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SUBSIDIZED RENTAL APPLICATION QUAD Inc. is an Equal

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QUAD Inc. Housing Application Page 1 of 4
Revised 04232020
Quadriplegics United Against Dependency, Inc. (QUAD Inc.)
Management use only: Date received ____________ Time ______________ Initial ______________
QUAD Inc. offers barrier free, HUD subsidized housing designed for individuals with severe mobility impairments
that are reliant on a wheel chair for mobility. The information contained in this application will be kept confidential
and will only be used to determine eligibility for HUD Section 202 or 811 subsidized housing. If you have
questions; require assistance in completing this application; would like a tour or have questions, please contact us
at: (503) 287-4260, Fax: (503) 281-8176, Email: info@quadinc.org or visit our web page at www.quadinc.org
FAIR HOUSING POLICY- It is the policy of Quadriplegics United Against Dependency, Inc. (QUAD, Inc.) not to
discriminate in the housing it sponsors, operates and manages on the basis of race, color, religion, sex,
handicap, disability, familial status, sexual orientation or national origin; and to administer its programs and
activities relating to housing in such a manner as to affirmatively further fair housing.
REASONABLE ACCOMMODATION/ALTERNATE FORMAT- QUAD Inc. is committed to providing reasonable
accommodation to individuals with disabilities in the all aspects of its Housing operations. If you need
accommodation due to disability or for alternate format application and publications please contact us at
503.287.4260 via Oregon Telecommunications Relay Services, Dial 777 in Oregon.
SOCIAL SECURITY DISCLOSURE/IDENTITY VERIFICATION -The applicant must disclose a valid Social
Security Number for all household members. Applicants who do not provide a valid Social Security Number/Card
for all household members will have their application suspended for up to 90 days while they obtain the necessary
Social Security Number documentation. During this 90-day period the applicant will remain on the waiting list but
we will process the next eligible household on the waiting list. Should the applicant fail to provide the required
Social Security Number documentation within 90 days of the request they will be deemed ineligible and their
application will be rejected. Exception: Applicants that were 62 years of age or older as of 01/31/2010 and who’s
initial eligibility for Section 8 assistance was established prior to 01/31/2010 are exempt from the Social Security
Number verification. Applicants who choose not to contend US Citizenship or eligible immigration status are
exempt from Social Security Number requirements. All adult household members must provide a current original
photo ID.
VICTIMS OF DOMESTIC VIOLENCE- An applicant’s or a tenant’s status as a victim of domestic violence, dating
violence, or stalking is not a basis for denial of rental assistance or for denial of admission, if the applicant
otherwise qualifies for assistance or admission.
NO SMOKING- Smoking is prohibited in all QUAD Inc. managed buildings including individual apartments,
common areas and outside spaces that are on the projects premises.
WAITLIST- Applications are added to our waiting list in date order. We will contact you when your application is
next in line for an available unit. Applicant’s cannot be approved for occupancy until all information they provide is
verified by a third party. To keep your application current on the waiting list you must tell us if your contact
information changes. You must also check in at least every six months to inform us of your continued interest in
QUAD Inc. Housing.
Applications can be delivered to the Manager of any QUAD Inc. property, faxed to 503.281.8176, emailed
to info@quadinc.org or mailed to QUAD Inc. at 6645 NE 78
th
Court., STE C-7, Portland, OR. 97218
Facility Preference: Myers Court-N Portland Rolling Green-Hillsboro
Check all you are interested in Central Station- Gresham Burnside Station-East Portland
Bedrooms: Studio 1 Bedroom 2 Bedroom Number of Occupants ________
SUBSIDIZED RENTAL APPLICATION
QUAD Inc. is an Equal Housing Opportunity Provider
QUAD Inc. Housing Application Page 2 of 4
Revised 04232020
Applicant: Please complete this application, the attached tenant screening form and HUD 92006 Supplemental
Information. Print legibly in ink. All blanks must be filled in before the application will be considered complete and
can be processed for eligibility. If the requested information does not apply to you put N/A in the blank.
APPLICANT FULL NAME (LAST, FIRST, MI)
EMAIL ADDRESS
TELEPHONE NUMBER
DATE OF BIRTH
CURRENT ADDRESS
DRIVER'S LICENSE/ID NUMBER/STATE
CURRENT RESIDENCE
RENT OWN OTHER
DATES AT CURRENT ADDRESS:
FROM: _______________________________ TO: ________________________________
REASON FOR MOVING
CURRENT LANDLORD /MORTGAGE HOLDER NAME
ADDRESS (STREET, CITY, ZIP)
TELEPHONE NUMBER
PREVIOUS RESIDENCE
RENT OWN OTHER
PREVIOUS ADDRESS:
FROM: _____________ TO:____________
REASON FOR MOVING
PREVIOUS LANDLORD /MORTGAGE HOLDER NAME
ADDRESS (STREET, CITY, ZIP)
TELEPHONE NUMBER
Household members: List all persons who will live in your apartment and provide requested information below:
1.
APPLICANT
/
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY NUMBER BIRTH DATE
DRIVER
'
S LICENSE
/
ID
#
ARE YOU SUBJECT TO STATE LIFETIME SEX OFFENDER
REGISTRATION IN ANY STATE
?
YES NO
LIST ALL STATES YOU HAVE RESIDED IN
ARE YOU PHYSICALLY DISABLED
YES NO
ARE YOU A STUDENT
YES NO
2.
HOUSEHOLD MEMBER FULL NAME
SOCIAL SECURITY NUMBER BIRTH DATE
DRIVER
'
S LICENSE
/
ID
#
ARE YOU SUBJECT TO STATE LIFETIME SEX OFFENDER
REGISTRATION IN ANY STATE?
YES NO
ARE YOU PHYSICALLY DISABLED
YES NO
ARE YOU A STUDENT
YES NO
3. HOUSEHOLD MEMBER FULL NAME
BIRTH DATE
DRIVER'S LICENSE/ID #
ARE YOU SUBJECT TO STATE LIFETIME SEX OFFENDER
REGISTRATION IN ANY STATE
?
YES NO
LIST ALL STATES YOU HAVE RESIDED IN
ARE YOU PHYSICALLY DISABLED
YES NO
ARE YOU A STUDENT
YES NO
4.
HOUSEHOLD MEMBER FULL NAME
SOCIAL SECURITY NUMBER BIRTH DATE
DRIVER
'
S LICENSE
/
ID
#
ARE YOU SUBJECT TO STATE LIFETIME SEX OFFENDER
REGISTRATION IN ANY STATE
?
YES NO
LIST ALL STATES YOU HAVE RESIDED IN
ARE YOU PHYSICALLY DISABLED
YES NO
ARE YOU A STUDENT
YES NO
Sources of Income: List total income from all sources for each household members. Income includes, but is not
limited to, full time/part time/self-employment, unemployment, worker’s compensation, social security, SSI, public
assistance, pensions, child support, student grants/scholarships, the sale of property, interest on assets, dividends,
annuities and regular contributions from people who are not household members.
1. APPLICANT/HEAD OF HOUSEHOLD NAME
EMPLOYER, AGENCY, INSTITUTION OR OTHER SOURCES OF INCOME TO YOU- LIST NAME AND ADDRESS OF SOURCE
ANNUAL AMOUNT
$
2. HOUSEHOLD MEMBER NAME
EMPLOYER, AGENCY, INSTITUTION AND OTHER SOURCES OF INCOME TO YOU- LIST NAME AND ADDRESS OF SOURCE
ANNUAL AMOUNT
$
3. HOUSEHOLD MEMBER NAME
EMPLOYER, AGENCY, INSTITUTION AND OTHER SOURCES OF INCOME TO YOU- LIST NAME AND ADDRESS OF SOURCE
ANNUAL AMOUNT
$
4.
HOUSEHOLD MEMBER NAME
EMPLOYER
,
AGENCY
,
INSTITUTION AND OTHER SOURCES OF INCOME TO YOU
-
LIST NAME AND ADDRESS OF SOURCE
ANNUAL AMOUNT
$
QUAD Inc. Housing Application Page 3 of 4
Revised 04232020
Assets: List all assets for all household members. Assets include, but are not limited to, real estate, bank accounts,
certificate of deposits, life insurance, stocks and bonds, trust accounts, collections held as an investment, and, any
other investment or item of value except household goods and a private vehicle
1.
APPLICANT
/
HEAD OF HOUSEHOLD NAME
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
1.
APPLICANT
/
HEAD OF HOUSEHOLD NAME
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
1.
APPLICANT
/
HEAD OF HOUSEHOLD NAME
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
DO YOU HAVE ANY OTHER ASSETS NOT LISTED ABOVE
?
YES NO
IF YES
:
DESCRIBE TYPE OF PROPERTY
/
ASSET
VALUE OF ASSET
HAVE YOU SOLD OR DISPOSED OF ANY PROPERTY
/
ASSETS FOR LESS THAN
MARKET VALUE IN THE LAST TWO YEARS
?
YES NO
IF YES
:
DESCRIBE TYPE OF PROPERTY
/
ASSET
SALE PRICE OF ASSET
2.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
2.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
2.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
DO YOU HAVE ANY OTHER ASSETS NOT LISTED ABOVE?
YES NO
IF YES: DESCRIBE TYPE OF PROPERTY/ASSET
VALUE OF ASSET
HAVE YOU SOLD OR DISPOSED OF ANY PROPERTY
/
ASSETS FOR LESS THAN
MARKET VALUE IN THE LAST TWO YEARS
?
YES NO
IF YES
:
DESCRIBE TYPE OF PROPERTY
/
ASSET
SALE PRICE OF ASSET
3.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
3.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
3. HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK, BROKER, OR OTHER
VALUE OF ASSET
DO YOU HAVE ANY OTHER ASSETS NOT LISTED ABOVE?
YES NO
IF YES: DESCRIBE TYPE OF PROPERTY/ASSET
VALUE OF ASSET
HAVE YOU SOLD OR DISPOSED OF ANY PROPERTY
/
ASSETS FOR LESS THAN
MARKET VALUE IN THE LAST TWO YEARS
?
YES NO
IF YES
:
DESCRIBE TYPE OF PROPERTY
/
ASSET
SALE PRICE OF ASSET
4.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
REAL PROPERTY
,
OTHER LOCATION
VALUE OF ASSET
4. HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK, BROKER, OR OTHER
VALUE OF ASSET
4 HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK, BROKER, OR OTHER
VALUE OF ASSET
4.
HOUSEHOLD MEMBER
ACCOUNT NUMBER
ASSET TYPE
NAME AND ADDRESS OF BANK
,
BROKER
,
OR OTHER
VALUE OF ASSET
DO YOU HAVE ANY OTHER ASSETS NOT LISTED ABOVE
?
YES NO
IF YES
:
DESCRIBE TYPE OF PROPERTY
/
ASSET
VALUE OF ASSET
HAVE YOU SOLD OR DISPOSED OF ANY PROPERTY/ASSETS FOR LESS THAN
MARKET VALUE IN THE LAST TWO YEARS?
YES NO
IF YES: DESCRIBE TYPE OF PROPERTY/ASSET
SALE PRICE OF ASSET
General Eligibility Questions: HUD has certain eligibility requirements that apply to housing in QUAD Inc. facilities.
Please answer all of the questions below for any applicant or family member that they are applicable to. Use multiple
lines if needed.
HAS ANY HOUSEHOLD MEMBER EVER BEEN EVICTED FROM PUBLIC OR
OTHER HOUSING?
YES NO
HOUSEHOLD MEMBER
IF YES: ENTER LANDLORD, ADDRESS, AND DATE OF EVICTION
HAS ANY HOUSEHOLD MEMBER EVER BEEN CONVICTED
,
PLED GUILTY OR
NO CONTEST TO ANY CRIME
?
YES NO
HOUSEHOLD MEMBER
IF YES
:
ENTER CITY
,
STATE
,
CLASS OF CRIME AND DATE OF CONVICTION
QUAD Inc. Housing Application Page 4 of 4
Revised 04232020
DOES ANY HOUSEHOLD MEMBER OWN A PET
YES NO
HOUSEHOLD MEMBER
DESCRIPTION OF PET
:
TYPE
,
BREED
,
SIZE
-
PLEASE STATE IF THIS IS AN ASSISTANCE ANIMAL
DOES ANY HOUSEHOLD MEMBER OWN A VEHICLE?
YES NO
HOUSEHOLD MEMBER
DESCRIPTION OF VEHICLE: MAKE, MODEL, COLOR, YEAR AND LICENSE PLATE
DOES ANY HOUSEHOLD MEMBER HAVE A HISTORY OF DRUG OR ALCOHOL
DEPENDENCY?
YES NO
HOUSEHOLD MEMBER
LIST DATES OF TREATMENT AND DATE OF LAST RELAPSE IF ANY
IS ANY HOUSEHOLD MEMBER AN ADULT HAVING A PHYSICAL IMPAIRMENT THAT:
A) IS EXPECTED TO BE OF LONG-CONTINUED AND INDEFINITE DURATION;
B) SUBSTANTIALLY IMPEDES YOUR ABILITY TO LIVE INDEPENDENTLY; AND
C) IS SUCH THAT THE YOUR ABILITY TO LIVE INDEPENDENTLY COULD BE IMPROVED BY MORE SUITABLE HOUSING CONDITIONS (WHEELCHAIR ACCESSIBLE, BARRIER FREE HOUSING)
YES NO List Household Member ________________________________________________________________________
D
EMOGRAPHIC
I
NFORMATION
:
THE FOLLOWING INFORMATION IS REQUESTED BY THE FEDERAL GOVERNMENT TO MONITOR COMPLIANCE WITH FEDERAL LAWS
PROHIBITING DISCRIMINATION AGAINST APPLICANTS SEEKING TO PARTICIPATE IN THE PROGRAM
. YOU ARE NOT REQUIRED TO FURNISH THIS INFORMATION BUT YOU ARE
ENCOURAGED TO DO SO
. THIS INFORMATION WILL NOT BE USED IN EVALUATING YOUR APPLICATION OR TO DISCRIMINATE AGAINST YOU IN ANYWAY. HOWEVER, IF YOU DO NOT
FURNISH THE REQUESTED INFORMATION WE ARE REQUIRED TO NOTE THE RACE
/NATIONAL ORIGIN OF INDIVIDUAL APPLICANTS BASED ON VISUAL OBSERVATION OR SURNAME.
ETHNICITY: HISPANIC OR LATINO NOT HISPANIC OR LATINO
RACE (MARK ONE OR MORE): WHITE BLACK OR AFRICAN AMERICAN AMERICAN INDIAN /ALASKA NATIVE
ASIAN NATIVE HAWAIIAN OR PACIFIC ISLANDER
GENDER: MALE FEMALE
H
OW DID YOU HEAR ABOUT QUAD INC
. HOUSING? _____________________________________________________________
OPTIONAL SUPPORTIVE SERVICES – NOT A REQUIREMENT FOR HOUSING
ARE YOU INTERESTED IN APPLYING FOR SHARED ATTENDANT CARE SERVICES YES NO
IF YOU ARE INTERESTED IN THE QUAD INC. SHARED ATTENDANT CARE PROGRAM- A SEPARATE APPLICATION IS REQUIRED
Consent and Certification
I, the undersigned applicant, agree to give the owner/owner’s representative authorization to investigate and obtain my credit
rating, my criminal history, my financial records, my current and past rental records, and any other information necessary to
determine my eligibility for housing. The information obtained will be used for management purposes only and will be held in
confidence. I understand that I may be requested to provide additional information and consent to verification of the information
contained in this application. My signature below certifies that the statements made on this application are TRUE and CORRECT
and gives my consent for management to verify the information I have provided. I acknowledge that I must keep management
informed of my continued interest in the unit at least every 180 days.
FAILURE TO COMPLETE THIS APPLICATION FULLY OR GIVING FALSE INFORMATION MAY RESULT IN THIS
APPLICATION BEING DENIED OR EVICTION AFTER TENANCY. Applicant herby certifies that this apartment will be their
permanent residence and that they will not maintain a separate subsidized rental unit in a different location.
Applicant signature: _______________________________________ Date: ________________________
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 knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device material fact, or makes any
false, fictitious or fraudulent statements or representations, or makes or use any false writings or document knowing the same to contain false
writings or document knowing the same to contain false, fictitious, statement or entry shall be fined or imprisoned for not more than five years
or both.”
Submit applications to the Manager of any QUAD Inc. property. Fax to 503.281.8176, email to info@quadinc.org or via
US Mail to QUAD Inc. at 6645 NE 78
th
Court., Suite C-7, Portland, OR. 97218. Applications are added to our waiting list
in date order. We will contact you when your application is next in line for an available unit. Applications cannot be
approved for occupancy until all information provided is verified. To keep your application current on the waiting list
you must tell us if your contact information changes and inform us of your continued interest in QUAD Inc. housing
at least every 180 days.
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SUBSIDIZED RENTAL APPLICATION QUAD Inc. is an Equal

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Completed 10 May 2022

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