GSH #3700-AH Rev. 12/16 DEAR APPLICANT,

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1 GSH #3700-AH Rev. 12/16 DEAR APPLICANT, Thank you for your interest in this affordable housing community. This application for residency is being provided to you so that you can formally apply to reside at this community. This affordable housing community has specific residency criteria used to determine eligibility. The application for residency is used to gather necessary applicant data in a uniform manner to determine eligibility. THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY and Owner do business in accordance with the Fair Housing Act. WE DO NOT DISCRIMINATE AGAINST ANY PERSON BECAUSE OF RACE, COLOR, RELIGION, SEX, DISABILITY, GENETIC INFORMATION, FAMILIAL STATUS, SEXUAL ORIENTATION, NATIONAL ORIGIN OR OTHER PROTECTED STATUSES ACCORDING TO APPLICABLE FEDERAL, STATE and LOCAL LAW. Residents of this affordable housing community must meet the established age requirements and other qualifications as described in the Resident Selection Plan. A copy of the Resident Selection Plan will be sent to you upon receipt of your application. If you do not received a copy of the Resident Selection Plan, please notify the manager to request a copy. The following is important information for all applicants to be aware of: This application must be filled out in full, in ink and must be signed and dated. Please print legibly. Incomplete applications will not be accepted. Valid proof of age must be provided. Applicants are responsible to notify management of this affordable housing community if any material application information changes (change in address, contact information, etc.). Each property will have additional requirements for eligibility which may relate to citizenship, disclsoure of SSNs, income limits, and more. These requirements are listed in the Resident Selection Plan. THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY and Owner are committed to serving all eligible and qualified individuals regardless of disability. If you need a reasonable accommodation to have full use and enjoyment of your housing, you should bring that fact to the manager s attention. The manager will try to work with you to reach an accommodation in keeping with the fundamental nature of this affordable housing property. The designated person for coordinating efforts to comply with Section 504 requirements is: Director of Affordable Housing Property Management; 4800 W 57th Street, Sioux Falls, SD 57108; Phone (605) For Telecommunications Relay Service, dial 711. Please return this completed application to the affordable housing community office where it will be date and time stamped and reviewed. Contact the manager of this affordable housing community with any questions regarding the application for residency or the resident selection process. Again, thank you for your interest in this affordable housing community.

2 Page 2 APPLICATION FOR RESIDENCY 1. Applicant(s) information Applicant #1 (Head of Household) of Birth *Social Security # Phone # Sex M/F/ Response Applicant #2 of Birth *Social Security # Phone # Sex M/F/ Response Applicant #3 of Birth *Social Security # Phone # Sex M/F/ Response Applicant #4 of Birth *Social Security # Phone # Sex M/F/ Response *For HUD communities, the disclosure of the SSN is required for all household members except those who do not contend eligible immigration status where a declaration of citizenship is required and for those who were 62 as of Jan. 31, 2010, if the initial determination of eligibility was begun before Jan. 31, Please list the total current market value of all household assets. $ 3. Provide the names and addresses of homes and/or apartments where applicants have resided over the past five years. Include rental addresses listed above. Use additional sheets if necessary. Name of Applicant s of Occupancy Name, Address and Contact Information of Landlord and/or Housing Provider

3 Page 3 4. Applicant history (Please circle your answer) 4.1 Has any applicant had any outstanding property rental debt within the past five years? If yes, please describe: 4.2 Has any applicant been convicted of use, sale or possession of illegal drugs in the last five years? If yes, has the convicted applicant(s) successfully completed an approved drug rehabilitation program? Please attach documentation. 4.3 Is any applicant currently using, selling or in possession of illegal drugs? 4.4 Is any applicant currently charged with or has any applicant been convicted of a felony or any violent crime against another person in the last 10 years? 4.5 Has any applicant been convicted of a serious misdemeanor (refer to Resident Selection Plan for the definition of serious misdemeanor ) in the last three years? If yes, please describe: 4.6 Is any applicant currently a registered sex offender in any state? 4.7 Has any applicant had a court ordered eviction or been asked to move out of any type of housing in the past five years, or has any applicant had assistance or tenancy in a subsidized housing program terminated for fraud, non-payment of rent or failure to cooperate with recertification procedures? 4.8 Does any applicant have a history of alcohol abuse or any other pattern of abusive behavior that may interfere with the health, safety and right to peaceful enjoyment of residents of this affordable housing community? If yes, please describe: 4.9 Is any member of the household a full- or part-time student at an institution of higher education? 4.10 Does the head of household or spouse have a disability that requires the features of an accessible unit? If yes, please explain on a separate sheet of paper Is any member of the household a U.S. military veteran? 4.12 Please list the state(s) where the applicant and the members of the applicant s household have resided: te: For HUD communities, the Supplemental Information to Application for Assistance (HUD-92006) is required as an attachment to this application.

4 Page 4 5. How did you learn about this affordable housing community? Advertising Magazine/Publication Newspaper Yellow Pages Radio Television Internet Good Samaritan Society Website Other: Public Relations Good Samaritan Society Event Public Presentation Community Fair/Show Newspaper Other: Referral Resident/Client Employee Relative Friend Professional Agency Employer Other: Warning: WILLFUL FALSE STATEMENTS OR MISREPRESENTATIONS ARE A CRIMINAL OFFENSE UNDER SECTION 1001 OF TITLE 18 OF THE U.S. CODE. Knowingly providing inaccurate or misleading information or knowingly withholding important information during any part of the application, resident selection and occupancy process is grounds for denial of housing and/or termination of occupancy. This application must be signed by all persons who intend to occupy a unit. Completion of this application does not guarantee applicant(s) will be accepted for residency. Application information is used to make a preliminary determination of eligibility, but additional screening and verification steps will apply before a unit is offered to an applicant. All applicants must meet all residency requirements. I/We certify that the apartment unit will be a permanent residence, and I/we further certify that if the community stated is funded by HUD or Rural Development, I/we do/will not maintain a separate rental unit in a different location. I/We declare that the statements contained in this application are true and complete to the best of my/our knowledge. I/We understand that the above information is subject to verification to determine eligibility for federal programs. These programs may include, but are not limited to, the US Department of Housing and Urban Development, the USDA Rural Development and/or the Low Income Housing Tax Credit programs. Signature of Applicant #1 (Head of Household) Signature of Applicant #2 Signature of Applicant #3 Signature of Applicant #4 Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the Social Security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a) (6), (7) and (8).

5 Page 5 FOR OFFICE USE ONLY Applying for AFFORDABLE HOUSING: _ (Enter the name of the specific community or building as appropriate.) Application for Residency Received: Time Application for Residency Received: Received by: APPLICATION ACCEPTED APPLICATION DENIED List Reason for Denial: Denial Letter Sent? Letter Sent: Denial Appealed? Appeal Received: Denial Upheld? Applicant tified: tes/additional Information: Applications must be retained on file for three years past denial of the application or the move-out date of the resident(s).

6 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 OMB Control # Exp. (02/28/2019) 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 : Name of Additional Contact Person or Organization: Cell Phone : Address: Telephone : Address (if applicable): Cell Phone : 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 tification: Section 644 of the Housing and Community Development Act of 1992 (Public Law , 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 Check this box if you choose not to provide the contact information. Signature of Applicant 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 ). 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 ) 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 , 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 (05/09)