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PRELIMINARY APPLICATION

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  • 4 signatures
  • 10 check-boxes
  • 178 other fields

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NT 05-01.A
Rev. 11/2/2020
Page 1 of 4
Studio
**Office Use Only**
Received Date:
1 Bedroom
Time:
am/pm
2 Bedroom
Initials:
3 Bedroom
Prospect #:
4 Bedroom
Unit #:
This Preliminary Application is used to place applicants on our Waiting List and does not include all
information we require to determine program eligibility.
Instructions:
• It is important that all information on the Preliminary Application be legible, complete and correct. False,
incomplete, or misleading information will cause us to reject your application. Do not leave any sections
blank.
• It is your responsibility to notify us when any of the information contained in this application changes (i.e.
contact information, family size, income amounts, etc.). Failure to do so may result in the rejection of
your Rental Application.
• It is your responsibility to contact us within 48 hours after we contact you about scheduling the
Application Interview and/or for a specific apartment. If we do not hear from you within this timeframe,
we will move to the next applicant on the Waiting List.
This property does not discriminate on the basis of disability status in the admission or access to, or treatment or
employment in, its federally assisted programs and activities. You may contact our 504 Coordinator, Dustin
Tucker, at 2929 3rd Avenue North, Suite 538; Billings, MT 59101; dtucker@tamarackpm.com; (406) 252-3773 /
TTY 711 for assis
tance. Language interpreters and/or translated documents are available upon request.
Intérpretes de la lengua y documentos traducidos están disponibles a petición. Alternate formats are available
upon request.
Select the apartment size(s) you wish to apply for, in order of preference:
(1)
Be advised that not all unit sizes listed may be available at this property. Please reference the Resident Selection Plan
for apartment sizes or view floorplans on our property website.
How did you hear about the property?
Applicant’s Name:
In Care Of (optional):
Mailing Address(1):
/ TTY 711
Home Phone:
Cell Phone:
Message Phone:
Email Address:
PRELIMINARY APPLICATION
(HUD Properties)
Apartment Sizes
(1)
/Occupancy Standards
Studio (1-3 household members)
1 Bedroom (1-3 household members)
2 Bedroom (2-5 household members)
3 Bedroom (3-7 household members)
4 Bedroom (4-9 household members)
1
st
Preference:
2
nd
Preference:
3
rd
Preference:
(1)If you are currently homeless, please list a mailing address of a
family member or friend who will accept mail on your behalf.
When would you like to move in?
Transitional Living Center
725 Lomax Street #1
Idaho Falls, ID 83401
208-523-4102
844-270-3775
tlcenter@nwrecc.org
NT 05-01.A
Rev. 11/2/2020
Page 2 of 4
Household Information
List all individuals that are applying to live in this apartment.
Ex
clude live-in aides / attendants (they will be added at move-in).
(1)
Response Optional
Name
First, Middle Initial, Last
Aliases
Maiden
/ other
legal
names
Date
of
Birth
A
g
e
Social
Security
Number
Relationship
to Head of
Household
Gender
1
M / F / P
P=Prefer
not to
disclose
Is the
Individual:
A Student
(Y/N)
US Military Veteran (Y/N)
Disabled (Y/N)
1
Self
Household Income
Please disclose all
gross income & benefits (amount before deductions) received by members of your
household on a recurring basis.
Income sources to consider: Employment wages & tips, SSA benefits, rental income
, pensions,
unemployment, recurring gifts, income from assets, etc.
Household Member
Income or Benefit
Source Name
Amount Received
(before deductions)
Frequency
(hourly,
weekly, bi-
weekly, semi-
monthly,
monthly, etc.)
Total
Annual
Income
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
$
Per
NT 05-01.A
Rev. 11/2/2020
Page 3 of 4
Preliminary Application Questions:
Yes
No
Do you anticipate any changes to the number of people that will be living in your household?
If yes, please explain:
Do you or any household member need the features of an apartment home adapted for
wheelchair use or sensory impairments?
If yes, select type: Mobility Accessible Vision Accessible Hearing Accessible
Do you or any household member have special housing needs or need a reasonable
accommodation or modification to live here? Examples might be a live-in aide, assistance
animal or grab bar. If yes, complete the following:
Member Name:
Describe What Is Needed:
Have you been disp
laced from your previous home due to government action or a
presidentially declared disaster?
(If you mark yes, please be prepared to provide a written statement or certificate of displacement by
the appropriate governmental authority.)
Are you applying for Section 8 rental assistance at this property (if available)? If you mark
“no” we will assume you want to be considered only for apartments with no Section 8
assistance.
Do you have a voucher (i.e., rental assistance through a Housing Authority or similar agency)
that you would like to use at this property? Note: if this property is 100% Section 8, we
cannot accept your voucher.
Is any member of your household subject to state lifetime sex offender registration in any state?
Note: We are required by HUD and company policy to perform criminal background checks during
the application stage to determine if any member of your household, including live-in aides/attendants,
is subject to a lifetime registration requirement under any State sex offender registration program, or
is otherwise ineligible under our Resident Selection Plan. Failure to respond accurately to questions
regarding your criminal record during the application process may jeopardize approval of your application
and after move-in, continued assistance and/or occupancy.
Having a criminal record does not
necessarily mean that you or your household will be disqualified, but you should be prepared to provide
documentation regarding your criminal record and/or pending charges to assist in processing your
application expediently. Criminal background checks must be performed in this state and in all states
where all adult household members have resided.
NT 05-01.A
Rev. 11/2/2020
Page 4 of 4
St
atements by all Household Members
Signature – Household Member
Date
Signature – Household Member
Date
Signature – Household Member
Date
Signature – Household Member
Date
At
tachment(s):
Supplement to Application for Federally Assisted Housing
Race and Ethnic Data Form(s)
Applicant represents all of the above statements are true and correct. Applicant authorizes verification
of the above information including but not limited to references, criminal history, credit records, civil court
records and income & asset information through third party sources; releases from liability all persons
and entities requesting or supplying information; and acknowledges this information may be released to
appropriate Federal, state or local agencies. Applicant acknowledges that false, incomplete or
misleading information constitutes grounds for rejection of this application; and discovery of false,
incomplete or misleading information discovered after occupancy may result in termination of the right of
occupancy of all occupants. Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to
willfully falsify a material fact or make false statement in any matter within the jurisdiction of a
federal agency.
I have reviewed the Resident Selection Plan, which summarizes the procedures for processing
applications, and understand it is available to me upon request. I understand that I must notify
management in writing if there are any changes in household address, telephone numbers, income and
household composition and that I must respond to Waiting List update requests to remain on the
Waiting List.
We are using this brief form of application to gather the minimum information needed to determine if the
applicant should be put on the waiting list. Applicant’s position on the waiting list may change depending
upon the preferences that other households may qualify for. Applicant can find the most up to date
status of their waiting list application by calling our office or logging into the online portal.
If apartments are available (or will be soon), we must collect more detailed information from Applicant
during the Application Interview and verify all information. Please be aware that if Applicant is placed on
the waiting list, it does not indicate that Applicant is eligible to receiving housing at this property. Only
after all required information has been received and verified can we make an eligibility determination.
Failure to remain eligible as determined by the Resident Selection Plan will result in us rejecting
Applicant’s application.
Applicant acknowledges by providing an email address, applicant authorizes management to
communicate about this Preliminary Application and related documents and/or processes via email.
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OMB Control # 2502-0581
Exp. (
02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Applicant Name:
Mailing Address:
Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No: Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
Unable to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
Signature of Applicant
Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)
form HUD-27061-H (9/2003)
1
Race and Ethnic Data U.S. Department of Housing OMB Approval No. 2502-0204
Reporting Form and Urban Development (Exp. 06/30/2017)
Office of Housing
Name of Property Project No. Address of Property
Name of Owner/Managing Agent Type of Assistance or Program Title:
Name of Head of Household Name of Household Member
Date (mm/dd/yyyy):
Ethnic Categories*
Select
One
Hispanic or Latino
Not-Hispanic or Latino
Racial Categories*
Select
All that
Apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
*
Definitions of these categories may be found on the reverse side.
Signature Date
Public reporting burden for this collection is estimated to average 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This
information is required to obtain benefits and voluntary. HUD may not collect this information, and you are not required to complete this form,
unless it displays a currently valid OMB control number.
This information is authorized by the U.S. Housing Act of 1937 as amended, the Housing and Urban Rural Recovery Act of 1983 and Housing
and Community Development Technical Amendments of 1984. This information is needed to be incompliance with OMB-mandated changes to
Ethnicity and Race categories for recording the 50059 Data Requirements to HUD. Owners/agents must offer the opportunity to the head and co-
head of each household to “self certify’ during the application interview or lease signing. In-place tenants must complete the format as part of
their next interim or annual re-certification. This process will allow the owner/agent to collect the needed information on all members of the
household. Completed documents should be stapled together for each household and placed in the household’s file. Parents or guardians are to
complete the self-certification for children under the age of 18. Once system development funds are provide and the appropriate system upgrades
have been implemented, owners/agents will be required to report the race and ethnicity data electronically to the TRACS (Tenant Rental
Assistance Certification System). This information is considered non-sensitive and does no require any special protection.
There is no penalty for persons who do not complete the form.
_____________________________________ ____________________________
Transitional Living Center
124EH039
725 Lomax St #1 Idaho Falls, ID 83401
NorthWest Real Estate Captial Corp
Section 8
form HUD-27061-H (9/2003)
2
Instructions for the Race and Ethnic Data Reporting (Form HUD-27061-H)
A. General Instructions:
This form is to be completed by individuals wishing to be served (applicants) and those that
are currently served (tenants) in housing assisted by the Department of Housing and Urban
Development.
Owner and agents are required to offer the applicant/tenant the option to complete the form.
The form is to be completed at initial application or at lease signing. In-place tenants must
also be offered the opportunity to complete the form as part of the next interim or annual
recertification. Once the form is completed it need not be completed again unless the head of
household or household composition changes. There is no penalty for persons who do not
complete the form. However, the owner or agent may place a note in the tenant file stating
the applicant/tenant refused to complete the form. Parents or guardians are to complete
the form for children under the age of 18.
The Office of Housing has been given permission to use this form for gathering race and
ethnic data in assisted housing programs. Completed documents for the entire household
should be stapled together and placed in the household’s file.
1. The two ethnic categories you should choose from are defined below. You should check one
of the two categories.
1. Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central
American, or other Spanish culture or origin, regardless of race. The term “Spanish
origin” can be used in addition to “Hispanic” or “Latino.”
2. Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or
Central American, or other Spanish culture or origin, regardless of race.
2. The five racial categories to choose from are defined below: You should check as many as
apply to you.
1. American Indian or Alaska Native. A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains
tribal affiliation or community attachment.
2. Asian. A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
3. Black or African American. A person having origins in any of the black racial
groups of Africa. Terms such as “Haitian” or “Negro” can be used in addition to
“Black” or “African American.”
4. Native Hawaiian or Other Pacific Islander. A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
5. White. A person having origins in any of the original peoples of Europe, the Middle
East or North Africa.
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PRELIMINARY APPLICATION

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Completed 19 January 2021

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