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IMPORTANT NOTICE TO APPLICANT
READ THIS NOTICE BEFORE STARTING TO FILL OUT THIS APPLICATION
PLEASE ANSWER ALL QUESTIONS COMPLETELY!!!!!!
INCOMPLETE APPLICATIONS WILL BE RETURNED!!!!!!!
Failure to answer all questions will delay the processing of your application.
The application must be returned in person.
In order to be considered for tenancy with The Fucci Company, you must possess good credit, have good
rental history, and have no criminal record. If no rental history, you must provide us with 2 Credible
Character References.*
ALL LANDLORD REFERENCES AND CHARACTER REFERENCES MUST BE COMPLETED WITH
EXACT PHONE NUMBERS AND ADDRESSES IN ORDER FOR THIS OFFICE TO CONTACT THEM.
TYPE OR PRINT YOUR ANSWERS CLEARLY.
If this application has be returned to you for failure to complete it properly, it will cause an unnecessary delay in
processing.
MAKE SURE YOU SIGN YOUR NAME WHEREVER REQUIRED!!!!!
A Criminal Record Release Form will need to be signed at our office when application is returned.
WE WILL NEED A COPY OF YOUR SOCIAL SECURITY CARD ALONG WITH AN ADDITIONAL
FORM OF IDENTIFICATION (PREFERABLE A PICTURE ID.
See other side for directions to our office
* See Attachment #1 for Credible Character References.
6 Regency Manor, Suite 1, Rutland, VT 05701 Tel. (802) 773-9107 Fax: (802) 773-0518
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Directions to Regency Manor Office
From the North of Rutland:
Go South on Route 7, turn left onto Allen Street (near McDonald’s), then right onto Mussey Street, then left onto Haywood
Avenue. We are the second left off from Haywood Avenue. There is a sign at the entrance to the Development: Regency Manor,
follow the office signs once in the development.
From the South of Rutland:
Go North on Route 7, turn right onto Curtis Avenue, then left onto Mussey Street, then right onto Haywood Avenue. We are
the second left off from Haywood Avenue. There is a sign at the entrance of the development: Regency Manor. Follow the office
signs once in the development.
From the East of Rutland:
Go West on Route 4, turn left onto Stratton Road (near McDonald’s), continue on Stratton Road until you come to the
hospital Y-intersection, at that light turn right onto Allen Street, left onto Mussey Street, left onto Haywood Avenue. We are the
second left off from Haywood Avenue. There is a sign at the entrance of the development: Regency Manor, follow the office signs
once in the development.
From the West of Rutland (Route 4 Business District):
Go East on Route 4, then South on Route 7, continue on Route 7 until the intersection near McDonald’s, that that left onto
Allen Street, then right onto Mussey Street, left onto Haywood Avenue. We are the second left off from Haywood Avenue. There is a
sign at the entrance of the development: Regency Manor. Follow the office signs once in the development.
From the West of Rutland (Route 4 Bypass Near Diamond Run Mall):
Go East on Route 4, then North on Route 7, continue on Route 7 until you come to the 3
rd
traffic light, turn right at that light
(Curtis Avenue), then left onto Mussey Street, then right onto Haywood Avenue. We are the second left off from Haywood Avenue.
There is a sign at the entrance of the development: Regency Manor. Follow the office signs once in the development.
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Attachment #1
CREDIBLE CHARACTER REFERENCE
IF YOU DO NOT HAVE LEGAL LANDLORDS, you must provide this office with (2) Credible
Character References. We consider a credible character reference, someone that can testify on
your behalf, your character attributes (other than family members). Some examples of an
acceptable credible reference would be an employer, a teacher, your pastor, and/or an
upstanding citizen of the community that has known you for at least 5 years.
This is required if you have not established rental history.
Please have them write a letter on your behalf, explaining your relationship with them, how
long they've known you, why they think you would be a good tenant, they must also provide us
with their complete address and daytime telephone number so that we may contact them if we
have further questions.
Without these references you will be denied due to incomplete information.
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U.S. Department of Housing and Urban Development
Office of Inspector General
November 2004
Things You
Should Know
Purpose This is to inform you that there is certain information you must provide when applying for
assisted
housing. There are penalties that apply if you knowingly omit information or give false
information.
The United States Department of Housing and Urban Development (HUD places a high priority
on preventing
fraud. If your application or recertification forms contain false or incomplete information, you
may be:
Evicted from your apartment or house;
Required to repay all overpaid rental assistance you received:
Fined up to $10,000;
Imprisoned for up to 5 years; and/or
Prohibited from receiving future assistance.
Your State and local governments may have other laws and penalties as well.
Asking When you meet with the person who is to fill out your application, you should know what is
Questions expected of you. If you do not understand something, ask for clarification. That person can
Answer your question or find out what the answer is.
Completing When you answer application questions, you must include the following information:
The
Application
Income All sources of money you or any member of your household receive (wages, welfare
payments, alimony, social security, pension, etc);
Any money you receive on behalf of your children (child support, social security for children,
etc.);
Income from assets (interest from a savings account, credit union, or certificate of deposit:
dividends from stock, etc.);
Earnings from second job or part-time job;
Any anticipated income (such as a bonus or pay raise you expect to receive)
Assets All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc.. that are
owned by you and any adult member of your family’s household who will be living with you.
Don’t risk your chances for Federally assisted housing by providing false, incomplete, or
inaccurate information on your application forms.
Penalties
for
Committing
Fraud
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Any business or asset you sold in the last 2 years for less than its full value, such as your
home to your children.
The names of all of the people (adults and children) who will actually be living with you,
whether or not they are related to you.
Signing the Do not sign any form unless you have read it, understand it, and are sure everything is
Application complete and accurate.
When you sign the application and certification forms, you are claiming that they are
complete to the best of your knowledge and belief. You are committing fraud if you sign a
form knowing that it contains false or misleading information.
Information you give on your application will be verified by your housing agency. In
addition, HUD may do computer matches of the income you report with various Federal,
State, or private agencies to verify that it is correct.
Recertifications You must provide updated information at least once a year. Some programs require that you
report any changes in income or family/household composition immediately. Be sure to ask
when you must recertify. You must report on recertification forms:
All income changes, such as increases of pay and/or benefits, change or loss of job and/or
benefits, etc., for all household members,
Any move in or out of a household member; and,
All assets that you or your household members own and any assets that was sold in the last 2
years for less than its full value.
Beware of You should be aware of the following fraud schemes:
Fraud
Do not pay any money to file an application;
Do not pay any money to move up on the waiting list;
Do not pay for anything not covered by your lease;
Get a receipt for any money you pay; and,
Get a written explanation if you are required to pay for anything other than rent (such as
maintenance charges).
Reporting If you are aware of anyone who has falsified an application, or if anyone tries to
Abuse persuade you to make false statements, report them to the manager of your complex or your PHA.
If that is not possible, then call the local HUD office or the HUD Office of Inspector General
(OIG) Hotline at (800) 347-3735. You can also write to:
HUD-OIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington, DC 20410.
HUD-1140-OIG THIS DOCUMENT MAY BE REPRODUCED WITHOUT PERMISSION
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OMB Control # 2502-0581
Exp. (11/30/2015)
Optional and Supplemental 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.
Check this box if you choose not to provide the contact information.
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)
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.
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)
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PLEASE PRINT ALL INFORMATION CLEARLY
DATE: ______________ PROJECT APPLYING FOR: _____________________________ BEDROOM SIZE: _________
ANY SPECIAL ACCOMODATIONS NEEDED?: ___________________________________________________________
HOW SOON DO YOU NEED AN APARTMENT ?: _________________________________________________________
GENERAL INFORMATION:
NAME: _______________________________________________ HOME PHONE: _____________________
ADDRESS: _______________________________________________ WORK PHONE: _____________________
_______________________________________________ MESSAGE PHONE: __________________
PLEASE LIST BELOW EACH AND EVERY INDIVIDUAL TO BE INCLUDED IN YOUR HOUSEHOLD INCLUDING
YOURSELF.
HOUSEHOLD MEMBER
RELATIONSHIP TO
HEAD OF HOUSE
DATE OF
BIRTH
SOCIAL
SECURITY #
PLACE OF BIRTH
PLEASE PROVIDE OUR OFFICE WITH A PHOTOCOPY OF ALL HOUSEHOLD MEMBERS’ SOCIAL
SECURITY CARDS PER GOVERNMENT REGULATIONS.
HOUSING STATUS:
NUMBER OF BEDROOMS IN PRESENT UNIT: _________ PRESENT RENT: $____________/MONTH
IF RENT DOES NOT INCLUDE UTILITIES, PLEASE INDICATE WHAT UTILITIES COST YOU PER MONTH:
$_________________
ARE YOU CURRENTLY LIVING IN SUBSIDIZED HOUSING? ___________________________
DO YOU HAVE A RENTAL ASSISTANCE VOUCHER? _________________________________
ARE YOU BEING DISPLACED? _____________ IF SO, WHY? ___________________________________________
IS YOUR CURRENT UNIT IN A SUBSTANDARD CONDITION? __________ IF SO, DESCRIBE:____________
____________________________________________________________________________________________________
HAVE YOU EVER FILED AN APPLICATION WITH THE FUCCI COMPANY? ____________________________
HAVE YOU EVER BEEN A TENANT OF THE FUCCI COMPANY BEFORE? ____________________________
HAVE YOU EVER BEEN EVICTED? ________________ IF SO, EXPLAIN: ____________________________
ARE YOU HANDICAPPED OR DISABLED? __________
HOW LONG HAVE YOU LIVED AT YOUR CURRENT ADDRESS? _________________________________________
WHY DO YOU WISH TO MOVE? ______________________________________________________________________
ARE YOU APPLYING FOR STATUS AS AN ELDERLY HOUSEHOLD, WHERE THE TENANT OR CO-TENANT IS
62+ YEARS OLD OR HANDICAPPED OR DISABLED, AS DEFINED BY HUD AND RURAL DEVELOPMENT, AND
IF SO, ARE YOU AWARE YOU WILL RECEIVE A $400.00 ELDERLY HOUSEHOLD AND MEDICAL DEDUCTION?
IF SO, PLEASE INDICATE ____________________. PLEASE BE AWARE THAT ELIGIBILITY MUST BE VERIFIED.
DO YOU REQUEST A HANDICAP (BARRIER FREE) UNIT? _______________________________________________
DO YOU REQUEST ANY MODIFICATIONS OF AN APARTMENT? _________________________________________
HAVE YOU OR ANYONE IN YOUR HOUSEHOLD EVER BEEN CONVICTED OF A CRIME? ____YES ____ NO
IF YES, PLEASE EXPLAIN: ____________________________________________________________________________
(To be verified through Criminal Background check)
HAVE YOU OR ANYONE IN YOUR HOUSEHOLD EVER BEEN SUBJECT TO A LIFETIME STATE SEX OFFENDER
REGISTRATION PROGRAM IN ANY STATE? _____ YES _____ NO
IF YES, PLEASE EXPLAIN: ____________________________________________________________________________
6 Regency Manor, Suite 1, Rutland, VT 05701 Tel. (802) 773-9107 Fax: (802) 773-0518
EMAIL ADDRESS:
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ARE YOU LEGALLY CAPABLE OF ENTERING INTO A LEASE AGREEMENT? _____ YES _____ NO
OTHER INFORMATION:
VEHICLES: LIST ALL VEHICLES IN HOUSEHOLD. MAKE: ______________ MODEL: ______ PLATE #________
MAKE: ______________ MODEL: ______ PLATE #________
DO YOU OWN A PET? ______YES ______ NO IF YES, DESCRIBE ________________________________________
ARE YOU A FULL-TIME STUDENT? __________________
APPLICANT EMPLOYMENT INFORMATION: Applicant name:
CURRENT EMPLOYER: _______________________________________________________________________________
EMPLOYER ADDRESS: _______________________________________________________________________________
PHONE: _________________________ FAX: _____________________ EMAIL: ____________________________
POSITION: ________________ HOURLY SALARY MONTHLY GROSS INCOME: ________________________
(PLEASE CIRCLE)
DATES EMPLOYED: _______________ TO ______________.
PREVIOUS EMPLOYER: ______________________________________________________________________________
EMPLOYER ADDRESS: _______________________________________________________________________________
PHONE: _________________________ FAX: _____________________ EMAIL: ____________________________
POSITION: ________________ HOURLY SALARY MONTHLY GROSS INCOME: ________________________
(PLEASE CIRCLE)
DATES EMPLOYED: _______________ TO ______________.
CO-APPLICANT EMPLOYMENT INFORMATION: Applicant name:
CURRENT EMPLOYER: _______________________________________________________________________________
EMPLOYER ADDRESS: _______________________________________________________________________________
PHONE: _________________________ FAX: _____________________ EMAIL: ____________________________
POSITION: ________________ HOURLY SALARY MONTHLY GROSS INCOME: ________________________
(PLEASE CIRCLE)
DATES EMPLOYED: _______________ TO ______________.
PREVIOUS EMPLOYER: ______________________________________________________________________________
EMPLOYER ADDRESS: _______________________________________________________________________________
PHONE: _________________________ FAX: _____________________ EMAIL: ____________________________
POSITION: ________________ HOURLY SALARY MONTHLY GROSS INCOME: ________________________
(PLEASE CIRCLE)
DATES EMPLOYED: _______________ TO ______________.
OTHER INCOME AND ASSET INFORMATION:
PLEASE LIST BELOW ALL HOUSEHOLD INCOME FROM OTHER SOURCES. THIS INCLUDES, BUT IS NOT
LIMITED TO, FULL AND/OR PART-TIME EMPLOYMENT, ANFC, SOCIAL SECURITY, SSI, SSD, PENSIONS,
UNEMPLOYMENT COMPENSATION, CHILD CARE, ALIMONY AND CHILD SUPPORT, ANY INTEREST ON
ASSETS, DIVIDENDS, ANNUITIES, AND ANY REGULAR CONTRIBUTIONS FROM PEOPLE NOT RESIDING
WITH YOU.
HOUSEHOLD
MEMBER
NAME & ADDRESS OF
INCOME SOURCE
TYPE OF INCOME
(I.E. PENSION)
MONTHLY GROSS
AMOUNT
DO YOU ANTICIPATE ANY CHANGES IN THIS INCOME IN THE NEXT 12 MONTHS? ________________________
IF SO, EXPLAIN _____________________________________________________________________________________
The Fucci Company does not discriminate on the basis of race, color, religion, marital status, age or handicap/disability.
The Fucci Company will make every reasonable accommodation for persons with handicaps/disabilities.
To remain current on our waiting list you must write or telephone the Fucci Company every six (6) months to confirm
your interest in housing and to update any pertinent information.
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ASSETS:
CHECKING ACCT _____________ BANK: _______________________ BALANCE: $___________ RATE ______%
_____________ _______________________ $___________ ______%
SAVINGS ACCT _____________ _______________________ $___________ ______%
_____________ _______________________ $___________ ______%
CERTIFICATE _____________ _______________________ $___________ ______%
_____________ _______________________ $___________ ______%
DO YOU OWN ANY STOCKS OR BONDS? __________ IF SO, PLEASE DETAIL: ___________________________
DO YOU OWN ANY REAL ESTATE? __________ IF SO, PLEASE DETAIL: ___________________________
HAVE YOU SOLD; DISPOSED OF; OR OTHERWISE GIVEN AWAY ANY ASSETS OR REAL ESTATE IN THE
LAST 2 YEARS (EXAMPLES: GIVEN MONEY OR REAL ESTATE TO RELATIVES, SET UP IRREVOCABLE
TRUST ACCOUNTS) _____________ IF SO, PLEASE EXPLAIN: ______________________________________
MEDICAL, CHILD CARE, AND HANDICAP ASSISTANCE EXPENSES:
MEDICAL COSTS: Complete only if head or spouse is 62 or older, handicapped or disabled.
MEDICARE MONTHLY AMOUNT: $__________________
MEDICAL INSURANCE MONTHLY AMOUNT: $__________________
ANTICIPATED PRESCRIPTION COSTS, NOT COVERED BY INSURANCE MONTHLY $__________________
ANY OTHER MEDICAL EXPENSES NOT COVERED BY INSURANCE: LIST TYPE AND AMOUNTS:
___________________________________________________________________________ $__________________
HANDICAP ASSISTANCE EXPENSE: (COMPLETE ONLY IF A MEMBER OF THE HOUSEHOLD IS ABLE TO
WORK AS A RESULT OF THE ASSISTANCE PROVIDED)
TYPE OF EXPENSE: __________________ WEEKLY AMOUNT $____________ PAID TO: ___________________
CHILD CARE EXPENSES: (COMPLETE FOR CHILDREN 12 AND YOUNGER)
WEEKLY COST: $____________________ PAID TO:______________________________________________________
REFERENCE INFORMATION:
CREDIT REFERENCES: ______________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
TELEPHONE # ________________________ TELEPHONE #_________________________
PERSONAL REFERENCES: ___________________________________ ______________________________________
______________________________________ ______________________________________
______________________________________ ______________________________________
TELEPHONE #_________________________ TELEPHONE #_________________________
LEGAL LANDLORD REFERENCES FOR THE PAST TEN YEARS
The Fucci Company is authorized to obtain credit reports to establish my credit worthiness, or for any other purpose.
I hereby certify that I do not and will not maintain a separate, subsidized rental unit in another location. I understand I must
pay a security deposit for this apartment prior to occupancy. I certify that the housing I will occupy will be my permanent
residence.
I understand that eligibility for housing will be based on the Department of HUD’s eligibility criteria; Rural Development’s
eligibility criteria and/or The Fucci Company’s resident selection criteria. I understand that this application in no way ensures
occupancy and that my application can be rejected based on, but not limited to, poor credit or personal references, police
records indicating unacceptable or criminal behavior, or poor personal interview. I understand that the site will deny my
household’s application if any adult household member has been convicted of a felony crime.
I certify that the information given in this application is true to the best of my knowledge. I understand that any false
information is punishable by law, and could be grounds for cancellation of this application or termination of residency after
occupancy.
Release of information authorization:
I do hereby authorize The Fucci Company and its staff to attain any information or materials deemed necessary to determine
my eligibility for housing, including contacting agencies, offices, groups or organizations, which may provide information that
could substantiate or verify information given in this application; for example, local police department, welfare agency, or
senior service agency. By signing this form, I consent to the release of my credit report and criminal record to the site, and I
agree that I will not file any claim or lawsuit relating to the site’s use of my criminal record for screening purposes.
Signature of Applicant ________________________________________ Date ______________________________
Signature of Co-Applicant _____________________________________ Date ______________________________
The following information is required for statistical purposes so the Dept. of HUD and Rural Development may determine the
degree to which its programs are utilized by minority families.
Ethnicity: Hispanic or Latino ____ Not Hispanic or Latino ____ Gender: Male ____ Female ____
Race: (Mark one or more)
White ____ Black or African American ____ American Indian/Alaskan Native ____ Native Hawaiian or Other Pacific
Islander ____ Asian ____ Other ____
“The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the
Federal Government, acting through HUD/Rural Development that Federal Laws prohibiting discrimination against tenant
applicants on the basis of race, color, national origin, religion, sex, familial status, age, and disability 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, if you choose not to furnish it, the owner is required to note
the race/ethnicity and sex of an individual applicant on the basis of visual observation or surname.”
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DO NOT LIST FAMILY MEMBERS OR FRIENDS AS LEGAL LANDLORDS. (If evicted, a copy
of the eviction is required.) Must include 10 years of housing history.
Legal Landlord: ______________________________________________________ Tel #: __________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
Address of your apartment: _____________________________________________________________
Reason for leaving: __________________________________________________________________
In residence from ____________________ to _____________________
DATE DATE
Name on Lease: ______________________________________________________________________
Legal Landlord: ______________________________________________________ Tel #: __________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
Address of your apartment: _____________________________________________________________
Reason for leaving: __________________________________________________________________
In residence from ____________________ to _____________________
DATE DATE
Name on Lease: ______________________________________________________________________
Legal Landlord: ______________________________________________________ Tel #: __________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
Address of your apartment: _____________________________________________________________
Reason for leaving: __________________________________________________________________
In residence from ____________________ to _____________________
DATE DATE
Name on Lease: ______________________________________________________________________
Legal Landlord: ______________________________________________________ Tel #: __________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
Address of your apartment: _____________________________________________________________
Reason for leaving: __________________________________________________________________
In residence from ____________________ to _____________________
DATE DATE
Name on Lease: ______________________________________________________________________
Parent/Family Member: ___________________________________________ Tel #:___________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
Parent/Family Member: ________________________________________________ Tel #: __________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
Parent/Family Member: ________________________________________________ Tel #: __________
Street: ___________________________________ City: ___________________ State: ____ Zip: _____
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ABSENT PARENT INFORMATION
Absent Parent Information (re: all children that will be living with/visiting you)
Child’s
Name
Absent
Parent’s
Name
Street Address
City
State
Last Contact
Date
Comments
Visitation How
often?
*IF DIVORCED: ATTACH COPY OF COURT DOCUMENTS REGARDING CUSTODY OF
MINOR CHILDREN
If separated or divorced, list name and address of spouse/ex-spouse as follows or last known legal
residence:
________________________________________ __________________________________________
Name Name
________________________________________ __________________________________________
Street Address Street Address
________________________________________ __________________________________________
City, State, Zip City, State, Zip
________________________________________ __________________________________________
Social Security # (if known) Social Security # (if known)
DO YOU EXPECT ANYONE TO MOVE IN OR OUT OF YOUR HOUSEHOLD WITHIN THE
NEXT 12 MONTHS _______YES ________ NO
IF YES, NAME: __________________________
RELATIONSHIP: _________________________
IS THERE ANYONE LIVING WITH YOU NOW THAT IS NOT LISTED ABOVE?
_____ YES _____ NO
IF YES, NAME: __________________________________________
RELATIONSHIP: __________________________
EQUAL HOUSING OPPORTUNITY
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