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_____________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road l Concord, New Hampshire 03301-6000 l (603) 224-9221
Fax (603) 228-1387 l l TDD (800) 545-1833 X118 l Equal Opportunity Provider and Employer
Prior to starting your application, take a moment to carefully read
through the required items below. If your application is incomplete
or any of these required items are missing, IT WILL NOT BE
PROCESSED.
• Please write the specific property/properties you would like to
apply for. Do not write “All”.
• You must include a copy of each household member’s Social
Security card; or something legal with the full number on it.
• All household members over the age of 18 must report all asset
and income information.
• When completing the income portion, be sure to report all gross
weekly or monthly income (before taxes or deductions).
• All household members over the age of 18 must sign and date
the application and all forms with the application.
• You must provide complete landlord contact information (full
name, mailing address, and phone number; email, and/or fax if
available to expedite your application).
o If you do not have any rental history, please visit our
website to print a Co-Signer Application.
www.hodgescompanies.com
Apartment Communities
Affordable Housing scroll to the bottom of the page
where you will find our Co-Signer Application. Anyone over
the age of 18 can apply to be a co-signer unless they are
already on a current lease with Hodges.
If you have any questions, please feel free to contact our office. Thank
you.
_________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
1
Concord Village Apartments
Adopted November 1, 2015
Thank you for your interest in an apartment managed by The Hodges Companies.
Enclosed you will find your application package. Please complete all documents entirely
Return all “OFFICE COPY” documents along with copies of the social security cards
for each person who will reside in the apartment. Your application will be returned
if they are not included.
LIST OF DOCUMENTS INCLUDED IN THIS PACKAGE:
1. Application for Assisted Housing. Please complete in full. If a question does not
apply to you; please mark the answer space with a N/A. All household members
over the age of 18 must sign and date the application.
2. Selection Criteria for Housing. Please review the criteria for more information on our selection
process and become familiar with it.
3. Notice and Consent for the Release of Information.
4. Receipt of Things You Should Know (02/09). Please sign the receipt and submit it with
your housing application.
Note: This property has a “No Pet” policy.
Faxed applications will not be accepted.
Please feel free to call us at 603-224-9221 or TDD 1-800-545-1833 Extension 118 if you
have any questions. Our office hours are Monday through Friday, 8:00 AM to 4:30 PM.
If you’d like an appointment, please call to set up a convenient time. You may also
e-mail your request to housing@hodgescompanies.com
Sincerely,
The Hodges Companies
_________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
2
TENANT SELECTION PLAN FOR ASSISTED HOUSING
The Hodges Companies may reject an applicant, if at any time during the selection
process, any negative information is received from any source that would indicate that the
applicant would interfere with the other residents (such as disturbances, police reports,
criminal record, etc), diminish their right to quiet enjoyment of the premises, affect their
health or safety, welfare, comfort, or financial stability of the property.
The Hodges Companies will follow the Waiting List Procedures required by Rural
Development (RD).
Preference will be given to an applicant’s whose income is Very Low according the
published Income Limits.
Family or household size must meet and/or not exceed the following criteria:
Minimum 1 person per bedroom, or not more than 2 people per bedroom.
For example:
1 Bedroom Minimum 1 person Maximum 2 people
2 Bedroom Minimum 2 people Maximum 4 people
The Hodges Companies must prohibit admission of an applicant if any member has been
evicted from any federally assisted housing for drug-related criminal activity, if it is
determined that any household member is currently engaging in illegal use of a drug, or if
it is determined that we have reasonable cause to believe that a households member’s
illegal use or a pattern of illegal use of a drug may interfere with the heath, safety, or
right to peaceful enjoyment of the premises by other residents.
The Hodges Companies must prohibit admission of an applicant if they are subject to a
lifetime registration requirement under a State Sex Offender Registration Program.
All Rental Applications are considered without regard to race, color, religion, sex,
national origin, marital status, mental or physical handicap, and/or age.
_________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
3
ALL RENTAL APPLICATIONS ARE PROCESSED AND REVIEWED ACCORDING TO
THE FOLLOWING CRITERIA:
1). An applicant’s past and present performance in meeting financial obligations.
The following will be considered as examples of unfavorable credit references
and will serve as the basis for rejection of an application:
a). Any outstanding account or past due with a utility company or another
landlord or management company, within three years from the date of
application; excluding medical accounts (02/09).
2). All persons listed on the application 18 years and older are required to complete
a state Criminal Record Release form. The following will the basis for rejection:
a). Any misdemeanor within 3 years from the date of application; excluding
driving offenses
b). Any felony record on the applicant’s criminal record
c). Any drug-related criminal activity
d). Any sexual offense criminal activity
e). Any hate crime or violent criminal activity
f). Other criminal activity that would threaten the health, safety, security,
or right to peaceful enjoyment of the premises by other residents or of
the Owner’s or any employee, contractor, subcontractor or agent of the
Owner who is involved with the property.
3). An applicant’s ability to comply with the terms of the Lease or Rental
Agreement from past or current landlords. An applicant will be required to
provide a minimum of three years rental history (Note: Landlords who are
related will not meet the definition of a past or current landlord). If an applicant
cannot meet the minimum requirement, at least one of the following criteria
must be met in order to determine eligibility:
a). The applicant owned his/her own home within the last five years,
b). The landlord is no longer in business and is not able to be found
(documentation will be required)
c). The applicant must demonstrate good payment history (receipts) and
a letter of recommendation from the landlord will be required.
d). The applicant will be required to have a Co-signer on the lease. Rental
payments must be made directly by the applicant themselves. If the
applicant demonstrates a good payment history in the first year, they may
have the Co-signer removed. The Co-signer must meet the credit criteria
outlined in the Tenant Selection Plan.
_________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
4
An application will be rejected based on the following criteria:
a). A history of non-payment or late payment of rent,
b). A history of living or housekeeping habits that would pose a threat
to the health and safety of the other residents,
c). A history of disturbances or right to peaceful enjoyment,
d). A history of violations or non-compliance that resulted in an eviction or
termination from housing or rental programs. Management will reject
an application for three (3) years from the date of eviction or termination.
e). Refusal of the landlord to provide a written landlord reference. Several
attempts will be made to obtain this information and a phone reference
will be attempted before rejection.
f). Failure to respond to a written correspondence within the specified time
frame in the correspondence (02/09).
Information provided on the application must be true and accurate. Any false,
misleading, or incomplete information will result in rejection.
If an applicant is rejected, they must wait six (6) months from the time of rejection
to reapply for housing with The Hodges Companies.
The Fair Housing Act prohibits discrimination in the sale, rental, or financing of housing on the
basis of race, color, religion, sex, handicap, familial status, or national origin.
Federal law prohibits discrimination on the basis of age.
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
HODGES USE ONLY: DATE SENT:
DATE RECEIVED: ________________ TIME RECEIVED: _____________ INITIALS:___________ ID #:___________
APPLICATION FOR ASSISTED HOUSING (USDA, Rural Development)
• 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.
• 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 Hodges Development to avoid disturbing their neighbors, etc., but there is no requirement that they be able to do these
things without assistance.
• Hodges Development is a management company that provides low rent housing to eligible households, elderly households and single people.
Hodges Development is not permitted to discriminate against applicants on the basis of their race, color, religion, sex, national origin, sexual
orientation, age, maritial status, disability handicap or familial status. In addition, Hodges Development has a legal obligation to provide
"reasonable accommodations" to applicants if they, or any household member, have a disability or handicap.
• A reasonable accommodation is some modification or change Hodges Development can make to its apartments or procedures that will assist
an otherwise eligible applicant with a disability to take advantage of government programs.
• 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.
• The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national
origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all
programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape,
etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).
• To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue,
SW, Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
A. FAMILY SUMMARY -List all persons, including yourself, who will be living in the apartment. List head of household first.
Name
Relationship
Gender
Soc Sec #
Birth Date
Place of Birth
1
Head
2
3
4
5
6
Telehone No. _________________ E-Mail Address ___________________________________________ REV 07/14
Mailing Address:
__________________________
City:
_________________
State:
_____
Zip:
___________
Physical Address:
__________________________
City:
_________________
State:
_____
Zip:
___________
(if different than mailing address)
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
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
If you require any modifications to an apartment, check here and explain in a note to us
B. INCOME - All sources of regularly received monies must be listed regardless of recipient's age.
Family Member Name
Sources of Income
Gross Amount
Social Security Gross Monthly Amount
$
Social Security Gross Monthly Amount
$
Pension Gross Monthly Amount
$
Source:
Address:
Pension Gross Monthly Amount
$
Source:
Address:
Regular Pay from Military or Armed Forces
$
Source Address:
VA Benefits (Claim # )
$
SSI/SSD/SSA Benefits Gross Monthly Amount
$
Unemployment Compensation Gross Monthly Amount
$
Disability/Worker’s Comp Benefits Gross Monthly Amount
$
TANF. OAA, APTD 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, Business
income, rental income, annuities, resident services stipend over
$200/mo, severance pay, etc.)
$
Self-Employment Income
$
Education scholarships, grants
$
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
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 _______
Provide the following information for all members of the household (use another sheet of paper if necessary).
Checking/Savings Accounts/Debit Card
Bank
Bank
Address
Address
Account No.
Account No.
Int. Rate Balance $
Int. Rate Balance $
Life Insurance (Whole or Universal Life)
Name
Name
Address
Address
Policy No.
Policy No.
Cash Value $
Cash Value $
Certificates of Deposit, Money Market
Bank
Bank
Address
Address
Acct.# Int Rate Amt. $
Acct.# Int Rate Amt. $
Penalty for Early Withdrawal Maturity Date
Penalty for Early Withdrawal Maturity Date
Stocks IRA's, 40l-K, Annuities
Name
Bank
Address
Address
Value $ Div. Rate
Value $ Div. Rate
Savings Bonds, T-Bills Trust Accounts
Bank
Bank
Address
Address
Present Value $
Account No.
Maturity Date
Int. Rate Balance $
REV 07/14
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
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
Name
Name
Address
Address
Claim No. Monthly Amt. $
Claim No. Monthly Amt. $
Pharmacy
Name
Name
Address
Address
Anticipated 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______
Name
Name
Address
Address
Anticipated 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
Name
Name
Address
Address
Anticipated costs not covered by insurance -
Balance Due $ Monthly Amount $
Anticipated costs not covered by insurance -
Balance Due $ Monthly Amount $
REV 07/14
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
Child Care Expenses - Complete for children 12 and younger - Weekly cost for Child Care $_____________
Name & Address of Person/Agency caring for children: ______________________________________________________
____________________________________________________________________________________________________________
E. PROGRAM INFORMATION
Are you currently living in subsidized housing? Yes_____ No_____ Subsidy Type? HUD USDA SEC 8
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. Have you been served a Notice to Quit or been asked to leave by a previous landlord Yes_____ No_____
2. Have you been served with lease violations from a previous landlord Yes_____ No_____
3. Have you been evicted Yes_____ No_____ Name of Landlord and date
___________________________________________________________________________________________________
4. Have you or any household member have been evicted from federally assisted housing for drug-related
criminal activity? Yes_____ No_____ Name of Landlord and Date
____________________________________________________________________________________________________
5. Have 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? Yes_____ No_____
List all states in which all adult members have ever lived in during their lifetime?
___________________________________________________________________
6. Have you or a household member been convicted of a misdemeanor or felony? Yes_____ No_____
List the type, nature and date of criminal action. ______________________________________________________
7. Will all of the persons in the household be or have been full-time students during five calendar months of this
year or plan to be in the next calendar year at an education institution (other than correspondence school) with
regular faculty and students? Yes_____ No_____
If YES, please answer the following questions:
a) Are any full-time students married and filing a join tax return? Yes_____ No_____
b) Are any students enrolled in job-training program receiving instance under the Job Training partnership
Act? Yes_____ No_____
c) Are any full-time students a TANF or Title IV recipient? Yes_____ No_____
d) Are any full-time students a single parent living with his/her minor child who is not a dependent or
another’s tax return? Yes_____ No_____
REV 07/14
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
G. REFERENCE INFORMATION-Please list at least 3 years (If you don’t have three years, you may provide a
letter of recommendation from your current LL or request a Co-signer application from us.
Current Landlord (Name, Address,& Phone No.)
___________________________________________________________________________________________________________
How long have you lived there? __________________ Is this landlord related to you? Yes____ No____
Are you required to give a 30-day notice? Yes____ No____ What is the current amount of your rent?________
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)
(Example: 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 Hodges Development during the application process regarding the applicant
or applicant's household will be taken into consideration as part of the application.
Other Information
Please provide us with the name, address, & phone number of an emergency contact and relationship to you:
____________________________________________________________________________________________________________
Vehicles - List any vehicle owned
Type _______________________________________ Year/Make_________________________________________
Color _______________________________________ License Plate No. __________________________________
Do you own a pet? Yes_____ No_____ If yes, describe __________________________________________________
REV 07/14
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
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 Hodges Development’s resident selection criteria. 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
(
)
__________________________________________ Date
(
)
____________________________
Spouse/Co-Head
(
)
____________________________________________ Date
(
)
___________________________
For The Hodges Companies _________________________________ Date ______________________________
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/HUD, 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.
You are not required to furnish this information, but are encourage to do so. This information will not be used in
evaluating your application or to discriminate against you in any way.
Ethnicity: ( ) Hispanic or Latino ( ) Not Hispanic or Latino
Race: ( ) American Indian or Alaskan Native ( ) Black ( ) Hispanic
( ) Asian or Pacific Islander ( ) White ( ) Other
Gender: ( ) Male ( ) Female
REV 07/14
________________________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
TENANT RELEASE AND CONSENT
I/We________________________________the undersigned hereby authorize all persons or companies in the
categories listed below to release information regarding employment, income and/or assets for purposes
of verifying information on my/our apartment rental application. I/We authorized release of information
without liability to the owner/manager of the apartment community listed below, and/or the state
housing development agency or it’s service provider.
INFORMATION COVERED
I/We understand that the previous or current information regarding we/us may be needed. Verifications
and inquires that may be requested include but are not limited to: personal identity, student status,
employment income, assets, and medical or child care allowances. I/We understand that this
authorization cannot be used to obtain information about me/us that is not pertinent to my eligibility for
and continued participation as a Qualified Tenant.
GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information include, but are not limited
to:
Past and Present Employers Criminal Checks Veterans Administration
Support and Alimony Providers State Unemployment Agencies Retirement Systems
Educational Institutions Social Security Administration Medical Providers
Banks/Financial Institutions Curent and Previous Landlords Child Care Providers
Public Housing Agencies State and Federal Agencies Credit Agencies
CONDITIONS
I/We agree that a photocopy of the authorization may be used for the purposes stated above. The original
of this authorization is on file and will stay in effect for 15 months from the date signed. I/We
understand that I/We have a right to review this file and correct any information that is incorrect.
SIGNATURES
(
)
________
(
)
(
)
Head of Household (Print Name) Date
(
)
(
)
(
)
Co-Head/Spouse (Print Name) Date
(
)
(
)
(
)
Other Adult (Print Name) Date
REV 07/14
_________________________________________________________________
Celebrating Over 50 years of Integrity, Quality & Service
_________________________________________________________________________
201 Loudon Road Concord, New Hampshire 03301-6000 (603) 224-9221
Fax (603) 228-1387 l TDD (800) 545-1833 X118Equal Opportunity Provider and Employer
RECEIPT OF “THINGS YOU SHOULD KNOW
I/We ____________________________________________, acknowledge
Receipt of a copy of the USDA published “Things You Should Know” Notice
on this ______ day of ________________, 20____.
_____________________________ ________________ ______
Signature Property Unit #
_____________________________
Signature
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