DO NOT USE WHITE OUT

Housing Credit Program
Applicant Questionnaire
Apartment #  _________      Bedroom size ___________
	
Household Information	
List all household members. 	
Name
First, Middle Initial, Last	Relationship to Head of Household	
M/F	Social Security Number	Birth Date
Month, Date, Year	

					

					

					
Current Address:				
			
Daytime Phone:		Evening Phone:			
				
YES	NO			
		1.	Do you expect any additions, including pregnancy, to the household within the next twelve months?	
			Name & Relationship:		
			Explanation:		
		2.	Is there anyone living with you now who won’t be living with you at this property?	
			Name & Relationship: 		
			Explanation:		
		3.	Do you have full custody of your child(ren)? (If no, obtain proof  of amount of time child{ren} will be living in unit.)	
		Explanation: 		
		4.	Are there any absent household members who under normal conditions would live with you? (For example, a spouse away in the military.)		
		Explanation: 		

		5.	Does your household have or anticipate having any pets other than those used as service animals?	

Separation Affidavit		6.	Are you currently separated or in divorce proceedings with your spouse	
YES	NO			
		7.	Have you or any one else named on this application filed for bankruptcy?	
			Explanation:		
		8.	Have you or any one else named on this application been convicted of a felony?	
			Explanation:		
		9.	Have you or any one else named on this application been convicted for dealing or manufacturing illegal drugs	
			Explanation:		
		10.	Have you or any one else named on this application been convicted of property damage?	
			Explanation:		
		11.	Have you or any one else named on this application been evicted from a rental unit of any type including an apartment, home, mobile home or trailer?	
			Explanation:		
	
Housing References	
List the past THREE years of housing references.  (If additional space is required, use the back of this page.)	
Landlord’s Name/Address	Your Address	Own/Rent	Dates	
Name:				Own     	From:		
Address:				Rent     	To:		
						
Phone: 	(              )					
							
Name:				Own     	From:		
Address:				Rent     	To:		
						
Phone: 	(              )					
							
Name:				Own     	From:		
Address:				Rent     	To:		
						
Phone: 	(              )					

Personal Reference	
List a personal reference other than a relative.	
Name:		
Address: 		
Phone:		Relationship:		Years Known: 		
Vehicle  Information	
List vehicle information for all vehicles that are owned or operated by any household member.	
Tag/License Plate #	State Issued	Make/Model/Year	
Vehicle #1:						
Vehicle #2:						
	
Emergency Contact	
List someone in the area that is not already on the application.	
Name:		
Address: 		
Phone:		Relationship:		Years Known:		
	
Income Information	
Income is counted for anyone 18 or older (unless legally emancipated). However, if the income is unearned income such as a grant or benefit, it is counted for all household members including minors.
Include all income anticipated for the next 12 months.
Do YOU or ANYONE in your household receive OR expect to receive income from:	
YES	NO	
		12.	Employment wages or salaries? (Include overtime, tips, bonuses, commissions and payments received in cash.) 	
(EMC #01)			
			Household Member		Name of Company		Amount	

								
				
		13.	Self-employment? (Include overtime, tips, bonuses, commissions and payments received in cash.)	
(EMC #02)			
			Household Member		Type of Business		Amount	

				
		14.	Regular pay as a member of the Armed Forces/Military?	
(EMC #03)			
			Household Member		Base Name & Branch		Amount	

				
		15.	Unemployment benefits or workman’s compensation?	
(EMC #04)			
			Household Member		Case Worker		Amount	

		16.	Public Assistance, General Relief, AFDC or Temporary Assistance for Needy Families (TANF)?	
(EMC #05)			
			Household Member		Case Worker		Amount	

					
		17.	(a)	Child support or Alimony? 	
If yes,
(EMC #06)	If no,
(EMC #19)			(We must count court-ordered support whether or not it is received unless legal action has been taken to remedy. We must also count support that is not court-ordered rather received directly from payor.)	
			Household Member		Payor (list all)		Amount	

								
			(b)	How is the support received? (Check all that apply)	
			Child Support Enforcement Agency	Name of Agency:		
			Court of Law	Name of Court:		
			Directly from Individual	Name of Person:		
			Other	Explain:		
			(c)	If support/alimony is court-ordered but not actually received, are you taking legal action to remedy?	
(If yes, obtain court papers)		Explanation: 		
				
		18.	Social Security, SSI or any other payments from the Social Security Administration?	
(EMC #07)			
			Household Member		SSA Office		Amount	

				
		19.	Regular payments from a Veteran’s benefit, pension, retirement benefit or annuities?	
(EMC #08)			
			Household Member		Source of Benefit		Amount	

				
		20.	Regular payments from a severance package?	
(EMC #08)			
			Household Member		Source of Benefit		Amount	

				
		21.	Regular payments from any type of settlement?  (For example, insurance settlements.)	
(EMC #08)			
			Household Member		Source of Benefit		Amount	

				
		22.	Regular gifts or payments from anyone outside of the household? 	
(EMC #08)		(This includes anyone supplementing your income, paying any of your bills, rent or utility payments.)	
			Household Member		Source of Benefit		Amount	

				
				
		23.	Regular payments from lottery winnings or inheritances?	
(EMC #08)			
			Household Member		Source of Benefit		Amount	

				
		24.	Regular payments from rental property or other types of real estate transactions?	
(EMC #08)			
			Household Member		Source of Benefit		Amount	

				
		25.	Any other income sources or types not listed?	
(EMC #08)			
			Household Member		Source of Benefit		Amount	

				
		26.	Do you or any other household members expect any changes to your income in the next 12 months?	
			Explanation:  _______________________________________________________________________		
Asset Information:	
Include all assets held and the income derived from the asset. INCLUDE ALL ASSETS HELD BY ALL HOUSEHOLD MEMBERS INCLUDING MINORS.                           
Do YOU or ANYONE in your household hold:	
YES	NO	
		27.	Checking or savings account?	
(EMC #09)			
			Household Member		Financial Institute		Amount	

				
		28.	CDs, money market accounts or treasury bills?	
(EMC #09)			
			Household Member		Financial Institute		Amount	

				
		29.	Stocks, bonds, securities or mutual funds?	
(EMC #10)			
			Household Member		Company or Broker		Amount	

				
		30.	Trust Funds	
(EMC #09)			
			Household Member		Financial Institute		Amount	

		31.	Pensions, IRAs, Keogh or other retirement accounts?	
(EMC #09)			
			Household Member		Financial Institute		Amount	

				
		32.	Whole or Universal Life insurance policy?	
(EMC #10)			
			Household Member		Insurance Carrier		Amount	

				
		33.	Real estate, rental property, land contracts/contract for deeds or other real estate holdings? 	
(EMC #10)		(This includes your personal residence, mobile homes, vacant land, farms, vacation homes or commercial property.)
	
			Household Member		Address of Property		Amount	

				
		34.	Personal property held as an investment? 	
(EMC #10)		(This includes paintings, coin or stamp collections, artwork, collector or show cars, and antiques. This does not include your personal belongings such as your car, furniture, jewerly  or clothing.)	
			Household Member		Item		Amount	

				
		35.	A safe deposit box or cash on hand over $500?	
(EMC #13)			
			Household Member		Financial Institute		Amount	

				
		36.	Have you or any other household members disposed of or given away any asset(s) for LESS than	
(EMC #11)		fair market value within the past 2 years?	
			Household Member:		Amount:		
			Explanation:		
		37.	Do you or any other household members have a 401K account?	
(EMC #10)			_________________________________________________________	
	
Applicant Status	
The following questions pertain to specific eligibility requirements of the Housing Credit Program. 	
YES	NO			
		38.	Are you or any other ADULT household members claiming zero income?	
(EMC #20)			
			Household Member:		
			Explanation:		
		39.	Are you or any other household members (INCLUDING MINORS) currently a full-time student	
(EMC #12 & #18)		or expect to be one in the next 12 months?	
			Household Member(s):		
					
		40.	Will you or any ADULT household member require a live-in care attendant to live independently?	
(EMC #15 & #21)			
			Name of Attendant:		
			Relationship (if any):		
		41.	Will your household be receiving Section 8 rental assistance at time of move-in?	
			Name of Agency:		
			Contact Person:		
		42.	Will your household be eligible or are you applying to receive Section 8 rental assistance in the next 12 months?	
			Expected Date:		
			Name of Agency:		
			Contact Person:		

					
Signature Clause	
I understand that management is relying on this information to prove my household’s eligibility for the Housing Credit Program.  I certify that all information and answers to the above questions are true and complete to the best of my knowledge.  I consent to release the necessary information to determine my eligibility.  I understand that providing false information or making false statements may be grounds for denial of my application.  I also understand that such action may result in criminal penalties.
I authorize my consent to have management verify the information contained in this application for purposes of proving my eligibility for occupancy.  I will provide all necessary information including source names, addresses, phone numbers, account numbers where applicable and any other information required for expediting this process. I understand that my occupancy is contingent on meeting management’s resident selection criteria and the Housing Credit Program requirements.

By signing this form I/We understand that this application is preliminary only and the lessor or its Agents are not obligated to approve this application or deliver occupancy of the proposed premises.

The applicant(s) signature(s) that appear below hereby authorize Guardian Management, LLC, to investigate applicant(s) current and past history including but not limited to employment, credit bureaus, court records and other sources.  If this application in approved the applicant will be notified of the date an apartment will be available for occupancy and a move in date will be established.

Applicant(s) further agrees that if the application is disapproved, for whatever reason, the Lessor or Agent will notify the applicant and any apartment being held will be released so it can be re-rented and the deposit will be returned to the applicant.  If the applicant(s) cancel after the three-(3) day period, for any reason, the deposit being held on the apartment will be forfeited. 

I/We hereby certify that the foregoing information is true and complete to the best of my/our knowledge.

All ADULT household members must sign below:
												
Signature										Date
												
Signature										Date
												
Signature										Date	
	
For Office Use Only	
Date of Interview: 			Desired Apt. #: 			Desired Move-in Date: 			

Revised 4-22-04