Household Information: Complete the following information for each household member that will occupy the unit at time of move-in: Name Relationship to the Sex Birth Date Student Social Security (Last, First, MI) Head of Household (M/F) (mm, dd, yyyy) (Y/N) Number Current Address: Primary Phone: ( ) Alternate Phone: ( ) Are you claiming a Certain preferences are assigned to applicants in order to provide “Preference”? housing opportunities for households with special needs. See Tenant Selection Plan for greater detail. Displaced by Government Action or Presidentially Declared Disaster. Victim of Domestic Violence. Elderly, or Disabled. Other or Local Preference: ___________________________________________ Type: 1st Choice: 2 BR 3 BR 4 BR 5 BR 2nd Choice: 2 BR 3 BR 4 BR 5 BR Would you or anyone in your household benefit from a special needs unit? (Mobility, vision, or hearing impairment) Yes No Will you or anyone in your household require a live-in care attendant? Yes No Name of Live-In Care Attendant: Relationship (If any): Housing References: List the of housing references. past 3 years (If additional space is required, use the back of this page.) Landlord’s Name/Address Your Address Own/Rent Dates 1. Own From: ______ Rent To: Phone: ( ) 2. Own From: ______ Rent To: ( ) 3. Own From: ______ Rent To:
Household Information: Complete the following information for each household member that will occupy the unit at time of move-in: Name (Last, First, MI) Relationship to the Head of Household Sex (M/F) Birth Date (mm, dd, yyyy) Student (Y/N) Social Security Number Current Address: Primary Phone: ( ) Alternate Phone: ( ) Are you claiming a “Preference”? Certain preferences are assigned to applicants in order to provide housing opportunities for households with special needs. See Tenant Selection Plan for greater detail. Displaced by Government Action or Presidentially Declared Disaster. Victim of Domestic Violence. Elderly, or Disabled. Other or Local Preference: ___________________________________________ Type: 1st Choice: 2 BR 3 BR 4 BR 5 BR 2nd Choice: 2 BR 3 BR 4 BR 5 BR Would you or anyone in your household benefit from a special needs unit? (Mobility, vision, or hearing impairment) Yes No Will you or anyone in your household require a live-in care attendant? Yes No Name of Live-In Care Attendant: Relationship (If any): Housing References: List the past 3 years of housing references. (If additional space is required, use the back of this page.) Landlord’s Name/Address Your Address Own/Rent Dates 1. Own From: ______ Rent To: Phone: ( ) 2. Own From: ______ Rent To: ( ) 3. Own From: ______ Rent To:
Disaster-Recovery-Small-Rental-Rehab-Tenant-Application.docx