Application

APPLICANT INFORMATION

Applicant Name

First

Middle

Last

Gender

Male
Female
Prefer not to disclose

Citizenship Status

United States Citizen
Eligible Non-Citizen
Ineligible Non-Citizen

What is your relationship to the Head of household?

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email Address

May we contact you at work?

Yes
No

Birth Date

Age

Social Security Number

If you have no Social Security Number, you claim you are exempt because

You are an ineligible non-citizen
You were 62 as of 1/31/10 and receiving HUD housing assistance as of 1/31/10 (if you claim this exemption you must provide proof that you were receiving HUD assistance as of 1/31/2010 such as a copy of an executed HUD Form 50058 or 50059)

If the head-of household or co-head/spouse is not 62 or older, do you claim eligibility because the head-of-household or co-head/spouse is disabled?

N/A
Yes
No

Are you enlisted in the U.S. Military or are you a veteran of the U.S. Military?

Yes
No

Are you a victim of a recent presidentially declared disaster?

Yes
No

Are you currently receiving housing assistance from HUD or a PHA?

Yes
No

Are you a student enrolled in an institute of higher education?

Yes
No

Are you currently using marijuana?

Yes
No

Do you acknowledge that you are aware that the owner/agent has implemented a Smoke Free policy?

Yes
No

This means that smoking is prohibited in the unit, on unit balconies and porches and in all indoor and outdoor common areas. This includes the parking lot, balconies, sidewalks, hallways, elevators, etc.

Do you agree that you, your guests and service providers hired by you will abide by the Smoke Free policy?

Yes
No

Do you understand that failure to comply with Smoke Free policies as described in the House Rules will result in termination of tenancy (eviction)?

Yes
No

Have you ever been convicted of a crime?

Yes
No

Are you or is any member of the household required to register with any state lifetime sex offender or other sex offender registry?

Yes
No

Have you ever been evicted from a federally funded housing program for a lease violation including drug use or failure to report a crime?

Yes
No

RENTAL HISTORY

Have you previously rented with Atlas Realty Management Co., Inc.?

Yes
No

Are you currently homeless?

Yes
No

Have you given your current landlord notice that you will be moving?

Yes
No

Previous Landlords

Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Name

Phone Number

How long did you live at this address?

Reason for leaving

Were you ever asked to allow or participate in professional extermination services of pests other than regularly scheduled pest control?

Yes
No

(Includes bed bugs, roaches, etc.) An inspection by a licensed pest control person will be held within one week following move-in to verify. (Includes bed bugs, roaches, etc.)

Do you currently have any outstanding overdue balances owed to this landlord?

Yes
No

Have you been evicted or is this landlord attempting to evict you or another person living with you?

Yes
No

Have you ever been asked to sign a repayment agreement to return money to HUD?

Yes
No

UTILITY PROVIDERS

You may not live in the unit unless you can establish electric in the unit.

Do you have any overdue/outstanding balances owed to any utility provider?

Yes
No

Will you be able to establish Electric in your unit?

Yes
No
N/A

Do you receive any assistance to pay your utility bills?

Yes
No

Is assistance provided under the Low-Income Home Energy Assistance Program (LIHEAP)?

Yes
No
N/A

PETS & ASSISTANCE/COMPANION ANIMALS

The property pet/assistance animal rules are available upon request. The presence of any animal must be approved before housing the animal in the unit.

Do you plan to house an animal in the unit?

Yes
No

HOUSEHOLD COMPOSITION AND CHARACTERISTICS

If you are the Head of Household (HOH), please complete this section which provides information about other household members. Make a copy of this page if more than two people will live in the unit. This application must include information about everyone who will live in the unit.

Will anyone else live in the unit with you?

Yes
No

If yes, please complete the following and note that all adults must complete their own application. If no, please skip to the next section.

Requested Unit Size

1 Bedroom Unit

Special Features Requested

Mobility Accessible Unit
Communication Accessible Unit - Hearing
Communication Accessible Unit - Visual
Special Features - Please list below

INCOME INFORMATION

In order to determine eligibility and to ensure that your family receives the correct assistance, please provide the following information.

Are you employed?

Yes
No

Additional employment information

How much do you expect to receive in other income in the next 12 months?

Please write in 0.00 if you will receive no income from these sources. THE OWNER/AGENT WILL NOT PROCESS THE APPLICATION IF THESE FIELDS ARE NOT COMPLETE.

Monthly Social Security

Monthly Social Security Amount

Monthly SSP

Monthly SSP Amount

Monthly Retirement Benefits

Monthly Retirement Benefits Amount

Monthly VA Benefits

Monthly VA Benefits Amount

Monthly Unemployment Benefits

Monthly Unemployment Benefits Amount

Monthly Public Assistance

Monthly Public Assistance Amount

Child Support

Monthly Child Support Amount

Disability Benefits

Monthly Disability Benefits Amount

Any Benefits for a Child

Monthly Benefits for a Child Amount

Alimony

Are you entitled to Alimony?

Yes
No

Income from a pension or annuity or other asset

Are you entitled to income from a pension or annuity or other asset??

Yes
No

Regular contributions from organizations or from individuals not living in the unit?

Monthly Amount

Periodic Payments from Long-Term Care Insurance, Disability or Death Benefits?

Monthly Amount

Contributions from family for rent, child care or other bills.

Monthly Amount

Any lump sum amounts from delay of payments for SSI or VA Disability

Monthly Amount

Financial Aid

Do you receive financial aid for education assistance?

Yes
No

Utility Assistance

Do you receive any assistance to pay your utility bills?

Yes
No

Workers’ Compensation

Do you receive Workers’ Compensation?

Yes
No

Insurance Policy or Proceeds

Do you receive income from any insurance policy or proceeds?

Yes
No

Other income

Have you sold or given away real property or other assets valued at $1000.00 or more (including cash donations) in the past two years?

Yes
No

Have you given any money to charities in the past two years?

Yes
No

Do you have a checking account?

Yes
No

Do you have a savings account?

Yes
No

Do you have a Social Security Express Card?

Yes
No

Do you have cash that is not deposited in an account?

Yes
No

Do you have a 401K or other employment savings account?

Yes
No

Do you own an IRA or other retirement account?

Yes
No

Do any of your retirement accounts have a Required Minimum Distribution?

Yes
No

Do you own a home or other property?

Yes
Yes, jointly
No

Do you have a mortgage or home equity loan against your property? Other liens against the property?

Yes
No

Do you have business income?

Yes
No

Do you own stocks/bonds/certificates of deposit (CD)?

Yes
No

Do you own a life insurance policy?

Yes, Whole
Yes, Term
Yes, Universal
No

Do you own an annuity?

Yes
No

Is there a trust fund in your name or have you established a trust fund for someone else?

Yes
No

Do you have a safety deposit box?

Yes
No

Medical Expenses

Households in which the head-of-household, co-head of household or spouse are disabled or at least 62 years old qualify for deductions based on out-of-pocket medical expenses. Please let us know if you or any members of your household have out-of-pocket expenses for the following:

Health Insurance - 1 – annual premium