ࡱ>  ;bjbj$$ %QF|F| I FF$PTh\V$>u#w#w#w#w#w#w#$'F*#u@#$"""^u#"u#"""@m%"a#&$0V$"*l*""*"l"##9!V$*F f:  I N S T R U C T I O N S PLEASE READ CAREFULLY. Incomplete Applications submitted will be placed on the waiting list, but will not be given priority until all missing informaiton is supplied to management. 1. COMPLETE ALL AREAS. If an item does not apply to you, mark "N/A" on that line. 2. SIGNATURES are required by all adult applicants. 3. RETURN YOUR APPLICATION TO: Thurmont Village 15A Sunny Close Thurmont, MD 21788 NOTE: PETS ARE ONLY ALLOWED IN OUR SENIOR CITIZEN PROPERTIES OR FOR PERSONS WITH DISABILITIES WHO REQUIRE A SERVICE ANIMAL. Your application is being returned because: ( You did not complete all areas or you did not sign the application. Please return your application along with the information that was missing if you want to be considered for housing. REVISED 4/96 PAGE 1 USE ONLY: DATE RECEIVED: ________________ TIME RECEIVED: _______________ ID #: _____________________ APPLICATION FOR ASSISTED HOUSING (USDA, Rural Development) SYMBOL 183 \f "Symbol" \s 12 \h If the information provided by or about any applicant from any source at any time during the screening process reveals negative information relating to the applicant's ability to meet the obligations of tenancy, the information will be researched as part of the tenant selection screening process and that applicant will be asked to explain this information as part of a uniformly applied policy applicable to all applicants. SYMBOL 183 \f "Symbol" \s 12 \h All applicants must be able to meet essential obligations of tenancy -- they must be able to pay rent, to care for their apartment, to report required information to , to avoid disturbing their neighbors, etc., but there is no requirement that they be able to do these things without assistance. SYMBOL 183 \f "Symbol" \s 12 \h is a management company that provides low rent housing to eligible households, elderly households and single people. is not permitted to discriminate against applicants on the basis of their race, color, religion, sex, national origin, disability handicap or familial status. In addition, has a legal obligation to provide "reasonable accommodations" to applicants if they, or any household member, have a disability or handicap. SYMBOL 183 \f "Symbol" \s 12 \h A reasonable accommodation is some modification or change can make to its apartments or procedures that will assist an otherwise eligible applicant with a disability to take advantage of government programs. SYMBOL 183 \f "Symbol" \s 12 \h If you, or a member of your household, have a disability or handicap and think you might need or want a reasonable accommodation, or qualify for a handicap adjustment to income under the USDA, Rural Development program, or any other adjustment you are eligible for, you may request it at any time in the application process or after admission. This is up to you. If you would prefer not to discuss your situation with the management company, that is your right. A. FAMILY SUMMARY -List all persons, including yourself, who will be living in the apartment. List head of household first. NameRelationshipBirth DatePlace of BirthSoc. Sec. #1Head of Household23456 Mailing Address: City: State: Zip: Physical Address: City: State: Zip:(if different than mailing address)Telephone No. Home: ________________________ Work:____________________________ Cell:________________________ E-Mail Address ____________________________________________________________________________________ Applying to Property(s):_______________________________________ Requested Unit Size: ________ Bedrooms How did you hear about the apartment for which you are applying? ______________________________________________ If you require a handicap-accessible unit, check here  EMBED MSDraw \* mergeformat  If you require any modifications to an apartment, check here and explain in a note to us  EMBED MSDraw \* mergeformat  PAGE 2 B. INCOME - All sources of regularly received monies must be listed regardless of recipient's age. Family Member NameSources of IncomeAmountSocial Security Gross Monthly Amount$Social Security Gross Monthly Amount$Pension Gross Monthly Amount$ Source: Address: Claim No. Pension Gross Monthly Amount$ Source: Address: Claim No. VA Benefits (Claim # )$SSI Benefits Gross Monthly Amount$Unemployment Compensation Gross Monthly Amount$ Address:AFDC Gross Monthly Amount$Wages Gross Monthly Amount$ Employer: Address:Wages Gross Monthly Amount$ Employer: Address:Alimony Gross Monthly Amount$Child Support Gross Monthly Amount$Other Income Gross Monthly Amount (for example, rental income, etc.)$$ C. ASSETS: Have you sold or disposed of any asset(s) valued over $1,000 in the last two years? Yes_____ No_____ If yes, type of asset (e.g., money/land/house) ____________________________________________________________ Market value when sold/disposed $______ Amount sold/disposed for $______ Date of transaction _______ PAGE 3 C. ASSETS (continued) Provide the following information for all members of the household (use another sheet of paper if necessary). Checking Accounts BankBankAddressAddressAccount No.Account No.Int. Rate Balance $Int. Rate Balance $ Savings Accounts BankBankAddressAddressAccount No.Account No.Int. Rate Balance $Int. Rate Balance $Certificates of Deposit BankBankAddressAddressAcct.# Int Rate Amt. $Acct.# Int Rate Amt. $Penalty for Early Withdrawal Maturity DatePenalty for Early Withdrawal Maturity Date Stocks IRA's/40l-K's NameBankAddressAddressValue $ Div. RateValue $ Div. Rate Bonds Trust Accounts BankBankAddressAddressPresent Value $Account No.Maturity DateInt. Rate Balance $ PAGE 4 C. ASSETS (continued): Real Estate Do you own any property? Yes_____ No_____ If yes, type & location of property ___________________________________________________________________________ ____________________________________________________________________________________________________________ Appraised market value $_____________________ Mortgage or outstanding loan due $_______________________ Name & address of broker/realtor who would provide verification of market value: ____________________________________________________________________________________________________________ Broker/Realtor Address City State Zip D. MEDICAL AND CHILD CARE EXPENSES FOR ELDERLY, DISABLED, HANDICAPPED APPLICANTS ONLY Medical Costs - Complete only if head or spouse is 62 or older, handicapped, or disabled AND ONLY if these medical expenses are paid for out of your own pocket and not reimbursed by medical insurance. Medicare Monthly Amount $Monthly Amount $Medical Insurance NameNameAddressAddressClaim No. Monthly Amt. $Claim No. Monthly Amt. $Pharmacy NameNameAddressAddressAnticipated prescription costs not covered by insurance - Monthly Amount $Anticipated prescription costs not covered by insurance - Monthly Amount $Physician Are you seeing a physician REGULARLY? Yes______ No______NameNameAddressAddressAnticipated costs not covered by insurance - Monthly Amount $Anticipated costs not covered by insurance - Monthly Amount $ Outstanding Medical Bills for which You are Making Monthly Payments NameNameAddressAddressAnticipated costs not covered by insurance - Balance Due $ Monthly Amount $Anticipated costs not covered by insurance - Balance Due $ Monthly Amount $ Child Care Expenses - Complete for children 12 and younger - Weekly cost for Child Care $_____________ Name & Address of Person/Agency caring for children: ______________________________________________________ ____________________________________________________________________________________________________________ PAGE 5 E. PROGRAM INFORMATION Are you currently living in subsidized housing? Yes_____ No_____ F. APPLICANT INFORMATION-Please place a checkmark in the box if any of the following statements apply to you. Do you have a Section 8 Voucher or any other type of voucher? Yes_____ No_____ 1. You have been served a Notice to Quit or been asked to leave by a previous landlord EMBED MSDraw \* mergeformat 2. You have been served with lease violations from a previous landlord EMBED MSDraw \* mergeformat 3. You have been evicted EMBED MSDraw \* mergeformat 4. You or any household member have been evicted from federally assisted housing for drug-related criminal activity? EMBED MSDraw \* mergeformat If you checked any of the above boxes, please explain the circumstances on an attached sheet of paper and identify property & landlord. 5. You or a household member have been convicted of a sex related crime or are subject to a lifetime registration in a State sex offender registration program? EMBED MSDraw \* mergeformat 6. You or a household member have been convicted of a felony crime? EMBED MSDraw \* mergeformat 7. You or a household member have been convicted of a drug related crime? EMBED MSDraw \* mergeformat List all states, other than the one that you reside in now, in which you have lived in during the last seven years? ___________________________________________________________________ G. REFERENCE INFORMATION Current Landlord (Name, Address,& Phone No.) ___________________________________________________________________________________________________________ How long have you lived there? __________________ Is this landlord related to you? Yes____ No____ List all Previous Landlords for ALL Adults in Household (Attach a sheet of paper if more space is needed.) (Name, Address & Phone No.) 1.2.Address of Apt.Address of Apt.How long did you live there? How long did you live there? Is this landlord related to you? Yes____ No____Is this landlord related to you? Yes____ No____ List two Professional Personal References for ALL Adults in Household (Attach a sheet of paper if more space is needed.) (Name, Address, Phone No. & Relationship) (Examples: teachers, principals, past/present employers, physicians, etc.) Please do not list relatives or friends. 1.2.Phone No. Relationship Phone No. Relationship All information received by during the application process regarding the applicant or applicant's household will be taken into consideration as part of the application. PAGE 6 Other Information Please provide us with the name, address, & phone number of an emergency contact: ____________________________________________________________________________________________________________ Vehicles - List any vehicle owned Type _______________________________________ Year/Make_________________________________________ Color _______________________________________ License Plate No. __________________________________ Do you own a pet? Yes_____ No_____ If yes, describe __________________________________________________ CERTIFICATION I/we hereby certify that I/we do not and will not maintain a separate, subsidized rental unit in another location. I/we understand I/we must pay a security deposit for this apartment prior to occupancy. I/we certify that the housing I/we will occupy is/will be my/our permanent residence. I/we understand that eligibility for housing will be based on either the USDA, Rural Development or the Department of Housing and Urban Development's eligibility criteria and resident selection criteria (see attached). I/we understand that this application in no way ensures occupancy and that my/our application can be rejected based on, but not limited to (1) a history of unjustified and/or chronic nonpayment of rent and/or financial obligations; (2) a history of living or housekeeping habits that would pose a direct threat to the health and safety of other individuals or whose tenancy would result in substantial physical damage to the property of others; (3) a history of disturbance of neighbors; (4) a history of violations of the terms of previous rental agreements, especially those resulting in eviction from housing or termination from residential programs; (5) police records indicating any type of criminal activity or convictions; and (6) any records which show the applicant's behavior to be unacceptable, even if it is a manifestation of an applicant's disability. I/we certify that the information given in this application is true to the best of my/our knowledge. I/we understand that any false information or any omission of any significant information is punishable by law, and could be grounds for cancellation of this application or termination of residency after occupancy. Head of Household(P)____________________________________________ Date_______________________________ Spouse/Co-Tenant(P)____________________________________________ Date_______________________________ ____________________________________________ For The information regarding race, national origin, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the USDA, Rural Development, that Federal Laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial status, age, and handicap are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, we would like to make you aware that, if you do not provide this information, the owner/rental agent is required to note race/national origin and sex based on visual observation or surname. Ethnicity: Hispanic or Latino ______ Not Hispanic or Latino ______ Race: (Mark one or more) 1 American Indian/Alaska Native ______ 2 Asian ______ 3 Black or African American ______ 4 Native Hawaiian or Other Pacific Islander ______ 5 White ______ Gender: Male ______ Female ______ Please sign ALL black checkmarks Authorization I/we do hereby authorize and its staff to contact any agencies, offices, credit bureaus, landlords, or professional references for the purpose of verifying the information I/we have provided on the application. The information provided will be used solely for the determination of my/our eligibility and admission to the housing I/we are applying for and the information that is supplied will be kept confidential. Signatures (P)____________________________________________________ _____________________________ Applicant Signature Date (P)____________________________________________________ _____________________________ Co-Applicant Signature Date -------------------------------------------------------------------------------------------------------------------------------------------------------------- Authorization I/we do hereby authorize and its staff to contact any agencies, offices, credit bureaus, landlords, or professional references for the purpose of verifying the information I/we have provided on the application. The information provided will be used solely for the determination of my/our eligibility and admission to the housing I/we are applying for and the information that is supplied will be kept confidential. Signatures (P)____________________________________________________ _____________________________ Applicant Signature Date (P)____________________________________________________ _____________________________ Co-Applicant Signature Date -------------------------------------------------------------------------------------------------------------------------------------------------------------- *How did you hear about our property? (check all that apply) (Internet website: __________________________________ (Newspaper ____________________________________ (Housing or Government Agency: ________________________________ (Family/Friend ________________________________________________ (Apartment Guide _________________________________ ( Other (please specify)__________________________________ This institution is an equal opportunity provider and employer. 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@@CC_C`CCHDIDkDlDmDnDoDpDgd  8 gd h$]$$ h$]$a$ h$]$n?v?@ @@CjDlDDDDDDFFFFFFFGGGG@HAHHHHH"K$K:KǾseXeeXeS hP5hP5CJ4OJQJhhP5CJ4H*OJQJh!hP5B*CJOJQJ\phhP>*CJOJQJhPCJ OJQJhP5CJOJQJ\hPCJ OJQJ\hP>*CJOJQJ\hPOJQJ\hPCJPJ hPCJhhPCJOJQJaJhhPCJaJ hPCJhP hP5>* pDqDDDDDFFFFPGGGH@HAHHHHH"K$K:KK@KBK(L*L,L.LMM,N-N4NBN|N}NNNNNKOLOOOOO PPP Q!QTQUQƹmmXm(h 5hP>*B*CJ OJQJaJ ph%jh 5hPCJ OJQJUaJ h 5hPCJ OJQJaJ  j ohPCJ OJQJaJ hPCJ OJQJaJ hWehPCJ OJQJaJ hPOJQJ hP5 hP5>*hPhP5CJ OJQJhhP5CJ H*OJQJh%hP5B*CJOJ QJ \^J ph!LMM,N-NrNsNNNBOOO P PMP:;;;;;;;$a$gd4]gdP dgd 5 $ !a$gd 5$ H!a$gd 5`, or at any USDA office, or call Toll-free (866) 632-9992, Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at  HYPERLINK "mailto:program.intake@usda.gov" program.intake@usda.gov. In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discrimination on the basis of race, color, national origin, sex, age, familial status, religion or disability. To file a complaint of discrimination you may file in person with, or write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, DC 20250-9410 or call 800-795-3272 (voice) or 202-720-6382 (TDD).      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