Belmar Gardens Cooperative

C/O The Rubinoff Company

925 Liberty Avenue

Pittsburgh, PA15222

412-231-1000

APPLICATION FOR ADMISSION

INSTRUCTIONS:

1.Please complete all sections. Please do not leave any section blank, even sections that do not apply to you.

2.As Head of Household, you will complete this application, each additional adult 18 years of age and older who will be living in the unit must sign this application also.

3.It is important that all information on this form be complete and correct. False, incomplete or misleading information will cause your household’s application to be declined.

4.As long as your application is on file with us, it is your responsibility to contact us whenever your address, telephone number or income situation changes and whenever you need to add a person to your application or remove a person from your application.

5.Please include copies of your photo identification and 2 recent pay stubs or other proof of your income.

HEAD OF HOUSEHOLD/SPOUSE/CO-RESIDENT

Head of Household ______

Last NameFirst NameMI

Drivers License State & Number ______

Please provide a copy of your Photo ID

Spouse/Co-Resident(s) ______

DriversLicenseState & Number ______

Please provide a copy of your Photo ID

Current Address ______

City, State, Zip ______

Home Phone ______Work Phone ______

Spouse/Co-Resident Work Phone ______

HOUSEHOLD COMPOSITION AND CHARACTERISTICS

  1. List the Head of Household and all members who will be living in the unit.

Givethe relationship of each family member to the head of household.

Member’s Full Name / Relationship / Birth Date / Age / Sex / SS Number

2.Does anyone live with you now who is not listed above: YesNo

3.Do you expect a change in your household composition? YesNo

4.Do you currently own your home? YesNo

5.If you are renting your unit, please supply the name and telephone number of your

current landlord:

______

May we contact the person listed above? YesNo

If No, why not ______

6.Is there another person we may contact if we are unable to reach you?

______

Name Telephone Number

7.Relationship: ______

ASSETS

List all checking and savings accounts of all household members.

Name / Bank Name / Type of Account

.

INCOME:(Include Pension, Child Support, Alimony, Unemployment, Social Security, Disability, etc.)

Household Member Name / Source of Income/Type of Income / Annual Income

Please answer each of the following questions:

1.Do you work full-time, part-time or seasonally? (Circle which one)

2.Expect to work for any period during the next year?YesNo

3.Do you expect a leave of absence from work due to layYesNo

off, medical, maternity, ormilitary leave?

4.Do you now receive or expect to receive unemployment benefits?YesNo

EMPLOYMENT HISTORY:

Name and Address of Head of Household’s Present Employer:

______Telephone Number ______

______Supervisor’s Name ______

______Employed Since ______

Name and Address of Spouse’s or Co-Resident’s Employer

______Telephone Number ______

______Supervisor’s Name ______

______Employed Since ______

APPLICATION CERTIFICATION:

1.I/We certify that all the information given in this application and any addenda thereto is true, complete and accurate. I/We understand that if any of this information is false, misleading or incomplete, the Board of Directors of Belmar Gardens Cooperative may decline our application or if move-in has occurred, terminate our Occupancy Agreement.

2.I/We authorize The Rubinoff Company to make any and all inquiries to verify this information, either directly or indirectly or through information exchanged now or later with rental and credit screening services, and to contact previous or current landlords or other sources for credit and verification confirmation.

3.If this application is approved and move-in occurs,I/We certify that only those persons listed in this application will occupy the unit, and that there are no other persons for whom I/We have or expect to have to provide housing for.

4.I/We agree to notify management in writing immediately regarding any changes of telephone numbers and household composition.

5.I/We have read and understand the information in this application, in particular the information contained in the instructions for Head of Household; and I/We agree to comply with such information.

6.If this application is approved and move-in occurs, I/We certify that I/We will accept and comply with all conditions of occupancy as set forth herein, including specifically all conditions regarding pets and damages.

7.I/We authorize management to obtain one or more “consumer reports” as defined in the Fair Credit Reporting Act, seeking information on my/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 PROCEDURE FOR PROCESSINGYOUR APPLICATION, AN INVESTIGATIVE REPORT MAY BE MADEWHEREBYINFORMATION IS OBTAINED THROUGH PERSONAL INTERVIEWS WITH THIRDPARTIES – SUCH AS FAMILY MEMBERS, BUSINESS ASSOCIATES, FINANCIALSOURCES, 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 AND CREDIT BACKGROUND AND ALSO POLICE RECORDS. ALL INFORMATION YOU AND OTHERS GIVE US WILL BE HELD IN STRICT CONFIDENCE.

WE DO NOT DISCRIMINATE ON THE BASIS OF RACE, RELIGION, NATIONAL ORIGIN, COLOR, CREED, AGE, SEX, HANDICAP OR FAMILIAL STATUS.

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.

APPLICANT CONSENT TO OBTAIN CONSUMER REPORT

APPLICANT CONSENT TO OBTAIN CRIMINAL HISTORY

The undersigned applicant(s) hereby consent to allow the property listed on the applicationand The Rubinoff Company through its designated agents or employees, toobtain a consumerreport on each of us and to obtain and verify each of our credit andemployment information.

The undersigned applicant(s) and co-signer(s) herby consent to allow the property listedon theapplication and The Rubinoff Company through its designated agents oremployees, to obtain aconsumer report and criminal record on each of us. Upon my/ourrequest, owner will tell me/uswhether consumer reports or criminal record reports wererequested and the names and addressesof any consumer reporting agency that providedsuch reports.

I/WE HAVE READ AND UNDERSTAND THE ABOVE.

Signature of Head of Household:

______Date: ______

Signature of Spouse/Co-Head:

______Date: ______

Signature of Co-Applicant:

______Date: ______

Signature of Co-Applicant:

______Date: ______