Revised 06/23/10 09 APPLICATION FOR OCCUPANCY Eastbrook Apartments Community Name Would you or any member of your household benefit from the features of a barrier-free apartment, if so what special design features would you need? Indicate if you are 62 or older or disabled of any age to qualify for an elderly Project. Yes or No Official use only T Time: Date: Size of Apartment requested Desired Occupancy Date Part A. APPLICANT INFORMATION Applicant s Name Present City State Zip Telephone (H) (W) (message) Social Security # Birth Date E-Mail Co-Applicant Name Present City State Zip Telephone (H) (W) (message) Social Security # Birth Date E-Mail Other Members of Household: Name Sex Birth Date SSN# Relationship to Tenant Full Time Student Yes No Yes No Yes No Yes No Name of Current Landlord/Mortgage Holder Telephone Monthly Payments Reason for Moving Previous Own Rent from to
Name of Previous Landlord/Mortgage Holder Telephone Monthly Payments Reason for Moving Applicant Employer Years of Service Employer Spouse/C-Applicant Employer Years of Service Employer Credit References (List Three) Do Not Include Utility, Oil Co., or Landlord 1. Acct # 2. Acct # PERSONAL REFERENCES (LIST THREE) 1. Phone # 2. Phone # 3. Phone # Driver s License # Number of Automobiles 1. Make Year Color Tag # State 2. Make Year Color Tag # State Person to contact in the case of an emergency Name Relationship Telephone Complete all applicable information for Tenant, Spouse, and Co-Tenant. Attach an additional sheet if more space is needed. This information is to be completed by the applicant (Not by the agency, employer, or bank).
B. INCOME AND EXPENSE INFORMATION 1. SALARY/WAGES List gross amount (before deductions) of wages and salaries, overtime pay commissions; fees, tips, bonuses. Indicate Sources below: HOUSEHOLD MEMBER EMPLOYER NAME EARNINGS $ per hr, hrs. /wk. $ per hr, hrs./wk. $ per hr, hrs./wk. 2. NET INCOME FROM BUSINESS/PROFESSION ON RENTAL OF REAL ESTATE OR PERSONAL PROPERTY $ per 3. SOCIAL SECURITY / SSI PAYMENTS Household Member Social Security $ per month Social Security $ per month SSI $ per month SSI $ per month StateSSI $ permonth 4. PENSIONS; ANNUITIES; RETIREMENT FUNDS; IRA ACCOUNTS HOUSEHOLD MEMBER SOURCE & ADDRESS $ per month 5. ALL OTHER INCOME Include income from ALL OTHER SOURCES, such as: Unemployment; Disability Compensation; Workman s Compensation; allowances for Head of Household in Armed Forces; Public Assistance; AFC; Welfare or any other source. HOUSEHOLD MEMBER SOURCE & ADDRESS $ per hr $ per hr 6. CHILD CARE EXPENSE - List amount paid by family for the care of minor children age 12 or younger when such care is necessary to enable a family member to work or go to school NAME & ADDRESS OF BABYSITTER/CHILD CARE $ per hr. hrs per wk
C. ASSET INFORMATION List all information for Tenant, Spouse, Co-Tenant 1. Cash on hand not in the bank $ 2. CHECKING ACCOUNT Account # Bank Account # Bank $ $ 3. SAVINGS ACCOUNT (INCLUDING IRAs) Account # Bank Account # Bank 4. STOCKS AND / OR BONDS Type: Number Owned Value $ $ $ Type: Number Owned Value $ 5. C.D. and Money Market Accounts Account # Bank $ Account # Bank $ 6. REAL ESTATE OWNED AT PRESENT TIME OR SOLD WITHIN LAST 2 YEARS PERIOD: Market Value: $ year sold amount sold for (if sold within last 2 year period, list amount sold for) $ Market Value: $ year sold amount sold for (if sold within last 2 year period, list amount sold for) $ 7. PROPERTY SOLD UNDER LAND CONTRACT Original amount of land Contract Outstanding balance at present time. $ $ Terms of Land Contract: $ per mo. OR $ per year. 8. LIST ALL OTHER ASSETS Type: Value: $ Type: Value: $ 9. INTEREST EARNED AND DIVIDENDS
Type: Interest earned Dividends Value: $ Type: Interest earned Dividends Value: $ I/we certify that the rental unit which I/we will occupy will be my/our primary residence and further certify that I/we do not and will not maintain a separate subsidized rental unit in a different location. I/we certify that I/we are not presently using or addicted to a controlled substance, nor have I/we ever been convicted of possession or distribution of a controlled substance. I/we certify that I/we have never been convicted of a felony, and are not presently on any sex offenders list or registry. I/we certify that all of the information on this application is true and correct to the best of my/knowledge and belief. Inquires may be made to verify this information. Applicant s Signature Co-applicant s Signature Date Date The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through Rural Housing Service, that Federal Laws prohibiting discrimination against tenant applications 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 individual applicants on the basis of visual observation or surname. STATEMENT REQUIRED BY THE PRIVACY ACT. Rural Development is authorized by the Title V of the Housing Act of 1949, amended (42 U.S.C. 1471 et. seq.) to solicit the information requested on this form. Disclosure of the information requested is voluntary to enable monitoring. However, failure to disclose certain items of information may result in a delay in the processing of your eligibility or rejection, except that it is unlawful for Rural Development to deny eligibility because of the refusal to disclose the Social Security Number. The principal purposes for collecting the requested information are to determine eligibility for occupancy in the Rural Housing Services, rental project and to determine the amount of tenant contribution for rent. The information collected on this form may be released to appropriate Federal, State and Local Agencies when relevant to civil, criminal or regulatory proceedings. In accordance with Federal law and the U.S. Department of Agriculture's policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights, Room 326- W, Whitten Building, 1400 Independence Avenue, SW., Washington, DC 20250-9410 or call 202-720-5964 (Voice and TDD). USDA is an equal opportunity provider and employer.
APPLICANT VOLUNTARY INFORMATION The information solicited on this application is requested in order to determine eligibility for a government housing program and eligibility with respect to the owner s credit and reference policies. Applications will be judged on the basis of these written policies and NOT on the basis of race, color national origin, sex, marital status, age, familial status, or handicap. The following information is requested by the Michigan State Housing Development Authority to monitor this marketing agent s compliance with Equal Credit Opportunity and Fair Housing Law. The law states that a leasing agent may discriminate based neither on this information nor on whether or not it is furnished. Providing this information is optional. If you do not wish to furnish the following information, please initial below. Applicant: I do not wish to furnish this information. Co-Applicant: I do not wish to furnish this information. PLEASE COMPLETE BOTH SECTIONS Applicant: ( ) Hispanic or Latino Co-Applicant: ( ) Hispanic or Latino ( ) Not-Hispanic or Latino ( ) Not-Hispanic or Latino ( ) Male ( ) Female ( ) Male ( ) Female Race/National Origin: Applicant Co-Applicant ( )..American Indian or Alaska Native.( ) ( )..Asian......( ) ( )..Black or African American ( ) ( )..Native Hawaiian or Other Pacific Islander..( ) ( )..White....( )
NOTICE AND CONSENT TO RELEASE CREDIT & CRIMINAL BACKGROUND INFORMATION Eastbrook Apartments I hereby, authorize PK Housing & Management Co. or Eastbrook Apartments to request and obtain credit & criminal information from the Credit Bureau CoreLogic SafeRent, for the purpose of verifying my eligibility to rent from the referenced apartment community. Applicant s Signature Date Please Print the following information: First, Middle and Last Name Social Security Number: - - Date of Birth: Gender: (circle one) Male or Female Home Phone Number: ( ) - Employers Name: Current Street Include Apt # or Suite # - (NO P.O Box numbers please) City: State: Zip Code: Are you applying with someone else? Yes or No If yes, Who? Did you supply a copy of your Drivers License & Social Security Card? (If you do not we CANNOT qualify you for an apartment.) OFFICE USE ONLY: Sec. Dep. Amt: Rent Amt: # of Bedrooms: Current Monthly Income: Current Rent Amt: Marketing Source: APPROVED APPROVED WITH CO-SIGNER DENIED
Eastbrook Apartments LEASE ADDENDUM FOR DRUG-FREE HOUSING In consideration of the execution or renewal of a lease of the dwelling unit identified in the lease, Owner and Tenant agree as follows: 1. Tenant, any member of the tenant s household, or a guest or other person under the tenant s control shall not engage in criminal activity including drug related criminal activity, on or near project premises. Drugrelated criminal activity means the illegal manufactured, sale, distribution, use, or possession with intent to manufacture, sell, distribute, or use of a controlled substance (as defined in Section 102 of the Controlled Substance Act (21 U.S. C. 802). 2. Tenant, any member of the tenant s household or a guest or other person under the tenant s control shall not engage in any act intended to facilitate criminal activity, including drug-related criminal activity, on or near project premises. 3. Tenant or members of the household will not permit the dwelling unit to be used for or to facilitate criminal activity, including drug-related criminal activity, regardless of whether the individual engaging in such activity is a member of the household or a guest. 4. Tenant or members of the household will not engage in the manufacture, sale or distribution of illegal drugs at any location, whether on or near project premises or otherwise. 5. Tenant, any member of the tenant s household, or a guest or other person under the tenant s control shall not engage in acts of violence or threats of violence, including, but not limited to, the unlawful discharge of firearms, on or near project premises. 6. VIOLATION OF THE ABOVE PROVISIONS SHALL BE A MATERIAL VIOLATION OF THE LEASE AND GOOD CAUSE FOR TERMINATION OF TENANCY. A single violation of any of the provisions of this added addendum shall be deemed a serious violation and a material non-compliance with the lease. It is understood and agreed that a single violation shall be good cause for termination of the lease. Unless otherwise provided by law, proof of violation shall not require criminal conviction, but shall be by a preponderance of the evidence. 7. In case of conflict between the provisions of this addendum and any other provisions of the lease, the provisions of the addendum shall govern. 8. This Lease Addendum is incorporated into the lease executed or renewed this day between Owner and Tenant. Applicant Applicant Site Manager Date: Date: Date: