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RENTAL APPLICATION NOVEMBER 2016 PAGE 1 OF 4
ABOUT YOU: ( ❑TENANT OR ❑CO-TENANT)
Applicant’s full name: __________________________________________________ Current Landlord: __________________________________________
Present address: ______________________________________________________ Their Phone Number: ______________________________________
__________________________________________________________________ How long have you lived there? ______________________________
Phone Number: (Home)____________________ (Cell) ______________________ Current Monthly Rent: $ ____________________________________
Driver’s License Number:_________________________ (State) ________________ Previous Landlord: __________________________________________
Social Security Number: ________________________________________________ Address: ________________________________________________
Date of Birth: ________________________________________________________ How long did you live there?__________________________________
Marital Status (Optional): ________________________________________________ Their Phone Number: ______________________________________
Why are you moving? __________________________________________________ Previous Monthly Rent: $ ____________________________________
__________________________________________________________________ Are you currently attending any kind of school? ❑ Yes ❑ No
Do you receive job related or other income? ❑ Yes ❑ No ____________________ E-Mail Address: ____________________________________________
YOUR SPOUSE: (Note: Co-Tenants are required to complete a separate rental application)
Full Name: __________________________________________________________ Drivers License Number: ____________________________________
Present address: ______________________________________________________ Social Security Number: ____________________________________
__________________________________________________________________ Date of Birth: ______________________________________________
Phone Number: ______________________________________________________ Are you currently attending any kind of school? ❑ Yes ❑ No
Do you receive job related or other income? ❑ Yes ❑ No
OTHER OCCUPANTS:
(Anyone other than spouse, that is 18 or older, must complete a separate application)
Does the tenant or co-tenants have legal custody of all minor children listed below? ❑ Yes ❑ No
Do you or any occupant have a live-in attendant? ❑ Yes ❑ No
Do you anticipate any changes in household size (new members, birth of child, adoption, foster child, etc.)?
❑❑
Yes
❑❑
No
Name: ____
________________________ Relationship: ____________ SSN: ____________________ Birth date: ______________ Student ________
Name: ____________________________ Relationship: ____________ SSN: ____________________ Birth date: ______________ Student ________
Name: ____________________________ Relationship: ____________ SSN: ____________________ Birth date: ______________ Student ________
Name: ____________________________ Relationship: ____________ SSN: ____________________ Birth date: ______________ Student ________
\Name: ____________________________ Relationship: ____________ SSN: ____________________ Birth date: ______________ Student ________
VEHICLES: (List all vehicles, including motorcycles, RVs and trailers to be parked by you, your spouse or any occupants of the apartment.)
Vehicle Type: ________________________________________ Year: ______________ Color: __________________ License No.: __________________
Vehicle Type: ________________________________________ Year: ______________ Color: __________________ License No.: __________________
PREFERENCES:
What size unit are you requesting? ❑ Efficiency ❑ 1 Bedroom ❑ 2 Bedroom ❑ 3 Bedroom
Are you applying for a handicap accessible unit? ❑ Yes ❑ No
Do you wish to claim the deduction available for handicap or disabled persons? ❑ Yes ❑ No
Do you wish to make any modifications to the apartment to accommodate a handicap or disability? ❑ Yes ❑ No (If yes, please describe):
______________________________________________________________________________________________________________________________
EMERGENCY:
In the case of an emergency, notify __________________________________________________________________________________________________
Address: __________________________________________________________________________________________ Relationship: ____________________
Daytime phone number: ____________________________________________________ Evening phone number:___________________________________
In the case of serious illness, death or disappearance, is the above named person authorized to take possession of your property? ❑ Yes ❑ No
In the case of serious illness, death or disappearance, is the apartment property authorized to return any monies (rent or security deposit) due to the resident
to the above named person? ❑ Yes ❑ No
Other instructions: ________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
____________________________________________
Property Name
RENTAL APPLICATION
Copyright November 2016, Rural Rental Housing Association of Texas, Inc. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, without permission in writing from the copyright holder.
TTY: 1-800-735-2988
Application Submittal
For Office Use Only
Date Received: _____/_____/______
Time Received:__________________
Application Fee: $ ______________
Application Assignment
For Office Use Only
Apartment No.: __________________
Lease Date: ______/______/_______
Rent: $ ________________________
FORM VALID FOR RRHA of Texas MEMBERS ONLY
OF TEXAS
RURAL RENTAL HOUSING ASSOCIATION OF TEXAS, INC.
GENERAL INFORMATION:
Do you have a pet? ❑ Yes ❑ No Breed? ________________________________________________________________ Age:________ Weight:________
Are all household members citizens of the United States of America? ❑ Yes ❑ No
If any member is not a United States citizen, is that person a qualified resident alien as defined by law? ❑ Yes ❑ No
Have you or anyone in your household (adult or juvenile) ever been convicted of, pled no contest to, or entered a guilty plea, to any criminal offense other than
minor traffic violations? ❑ Yes ❑ No If yes, please describe: ____________________________________________________________________________
Have you or anyone in your household ever lived at this apartment property? __________________________________________________________________
Do you or anyone in your household use a controlled substance (drugs)? ____________________________________________________________________
Have you or anyone in your household ever:
1) broken an apartment lease? __________________________________________________________________________________________________
2) been requested to vacate an apartment? ________________________________________________________________________________________
3) been evicted or sued for non-payment of rent? __________________________________________________________________________________
4)
been evicted or sued for damage to rental property? ______________________________________________________________________________
5) received deferred adjudication for a felony? ______________________________________________________________________________________
6) been convicted of a felony? __________________________________________________________________________________________________
7) been arrested and convicted as a sex offender? __________________________________________________________________________________
Have you given notice to your present landlord of your intent to move?
______________________________________________________________
How did you hear about us (Newspaper ad, Internet, friend, etc.) __________________________________________________________________________
Is any member of the household a veteran? __________________________________________________________________________________________
Are you seeking housing because you have been displaced by a Presidentially declared disaster? ________________________________________________
Do you have a Letter of Priority Entitlement (LOPE)? ____________________________________________________________________________________
Please list each state that you or any member of the household have ever resided ____________________________________________________________
______________________________________________________________________________________________________________________________
Were you or any member of the household age 62 or older AND receiving HUD Rental assistance on or prior to Jan. 31, 2010? ________________________
STUDENT STATUS:
USDA requirements (determines eligibility for housing):
Will any tenant or co-tenant attend an institution of higher learning in the coming year? ❑ Yes ❑ No
1) Has the student established a separate household from parents for at least one year prior to occupancy? ❑ Yes ❑ No
2) Is the student claimed as a dependent on their parent’s tax return? ❑ Yes ❑ No
3) Is the student financially independent from their parents? ❑ Yes ❑ No
HUD (determines eligibility for Section 8 rental assistance)
1) Is the student 24 years of age or older? ❑ Yes ❑ No
2) Is the student a veteran? ❑ Yes ❑ No
3) Is the student married? ❑ Yes ❑ No
4) Does the student have a dependent child? ❑ Yes ❑ No
5) Is the student disabled? ❑ Yes ❑ No
6) Is the student currently living with their parents who are receiving section 8 assistance? ❑ Yes ❑ No
7) Are the student’s parent’s income eligible to receive section 8 assistance? ❑ Yes ❑ No 
LIHTC requirements (determines eligibility for housing):
Has any tenant or co-tenant in the household attended school full-time for at least 5 months in the past year? ❑ Yes ❑ No
Does any tenant or co-tenant in the household intend to go to school full-time in the coming year? ❑ Yes ❑ No
If the answer is “Yes” to either of the questions above, complete the section below:
LIST the name of each Full-time Student: ______________________________________________________________________________________________
NOTE: Households where all of the members are full-time students are not eligible unless they meet one of the exemptions:
1) Are all adult members of the household married and file a joint income tax return? ❑ Yes ❑ No
2) Does the household receive assistance under Title IV of the Social Security Act (i.e.. AFDC/TANF)? ❑ Yes ❑ No
3) Is the student a single parent with a minor child? ❑ Yes ❑ No
4) If you have children, do you claim them on your federal income tax return? ❑ Yes ❑ No
5) Has any member of the household received assistance under the Job Training Partnership Act or similar federal or state law? ❑ Yes ❑ No
6) Has any member of the household previously enrolled in a foster care program? ❑ Yes ❑ No
RENTAL APPLICATION NOVEMBER 2016 PAGE 2 OF 4
Copyright November 2016, Rural Rental Housing Association of Texas, Inc. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, without permission in writing from the copyright holder.
FORM VALID FOR RRHA of Texas MEMBERS ONLY
ASSET & INCOME QUESTIONNAIRE
The information on this form is authorized to be collected by the USDA Rural Housing Service to determine an applicant’s eligibility and the amount the tenant must pay toward rent and utilities.
This information may be released to appropriate Federal and State agencies. However, this information will not otherwise be released, except as permitted or required by law. Failure to disclose
certain
items of information requested may result in a delay in the processing of an application or its rejection.
INCOME:
Does any member of your household have a job? ❑ Yes ❑ No (Include wages, salary, overtime pay, military pay, commissions, fees, tips, bonuses. etc.)
CREDIT:
Credit Reference #1: __________________________________________________________________________ Phone #:___________________________
Address: ____________________________________________________________________________________ Account
#:__________________________
Credit Reference #2: __________________________________________________________________________ Phone #:___________________________
Address: ____________________________________________________________________________________ Account #:__________________________
Household Member Name Employer (Name, Address & Phone No.) Gross Monthly Wages
$
$
$
RENTAL APPLICATION NOVEMBER 2016 PAGE 3 OF 4
Copyright November 2016, Rural Rental Housing Association of Texas, Inc. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, without permission in writing from the copyright holder.
$
$
$
Does any member of your household receive unemployment, disability, death benefits, workers compensation payments, public assistance/TANF, etc.? ❑
Yes ❑ No
$
$
$
Does any member of your household receive interest or dividend income? ❑ Yes ❑ No
$
$
$
$
$
List all other household income. (Include severance pay, education grants, scholarships, etc.)
$
$
$
$
$
$
Does any member of your household receive alimony, child support or regularly recurring contributions from someone not residing in the dwelling? ❑ Yes ❑ No
Total Monthly Income. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total Annual Income expected for the next 12 months . . . . . . . . . . . . . . . . . . . . . . . . .
Household Member Name Source (Unemployment, workers comp, etc.) Monthly Income
Household Member Name Amount you are entitled to receive
Gross Amount
received monthly
Household Member Name Source Monthly Income
Household Member Name Source Monthly Income
FORM VALID FOR RRHA of Texas MEMBERS ONLY
ASSETS:
Total Cash on Hand for all members of the family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Does any member of your household have a bank account (checking, savings, etc)? ❑ Yes ❑ No
$
$
$
$
$
$
Does any member of your household own stocks, bonds, IRA, 401K, CD or retirement account? ❑ Yes ❑ No
$
$
Does any member of your household have a life insurance policy that has cash value? ❑ Yes ❑ No
Account Holder Bank (Name & address)
Financial Institution (Name & address)
Account Number
Interest Rate
Avg 6 month Balance
Account Holder Current Value
Household member name
Description (Term, whole life, etc.) Policy #
Cash Value
$
$
Does any member of your household have Direct Express Card or any other type of debit card that receives a monthly deposit? ❑ Yes ❑ No
Account Holder
Source Account Number
Balance
$
Account Number
Income
Name of Business Type of business
Years of Ownership
Monthly Profit
Does any member of your household own a business or rental property? ❑ Yes ❑ No
$
Does any member of your household receive payments or benefits from Social Security, SSI, annuities, veterans benefits, retirement funds, pensions, insur-
ance policies, etc.? ❑ Yes ❑ No
Household Member Name Source (SS, Veterans, etc.) Monthly Income
$
$
$
RENTAL APPLICATION NOVEMBER 2016 PAGE 4 OF 4
Copyright November 2016, Rural Rental Housing Association of Texas, Inc. All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, without permission in writing from the copyright holder.
$
$
$
$
Does any member of your household own any property? ❑ Yes ❑ No
$
$
$
$
Has any member of your household sold or given away any assets in the last two (2) years? ❑ Yes ❑ No
Have you or any household member received any lump sum payments, such as lottery winnings, inheritance or insurance settlements?
❑ Yes ❑ No (If yes, please describe) __________________________________________________________________________________
Does any member of your household own any asset not listed above? ❑ Yes ❑ No (If yes, please describe in detail.)
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
EXPENSES:
CHILD CARE: To enable a household member to be employed or attend school, does anyone in your household pay for childcare services? ❑ Yes ❑ No (If
yes, please list each provider):
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
MEDICAL EXPENSE: (Complete this section when the Tenant or Co-Tenant is at least 62 years old, or handicapped or disabled.)
Does your household pay medical expenses that are not covered by insurance? ❑ Yes ❑ No
If the answer is yes, you may be eligible for a reduction in your monthly rental payment. Please submit to the property manager the information necessary to
document the amount of un-reimbursed medical expenses you expect to pay in the next 12 months.
Please list all states in which any and all occupants have ever resided:
Applicant: ______________________________________________________________________________________________________________________
Co-Applicant:____________________________________________________________________________________________________________________
Other occupant #1: ______________________________________________________________________________________________________________
Other occupant #2: ______________________________________________________________________________________________________________
Other occupant #3: ______________________________________________________________________________________________________________
Other occupant #4: ______________________________________________________________________________________________________________
Are any proposed Applicants or occupants subject to a lifetime sex offender registration of any state? ❑ Yes ❑ No (If yes, please list below)
______________________________________________________________________________________________________________________________
If any member of the household is subject to a lifetime sex offender registration, you will be given the opportunity to permanently remove the individual from the
household and, if such person is not permanently removed and barred from the property, you will not be allowed to occupy an apartment.
If you or any occupant of the household falsifies any information or otherwise fails to disclose criminal history in this application or in any recertification forms,
then your occupancy shall terminate and you shall be evicted.
CERTIFICATION AND SIGNATURES: (All Adults in household must sign application.)
All statements contained in this application are true and correct. I authorize the owner or its representatives to contact any person to verify any information con-
tained herein. In the event that information given above is discovered to have been false or incomplete, the applicant understands that their application may be
rejected or they may lose any subsidy that the Federal Government pays and have their rent increased and be sued for eviction. The Applicant also certifies that
the unit applied for will be the Applicant’s Household’s permanent residence and it does/will not maintain a separate subsidized rental unit in a different location.
Signing this acknowledgment indicates that you have had the opportunity to review the landlord’s tenant selection criteria. The tenant selection criteria
may include factors such as criminal history, credit history, current income, and rental history. If you do not meet the selection criteria, or if you pro-
vided inaccurate or incomplete information, your application may be rejected and your application fee will not be refunded.
______________________________________________________ __________________________________________________________________
Date Signature of Applicant
______________________________________________________ __________________________________________________________________
Date Signature of Applicant
WARNING: Section 1001 of Title 18, United States code provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States makes a false, fictitious, or fraudulent statement or representation, or
makes or uses any false writing or docu ment knowing the same to contain false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000.00 or imprisoned not more than five years, or both.”
---Household member name
Location of property
Appraised Value
Outstanding Mortgage
Household member name
Description of property
Market value or
appraised value
Amount of Sale
FORM VALID FOR RRHA of Texas MEMBERS ONLY
CENSUS INFORMATION (OPTIONAL):
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 Rural
Development/USDA, that Federal laws prohibiting discrimination against tenant applicants on the basis of race, color, national origin, religion, sex, familial status, age and handicap are c
om-
plied 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, if you choose not to furnish it, the owner is required to note the race, national origin and sex of an individual applicant on the basis of visual observation or surname.
ADUL
T APPLICANT #1
ADUL
T APPLICANT #2
Ethnicity
: Ethnicity:
❑ Hispanic or Latino ❑ Hispanic or Latino
❑ Not Hispanic or Latino ❑ Not Hispanic or Latino
Race:
(Mark one or more) Race: (Mark one or more)
❑ White ❑ Black or Africa American ❑ White ❑ Black or Africa American
❑ American Indian/Alaska Native ❑ Asian ❑ American Indian/Alaska Native ❑ Asian
❑ Native Hawaiian or other Pacific Islander ❑ Native Hawaiian or other Pacific Islander
Gender
: ❑ Male ❑ Female Gender: ❑ Male ❑ Female
This institution is an equal opportunity provider. Esta institution es un proveedor de services con igualdad de opportunidades.
Description Current Value
Does any member of your household have personal property held as an investment (gem & coin collections, antique autos, art, etc.)? ❑ Yes ❑ No
$
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FORM VALID FOR RRHA of Texas MEMBERS ONLY:

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Completed 15 June 2021

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