Fillable Thank you for your interest in our apartment

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Thank you for your interest in our apartment

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Dear Applicant:
Thank you for your interest in our apartment community. Below please find additional information that is useful in
understanding the application process.
NOTE: This property may be a non-smoking facility in accordance with notice H2010-21 issued by the US
Department of Housing and Urban Development (HUD) on September 15, 2010. If this property is designated
Smoke Free, smoking is not permitted within the premises or in any apartment dwelling at any time. The rules
and regulations are amended to reflect this policy.
1.
Complete the attached Application, Income and Expense Questionnaire, Contact Information Supplement to
Application (HUD-92006), Student Questionnaire and the Special Unit Requirement Questionnaire and Working
Preference Rule in full. Please complete in ink, not pencil, and do not use correction tape or fluid. If an error is
made, please strike through and initial the correction. A complete mailing address and working phone number
are required for correspondence. All applicants 18 or older must sign the application and complete the Student
Questionnaire. The waiting period varies, however applicants will be contacted periodically to determine if they
want to stay on the list. Make sure to report any changes in address, phone number, income or family size to the
rental office, if they occur before contact is made for processing the application. Please make sure that you
have completed all sections of the application or write “N/A” in any box that does not pertain to you.
2.
Applicants will be contacted once their name gets to the top of the list. The contact is usually by mail. The
contact letter will give a deadline date to respond. If you do not respond, your application will be removed
from the waiting list. The letter will ask you to call the rental office for an interview date at which time
management will process all background checks including credit, criminal, sex offender and landlord. Income,
family size, and expenses will also be verified at this time. Prior to move in, all family members must provide
documentation of Social Security Number. Documentation can include an original Social Security Card, a valid
Driver’s License with SSN OR ITIN, an ID card issued by a federal, state, or local agency, a medical insurance
provider, or an employer or trade union, earnings statements or payroll stubs, bank statements, Form 1099,
Benefit Award letters, Retirement Benefit letters, Life Insurance Policies, or Court Records.You will need to
furnish birth certificates and social security cards for each family member at the interview.
3.
If your application is approved, you will be informed as to the amount of security deposit and rent required. The
security deposit and first month’s rent are due on move-in day. Utilities must be connected in the applicant’s
name on or before move-in day. The utility companies will most likely require deposits and the applicant should
contact them directly for amounts. Keys for the apartment will not be issued without proof of utilities in your
name.
Westminster Company appreciates your interest in our community and look forward to receiving your application. This institution is
an equal opportunity provider and employer.
IMPORTANT – Please visit our website at www.westminstercompany.com and navigate to apartments search. This will show a
completelistofproperties.Thewebsitewillprovidegeneralinformationabouttheproperty,contactinformationforsitestaff,and
howtoapplyforanapartmentonline. If you complete handwritten documents, they MUST be returned directly to the property
(or properties) that you are interested in or you may email, fax or mail.
PM-001
Eff. 10/11/03; Rev. 12/31/2019
Page 1 of 2
Site Name:
Phone Number:
Site Address:
City, State, Zip:
RENTAL APPLICATION-Subsidy Properties Only
Head of Household FIRST NAME
Head of Household LAST NAME
Head of Household SS#
If you have no Social Security Number, you claim you are exempt because (CHECK ONE):
You are an ineligible non-citizen You were 62 as of 1/31/10 and receiving HUD housing assistance
as of 1/31/10
Present Address
City, State, Zip Code
Date of Birth
Driver’s License Number/State ID Number
State of Issue
Email Address
Home Phone #
Business Phone #
Mailing Address (if different from Present Address listed above)
Name of Current Residence (for example-name of apts., family member you now live with…)
Current Landlord’s Name
Current Landlord’s Address
City
State
Zip Code
Current Landlord’s Phone #
Rent
Lived There
Since
Reason for Moving
Name of Previous Residence (for example-name of apts., family member you lived with…)
Previous Landlord’s Name
Applicant’s Previous Address
City
State
Zip Code
Previous Landlord’s Address
City
State
Zip Code
Previous Landlord’s Phone #
Rent
Lived There
Since
Reason for Moving
List ALL Adults INCLUDING HEAD OF HOUSEHOLD (age 18 and over) who will live in the apartment. If more than 4 adults will live in the apartment, give
details on a separate signed sheet. Please provide ALL requested information for each adult, including FULL first name, middle name and last name.
1. First Name, Middle Name and Last
Name
Relationship
Sex
Male ( )
Female ( )
Wish Not to
Disclose ( )
Birth date
Social Security #
Occupation
US Citizen?
Yes ( ) No ( )
2. First Name, Middle Name and Last
Name
Relationship
Sex
Male ( )
Female ( )
Wish Not to
Disclose ( )
Birth date
Social Security #
Occupation
US Citizen?
Yes ( ) No ( )
3. First Name, Middle Name and Last
Name
Relationship
Sex
Male ( )
Female ( )
Wish Not to
Disclose ( )
Birth date
Social Security #
Occupation
US Citizen?
Yes ( ) No ( )
4. First Name, Middle Name and Last
Name
Relationship
Sex
Male ( )
Female ( )
Wish Not to
Disclose ( )
Birth date
Social Security #
Occupation
US Citizen?
Yes ( ) No ( )
List ALL Children (under age 18) who will live in the apartment. If more than 4 Children will live in the apartment, give details on a separate signed sheet.
Please provide ALL requested information for each child, including FULL first name, middle name and last name.
1. First Name, Middle Name and Last Name
Foster Child?
Yes ( ) No ( )
Sex
Male ( ) Female ( )
Wish Not to Disclose ( )
Birth date
Social Security #
US Citizen?
Yes ( ) No ( )
2. First Name, Middle Name and Last Name
Foster Child?
Yes ( ) No ( )
Sex
Male ( ) Female ( )
Wish Not to Disclose ( )
Birth date
Social Security #
US Citizen?
Yes ( ) No ( )
3. First Name, Middle Name and Last Name
Foster Child?
Yes ( ) No ( )
Sex
Male ( ) Female ( )
Wish Not to Disclose ( )
Birth date
Social Security #
US Citizen?
Yes ( ) No ( )
4. First Name, Middle Name and Last Name
Foster Child?
Yes ( ) No ( )
Sex
Male ( ) Female ( )
Wish Not to Disclose ( )
Birth date
Social Security #
US Citizen?
Yes ( ) No ( )
Dial 711 for Telecommunication Relay Service
PM-001
Eff. 10/11/03; Rev. 12/31/2019
Page 2 of 2
How did you hear about this property? __________________________________________________________
Primary Language Spoken in Home: __________________________________________________________
1. YES [ ] NO [ ] Will the unit you are applying for be your permanent residence and do you agree not to
maintain a separate subsidized rental unit?
2. YES [ ] NO [ ] Have you been displaced by government action or a presidentially declared disaster?
3. YES [ ] NO [ ] Are you a student at an institute of higher education?
4. YES [ ] NO [ ] Are you (or any member of your household) a current or former member of the United
States Military?
If yes, which branch? ____________________________________________________
5. YES [ ] NO [ ] Are you (or any member of your household) subject to a lifetime state sex offender
registration program in ANY state?
6. Please list all states applicant and household members have lived in:
_________________________________________________________________________________________
_________________________________________________________________________________________
7. YES [ ] NO [ ] I (or any member of my household) am related to or have a personal
relationship with an employee of Westminster Company and/or the site at which I am
applying for residence. If yes, please disclose relationship below:
Employee Name:
Relationship:
Owners shall accommodate persons with disabilities who, as a result of
their disabilities, cannot utilize the owner’s preferred application process
by providing alternative methods of taking applications.
Specially designed smoke alarm systems are available upon requests.
Specially designed units are available upon request.
An allowance for disabled households is available upon request.
In consideration for being permitted to apply for this apartment, I Applicant do represent all this information in this application to be true and accurate
and that the owner/manager/agent may rely on this information when investigating accepting this application. Applicant hereby authorizes the
owner/manager/agent to make independent investigations to determine my credit, financial and character standing. Applicant authorizes any person, or
credit checking agency having information on him/her to release any and all such information to the owner/manager/employee or their agents or credit
checking agencies. Applicant hereby releases, remise and forever discharges from any action whatsoever, in law any equity all owners, managers and
employees or agents, both of landlord and their credit checking agencies in connections of processing, investigating, or credit checking this application,
and will hold them harmless of any suit or reprisal whatsoever. I understand that the credit report (rental history, arrest and/or conviction records and
retail credit history) will be done through bureau contracted with the apartment community.
Applicant’s Signature Receiving Site Staff Signature:
Co-Applicant’s Signature Date Signed
Date Signed Date Received Time Received
IF YOU WOULD LIKE A COPY OF OUR APPLICANT SCREENING GUIDELINES, REQUEST A COPY OF THE
RESIDENT SELECTION PLAN AT THE TIME OF SUBMISSION OF YOUR APPLICATION.
PM-001a
Eff. 03/24/05; Rev. 04/19/2021
Questionnaire for Student Household
(to be completed by all household members age 18 and older)
To be a student household, you must meet special HUD rules. So that we can determine if you meet these rules, please answer
the following questions. All information provided will be verified.
Name:
Current Address:
Telephone #:
Date:
*Institutes of higher education include post-secondary vocational institution; “proprietary institutions of higher education” which
prepare students for “gainful employment in a recognized occupation,” and accredited post-secondary colleges and universities. If
you are not sure, please mark “yes” and we will verify.
If you are a person with a handicap or disability, please contact us so that we can determine whether there are mitigating circumstances that should be considered
in your case, or whether reasonable accommodations would allow us to continue processing your application.
If you or another member of your household is determined to be an ineligible student now or in the future, you may not be eligible for assistance. If we determine at any time after move-in that you are ineligible for assistance, we
will notify you by providing a 30-day notice that your assistance will be terminated. WARNING: Section 1001 of Title 18 of the United States Code makes it a criminal offense to make a willfully false statement or
misrepresentation to any Department or Agency of the United States as to any matter within its jurisdiction.
I do hereby swear and attest that all the information given above is true and correct.
_______________________________________________________________________ ______________________________
Signature Date
FOR OFFICE USE ONLY:
This applicant: QUALIFIES as a student household and is eligible for assistance. DOES NOT QUALIFY as a student household and is not eligible for assistance.
N/A – Applicant/Resident is not a student household.
Check the box that applies for each question below
YES
NO
1.
Are you a Full/Part Time student at an institution of higher education?
(If you answered No, STOP and sign/date below)
2.
Do you live in the household with your parent(s) or guardian(s) who receive Section 8 assistance?
(If you answered Yes, STOP and sign/date below)
If you answered YES to #1 or NO to #2, check the box that applies for each question below
YES
NO
3.
Are you or will you turn 24 years old or older on/or before December 31
st
of the year assistance is
requested?
Were you an orphan, in foster care, or a ward of the court at any time from 13 years of age or older?
Are you now, or were you an emancipated minor or in a legal guardianship as determined by a court?
Are you a Veteran of the US Military or currently serving on active duty in the military for other than training
purposes?
Were you disabled and receiving assistance as of November 30, 2005?
Are you married?
Do you have legal dependents other than a spouse?
If yes, please list names and ages:
Are you a graduate or professional student?
(Majoring in professional degrees such as Medicine, Veterinarian Medicine, Law, Master’s Program)
Are you a homeless youth or at risk to become homeless, and self-supporting?
Are you a student for whom a financial aid administrator has determined independence by reason of other
unusual circumstances?
If you answered NO to all questions in #3 above, please complete the following question:
YES
NO
4.
For the past year, have you maintained a separate household from your parents/legal guardians, and you
are NOT claimed as a dependent on your parent’s tax return? (Must provide a copy of parent(s) most recent tax return)
If you answered NO to #4 continue to next questions
YES
NO
5.
Are your parents eligible for Section 8 Assistance?
(If yes, complete PM-470)
6.
Do you receive educational financial support (grants, scholarships, educational entitlements, work/study
programs, etc.) (If yes, sign PM-508)
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.
_____________________________________ ____________________________
click to sign
signature
click to edit
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.
Page 1 of 6
PM-004
Eff. 05/30/07, Rev. 01/07/2022
Income, Assets, and Expense Questionnaire
Please print clearly in blue or black ink only.
Property
Name:
Resident/Applicant
Name:
Apartment #:
Date:
Home Phone #:
Work Phone #:
Cell Phone #:
Can receive text messages? YES NO
Primary Language Spoken in Home:
Email Address:
PLEASE NOTE: When you provide us with a wireless telephone number or land line number, you are giving Westminster
Company or our representatives your prior express consent to call that number.
HOUSEHOLD COMPOSITION AND CHARACTERISTICS: List the Head of Household and all other people who live in the unit.
Family Member Name – List all persons who will be
living in the apt.
Birth Date Occupation
Driver’s License
or State ID #
Student (Full or
Part Time
)
?
1 (Head of Household):
YES NO
2
YES NO
3
YES NO
4
YES NO
5
YES NO
6
YES NO
7
YES NO
8
YES NO
9
YES NO
10
YES NO
Do you expect any changes in your family size during the next year?
YES NO
If yes, please explain. ________________________________________________________________________________
___________________________________________________________________________________________________
Are there any Live In Care Attendants who are part of the household?
YES NO
If yes, whom? Please explain. ________________________________________________________________________
___________________________________________________________________________________________________
Will all the above family members live in the apartment full time?
YES NO
If no, please explain. _________________________________________________________________________________
___________________________________________________________________________________________________
Page 2 of 6
PM-004
Eff. 05/30/07, Rev. 01/07/2022
Are you or any other household members subject to a lifetime registration requirement under a State Sex Offender
Registration program? YES NO If yes, list state(s): ______________________________________
INCOME INFORMATION
Please list the TOTAL amount of income received for all members of your household below. Where no income is received,
put zero in the block. In accordance with HUD regulations governing the gross income for all sources, I certify that:
EMPLOYMENT INCOME
HEAD OF HOUSEHOLD
CO-HEAD
OTHER ADULT
HOUSEHOLD MEMBERS
INCOME OF MINOR
CHILDREN
Wages from Employment
$ $ $ $
Overtime from employment
$ $ $ $
Commissions or Fees $ $ $ $
Tips or Bonuses $ $ $ $
Self-employment $ $ $ $
Workmen’s Compensation $ $ $ $
Severance Pay $ $ $ $
Military Pay $ $ $ $
Employer’s
N
ame
Stree
t
Address City State Zip Code
Date Hire
d
Hourly Weekly Bi-Weekly twice a month
Gross Salary $ Monthly Yearly Other
Hours worked
p
e
r
week
Termination Date (If
Applicable)
Supervisor’s
N
ame Wor
k
Telephone # Wor
k
Fax #
Employer’s
N
ame
Stree
t
Address City State Zip Code
Date Hire
d
Hourly Weekly Bi-Weekly twice a month
Gross Salary $ Monthly Yearly Other
Hours worked
p
e
r
week
Termination Date (If
Applicable)
Supervisor’s
N
ame Wor
k
Telephone # Wor
k
Fax #
Page 3 of 6
PM-004
Eff. 05/30/07, Rev. 01/07/2022
BENEFIT INCOME
HEAD OF HOUSEHOLD
CO-HEAD
OTHER ADULT
HOUSEHOLD MEMBERS
INCOME OF MINOR
CHILDREN
Social Security
$ $ $ $
SSI
$ $ $ $
Disability $ $ $ $
TANF $ $ $ $
Child Support/Alimony $ $ $ $
Unemployment $ $ $ $
Work First Program $ $ $ $
Veteran’s Benefits $ $ $ $
Retirement $ $ $ $
Pension $ $ $ $
OTHER INCOME
HEAD OF HOUSEHOLD
CO-HEAD
OTHER ADULT
HOUSEHOLD MEMBERS
INCOME OF MINOR
CHILDREN
Recurring Gift/Cash
Contributions
$ $ $ $
Educational Grants
$ $ $ $
Scholarships $ $ $ $
Work Study Programs $ $ $ $
Self-employment $ $ $ $
Lump Sum Amounts $ $ $ $
Other (List Source) $ $ $ $
Page 4 of 6
PM-004
Eff. 05/30/07, Rev. 01/07/2022
ASSET INFORMATION
Do you or any other member of your household own or have money in any of the following types of assets? If yes, please
supply the value.
TYPE OF ASSET
HEAD OF HOUSEHOLD
CO-HEAD
OTHER ADULT
HOUSEHOLD MEMBERS
ASSETS OF MINOR
CHILDREN
Checking
$ $ $ $
Savings
$ $ $ $
Direct Express Card $ $ $ $
e-Wallet (PayPal, Venmo,
Apple Pay)
$ $ $ $
Whole Life Insurance $ $ $ $
Stocks/Bonds $ $ $ $
IRAs/Retirement Accts $ $ $ $
Savings Certificate (CD) $ $ $ $
Money Market Funds $ $ $ $
Safety Deposit Box $ $ $ $
Rental Property/Other Real
Estate
$ $ $ $
Mortgages/Deed of Trust $ $ $ $
Revocable Trust Account $ $ $ $
Annuities $ $ $ $
Personal Property Held for
Investment
$ $ $ $
Other $ $ $ $
Assets Disposed of for Less Than Fair Market Value
Have you sold or given away cash, real property or other assets, valued at more than $1000 in the past two years? This
includes charitable contributions? _________________________________________________________________________
If yes, please describe: __________________________________________________________________________________
Page 5 of 6
PM-004
Eff. 05/30/07, Rev. 01/07/2022
_______________________________________________________________________________________________________
EXPENSE INFORMATION
Are you currently paying either of the following so that you or another adult member of your household can work, look for
work, or attend school?
TYPE of EXPENSE
AMOUNT ($)
Per Week, Per Month
YES NO Child Care
WK MO
YES NO Care of Disabled Persons
WK MO
THIS SECTION APPLIES TO ELDERLY/DISABLED/HANDICAPPED HOUSEHOLDS ONLY:
If your out-of-pocket medical expenses exceed 3% of your income, you may be eligible for medical expense deductions.
1. I do not wish to count out-of-pocket medical expenses. (Proceed to next page)
2. I anticipate having medical/dental expenses in the next 12 months that exceed 3% of my income from the
sources listed below.
Please provide copies of receipts, prescription print outs, mileage information, etc.
MEDICAL EXPENSES (DO NOT INCLUDE AMOUNTS COVERED BY INSURANCE)
AMOUNT ($)
Per
Month
/
Annuall
y
Doctor Bills
MO ANNUAL
Dental Bills
MO ANNUAL
Hospital Bills
MO ANNUAL
Pharmacy Expense
MO ANNUAL
Prescribed Equipment
MO ANNUAL
Eyeglasses
MO ANNUAL
Non-prescription medication with Dr.’s order
MO ANNUAL
Insurance/Supplemental Insurance
MO ANNUAL
Do you participate in the Medicare Pres. Drug Discount Card Program? If yes,
do
y
ou pa
y
a premium? List amount?
MO ANNUAL
Are you currently making monthly payments to a doctor, hospital, etc. for any
outstanding medical expenses?
Have you incurred any one-time medical bills, but not claimed them, in the 12-
month period preceding your anniversary date? (This question only applies for
recertification
–
not move in
)
MO ANNUAL
MO ANNUAL
Child Care Providers
Name
Child(ren) Name(s)
Provider Address
City, State, Zip
Phone
Page 6 of 6
PM-004
Eff. 05/30/07, Rev. 01/07/2022
ALL HOUSEHOLDS must answer all questions below. If you answer “YES” to any of the questions, the additional
information must also be completed.
1.
Do you own or operate a vehicle?
YES NO
Automobile Make Year Model Color
License Tag
and State
Monthly Car Payment $________________
Monthly Auto Insurance $______________
Monthly Gas Expense $________________
Source of income used for expense:
___________________________________
2.
Do you have internet at home?
YES NO
Do you subscribe to cable television?
YES NO
Do you have telephone service in your apartment?
YES NO
Do you have a cell phone?
YES NO
Monthly Internet Cost $_____________
Monthly Cable Cost $_______________
Monthly Phone Cost $______________
Monthly Cell Phone Cost $___________
Source of income used for expense:
_______
_
_______
_
_
_
_
_______________
_
3.
Do you or other household members receive cash contributions for sources or
persons outside the household?
YES NO
Monthly cash contribution? $____________
Source of income for cash contribution:
_______
_
________________
_
_________
_
4.
What was the total food cost for your family for the past 30 days?
$__________________________________
Source of income for food cost:
____________
_
_
_
___________________
_
5.
How much did you spend during the past 30 days for toiletries & other non-food
items?
$__________________________________
Source of income for cost of items:
___________________________________
6.
What were your utility costs for the past 30 days?
$__________________________________
Source of income for utility costs:
_
_
___
_
______________
_
_____________
_
I certify that the information given on this form is correct and complete. I understand that failure to report all income for
rent purposes is fraud and may result in termination of my lease, federal prosecution, or both.
WARNING: 1010 of Title 18 of the United States code makes it a criminal offense to make willfully false statements or
misrepresentation to any Department or Agency of the United States as to any matter within its jurisdiction.
Si
g
nature of Applicant/Resident Date
______________________________________________________________________ ____________________
Signature of Applicant/Resident Date
______________________________________________________________________ ____________________
Signature of Applicant/Resident Date
PM-005
Eff. 07/07/00; Rev. 05/03/2013
SPECIAL UNIT REQUIREMENT(S) QUESTIONNAIRE
Applicant/Resident Name:
I choose not to complete this form.
1. Please check all that apply. Do you, or does any member of your family have a condition that requires:
Physical modifications to a typical apartment
A separate bedroom Unit for Vision-Impaired
A barrier-free apartment Unit for Hearing-Impaired
One-level unit BR/Bath on 1st floor
2. Can you and all your family members go up and down stairs unassisted?
Yes No
If No, please indicate how we should accommodate your family:___________________________
_________________________________________________________________________________
_________________________________________________________________________________
3. Will you or any of your family members require a live-in aide to assist you?
Yes No
If Yes, please explain._____________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
4. If you checked any of the above listed categories of units, please explain exactly what you need to
accommodate your situation.________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. What is the name of the family member who needs the features identified above?
_________________________________________________________________________________
6. What health professional should be contacted to verify your need for the features you have identified above?
Name : _________________________
Address: ________________
Phone #:
___________________________________________________________________________/____/_______
Signature Date
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)
PM-332
Eff. 02/01/2014; Rev. 10/11/2017
WORKING PREFERENCE RULE
Effective 08/01/2017
Applicant Name:
Address:
Phone Number:
The Quality Housing and Work Responsibility Act of 1998 (QHWRA), gives admission preferences in
certain circumstances. Please check all of the following that apply to your household:
One or more of the following household members (Head of Household, Co-Head or
Spouse) are employed at least 25 hours per week, and have been for at least 6 consecutive
months. There can be no more than a 30-day lapse between employers. In the event of a
lapse, employment will be verified by both the current and former employers. Proof in the form
of check stubs, letter from employer on Company Letterhead, income verification, or other
requested as needed must be received prior to assigning the “Working Family” preference.
Your preference will be updated effective the date verified proof is received;
The Head of Household, Co-Head or Spouse is 62 years of age or older;
The Head of Household, Co-Head or Spouse get State or Federal benefit payments due to
being unable to work (including Social Security Disability Benefits and Supplemental Security
Income Disability Benefits). Proof in the form of a current income letter from the Social
Security Administration must be received prior to assigning preference;
I do not qualify for any of the above preferences.
In order to be eligible for priority admission, I understand that I must qualify for one of the above
preferences at the time of application, interview and move-In. I further understand that if any
information provided above is found to be false at time of Interview or Move In, my position on the
waiting list may change.
Applicant’s Signature
Date
Westminster Company Agent Signature
Date
If your circumstances change and you find you are not qualified for any of the above or you find out
that you are qualified for the above, please let us know immediately, as this will affect your status on
the waiting list.
OFFICE USE ONLY
Date Preference Verification(s) Received
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Completed 27 February 2022

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