name of Person with Income / Source of Income / Gross Amount / Per Week Month

Page 1 of 2

Application for Riverview Towers / Low Income Application for Public Housing

Do you, your co-head or spouse own a home or other real estate? ______

Have you, your co-head or spouse ever been convicted of a felony? ______If “yes”, please explain: ______

Have you, your co-head or spouse ever been evicted from a rental unit while participating in a Rent Assistance Program? ____ If “yes” please explain: ______

Are you currently participating in a Rent Assistance Program? ______

Do you own a Pet?______(Pets must meet Lapeer Housing Commission’s Pet Policy)

Please list your previous Landlord’s Name, Address and Phone Number:

Landlord Name / Landlord Address / Landlord Phone Number / Unit Address You Resided In
Landlord Name / Landlord Address / Landlord Phone Number / Unit Address You Resided In

Why did you move from the above mentioned address? ______

I consent to release criminal conviction records including sexual offenses and give permission for Lapeer Housing Commission to obtain a credit rating report.

I certify that I have not been evicted from any type of Section 8 /Housing Choice Voucher Program or from Public or Indian Housing due to drug related criminal activity, no member of my household has been convicted of manufacturing or producing methamphetamine on the premises of federally-assisted housing, no member of my household has been evicted within the last five years from federally assisted housing. I will not receive Public Housing Assistance while receiving another housing subsidy, for the same unit or different unit and all information contained in this Application is true and complete to the best of my knowledge.

I authorize Lapeer Housing Commission to contact any agency, offices, groups, organization and/or past Landlords to obtain information or materials necessary to complete my application for Riverview Towers.

I understand that this is not a contract and does not bind either party. The above information is full, true and complete to the best of my knowledge.

______

Head of Household Date

______

Co-head / Spouse Date

Date Received in Riverview Tower’s Office Manager’s office ______Page 2 of 2