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RENTAL A P P L I C A

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RENTAL A P P L I C A T I O N
EDEN S UPPO R T IVE L I VING
How did you hear about us? ________________________________________________________________________
CONTACT INFORMATION
Home Other
Name: __________________________________ Phone: __________________ Phone: ____________________
Address: ___________________________________________________________ Apartment #: ____________
City: ___________________________ State: _________ Zip: ___________
Date of Birth: ____ /_____/_______ Age: _______ Social Security #: ______-_____-________
Email Address: __________________________________________ OK to call? Yes: ______ No: ______
Emergency Contact Name: ____________________________________________ Phone: ___________________
GENERAL INFORMATION
1. Please indicate sources of income and medical reimbursement (if any):
Employer: _________________________________ Phone: _______________________
Position: __________________________________ Contact: ______________________
Monthly Salary: $______________
Other Financial Source(s) (i.e., Dividends, Pension, Social Security, LINK, Teacher Retirement, etc.)
Monthly Amount
$________________
$________________
$________________
$________________
$________________
Source(s)
A.______________________________
B.______________________________
C.______________________________
D.______________________________
E.______________________________
Long-Term Care Insurance: (select one)
Medicaid: (select one) Yes
No
Yes No
Medicare: (select
one) Yes No
3.
Marital Status: Single: ____ Married: ____
4.
Have you ever been evicted from an apartment? Yes: _____ No: ______
If Yes, explain: ____________________________________________________________________________
5.
Where do you currently live? (Circle one)
a. Nursing home: ___________________________________________
b. Apartment
c. Private Home:
d. Other
940 West Gordon Terrace
Chicago, IL 60613
www.LivingInEden.com
Phone: (773) 472 -1020
Fax: (312) 463 -4484
6. Provide rental history for the past 5 years:
Address # of Years Rent Amount
A. ________________________________________________
B. ________________________________________________
C. ________________________________________________
D . ________________________________________________
E. ________________________________________________
_____________ $___________
_____________ $___________
_____________ $___________
_____________ $___________
_____________ $___________
7. Do you have any wounds or a history of wounds? If so, please explain:
_________________________________________________________________________________________
8. Do you need assistance with incontinence care/maintenance? If so, please explain:
9. Are you able to self-medicate or do you need assistance with administering medications? If so, please explain:
NON-DISCRIMINATION POLICY
Eden does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin
(ancestry), disability, VESSA, marital status, familial status, sexual orientation, military discharge, or military status, in any of its
activities or operations. These activities include, but are not limited to, selection of Residents, hiring and firing of staff, volunteers
and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all Residents
and members of our community, staff, clients, volunteers, subcontractors, vendors, and clients.
REASONABLE ACCOMODATION
Under state and federal laws, individuals with disabilities may request reasonable accommodations from housing providers and we
must consider the request. Reasonable accommodations in rules, policies, practices, and services must be allowed to give persons
with disabilities an equal opportunity to use and enjoy housing, provided such accommodation does not impose an undue hardship or
requests a change in the fundamental nature of our business. Residents with disabilities must be allowed to make reasonable modifi-
cations to their apartments and common areas subject to appropriate construction and restoration considerations. Any resident or appli-
cant seeking a reasonable accommodation should complete a Confirmation Of Request For Reasonable Accommodation form and return it to the
Executive Director.
This application is not a rental agreement, contract or lease. All applications are subject to the approval of the owner or managing agent. I
(we) certify under penalty of perjury that the information and statements provided above are true and complete to the best of my (our)
knowledge. I (we) consent to release this information. I (we) understand that providing false information may be grounds for denial of my
(our) application and may subject me (us) to criminal penalties. I (we) give consent and authorization to have management verify the infor-
mation contained in this application for the purpose of approving my (our) eligibility for occupancy. I (we) will provide all necessary infor-
mation to expedite this process. I (we) understand that my (our) occupancy is contingent on meeting resident selection criteria and the Low
Income Housing Tax Credit Program guidelines (Eden Champaign only). I (we) understand and agree that inquiries may include in for-
mation related to credit, employment, rental and criminal records. I (we) further agree that verification of all information and references
regarding sources of income and assets may be conducted and I (we) release all parties for any liability for disclosing factual information
obtained by management. I (we) understand and agree that a photocopy or fax of this authorization can be used in lieu of an original. The
$125.00 application fee is not refundable if Lessor declines the applicant. Moreover, if the Applicant choose not to rent the premises, then
all application fees and any and all security deposits or monies used to hold the apartment shall be retained by leaser as liquidated damages.
______________________________________
(Applicant Signature)
940 West Gordon Terrace
Chicago, IL 60613
www.LivingInEden.com
Phone: (773) 472 -1020
Fax: (312) 463 -4484
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RENTAL A P P L I C A

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Completed 15 January 2022

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