WASHINGTON SQUARE APARTMENTS
163 SOUTH WASHINGTON STREET
WILKES-BARRE, PENNSYLVANIA 18701
570-823-0127
APPLICATION FOR RESIDENCE
Please help us speed your application by giving this information and return to the above address. It will be treated as confidential and retained in your private file.
(PLEASE PRINT)
Telephone No. ______Soc. Sec. Number ______
1. ______
LAST NAME FIRST INITIAL DATE OF BIRTH
______
ADDRESS CITY STATE ZIP CODE
(SECOND PERSON) Soc. Sec. Number ______
2. ______
LAST NAME FIRST INITIAL DATE OF BIRTH
______
ADDRESS CITY STATE ZIP CODE
Check one: Elderly ______Physically Handicapped ______
Where did you hear about Washington Square Apartments? ______
______
Do you need a parking space: Yes ______No ______
Description of Auto: Year ______Make ______Color ______
License Plate No. ______
______
INCOME INFORMATION Amount Per Month Amount Per Month
Social Security ______Other Income ______
Pension ______Wages ______
ASSETS
Name of Bank Type of Account Current Balance Interest Rate
______
______
______
Name of Stocks, Bonds, Annuity Annuity Value Annual Div. Earned
______
______
Personal References: (DO NOT INCLUDE RELATIVES)
1. Name ______2. Name ______
Address ______Address ______
______
Phone ______Phone ______
Landlord References:
CURRENT PRIOR
1. Name ______2. Name ______
Address ______Address ______
______
Phone ______Phone ______
Reason for leaving ______Reason for leaving ______
______
1. Have you ever been convicted of any criminal offense? Yes ______No ______
If yes, give details and dates on the bottom of this form.
2. Has applicant or co-applicant subject to State lifetime sex offender registration in any state? Yes___ No ___
3. List states where applicant and co-applicant have resided: ______, ______,
______.
IMPORTANT TO ALL APPLICANTS
1. You may qualify for “Federal Preference” on you waiting list if one of the following is true. A. You are living
in Substandard Housing, B. You are now paying 50% of your income for rent and utilities, C. You are (or about to be) involuntarily displaced.
2. Rent is based on your Gross Income and any interest from Assets, with an allowance for Medical Expenses. It will be 30% of the monthly income and will include all utilities except for telephone and cable television.
3. All applicants may be subject to medical examination and housekeeping inspection.
4. Credit and criminal reports will be part of this application process.
5. Disclosure of SSN for applicant and co-applicant, except those applicants who do not contend eligible immigration status will be required.
6. Information from applicant who were 62 or older as of January 31, 2010, and who do not have SSN if they were receiving HUD rental assistance at another location on January 31, 2010. This information is needed in order for the owner to verify whether the applicant qualifies for exemption from disclosing and providing verification of a SSN.
7. Washington Square Apartments is a SMOKE FREE BUILDING.
SIGNATURE OF APPLICANT ______
______
Date