Housing Community Information

RESIDENTIAL RENTAL PRE-APPLICATION

Completed pre-applications should be submitted directly to the MANAGEMENT OFFICES of the HOUSING COMMUNITIES being applied to (refer to the Dwelling Place Housing Fact Sheet for contact details). Apply to ONE community PER pre- application. Individual pre-applications are to be completed by each household member 18 years or older. Contact the management offices with property specific questions or if there are any changes to the information provided on this pre-application.

HOUSING COMMUNITY APPLYING FOR:

(Specify the name of ONE housing community as described above) WHEN ARE YOU AVAILABLE TO MOVE?

APARTMENT REQUIREMENTS

Type of Residence: Efficiency/studio 1 bedroom 2 bedrooms 3 bedrooms Do you require barrier-free, hearing, and/or visually impaired accommodations? Yes No Do you have a pet? Yes No

APPLICANT INFORMATION

Last Name First Name Middle Name

Address City State Zip Code

Mailing Address (if different from above) City State Zip Code Phone Number(s) Email Address

Date of Birth / / __ Last 4 digits SSN XXX – XX - Current Landlord’s Name Address

Phone Number Length of Stay Rent Amount

HOUSEHOLD INFORMATION: Complete the information below for ALL persons to occupy the residence. Include income for all persons to occupy the residence. Types of income include wages, social security, pensions, etc. Full Legal Name Relationship Full Time Student Date of Birth Total Gross Income (circle one) Head of

Household

Yes / No

Weekly

Monthly

Yearly

Yes / No

Weekly

Monthly

Yearly

Yes / No

Weekly

Monthly

Yearly

Yes / No

Weekly

Monthly

Yearly

Yes / No

Weekly

Monthly

Yearly

Yes / No

Weekly

Monthly

Yearly

Updated 10.28.2020

MISCELLANEOUS INFORMATION

Are you or a member of your household listed on a sex offender registry? Yes No Do you have any rental assistance (i.e. tenant/housing voucher, etc.)? Yes No If yes, name subsidy provider.

Do you have a legal guardian? Yes No

If yes, the legal guardian must sign this pre-application and provide their name, contact information, and court order. EMERGENCY CONTACT

CASEWORKER (if applicable)

HOW DID YOU HEAR ABOUT THE COMMUNITY?

VOLUNTARY INFORMATION

RACE/ETHNICITY FOR HEAD OF HOUSEHOLD (Choose all that apply):

Caucasian African American American Indian Asian Hispanic Pacific Islander Multi Other GENDER:

Male Female Non-Binary or Third Gender Prefer to self-describe SIGNATURE

I CERTIFY THAT I AM NOT RENTING A ROOM OR APARTMENT UNDER ANY OTHER NAME AND HAVE NOT USED ANY OTHER SOCIAL SECURITY NUMBER OTHER THAN THAT WHICH HAS BEEN LISTED. I CERTIFY THAT THE APARTMENT/HOME WILL BE MY/OUR ONLY RESIDENCE IF ACCEPTED. I UNDERSTAND THAT THE ABOVE INFORMATION IS BEING COLLECTED TO DETERMINE MY ELIGIBILITY. I AUTHORIZE THE OWNER/ MANAGEMENT TO VERIFY ALL INFORMATION PROVIDED ON THIS APPLICATION AND TO CONTACT PREVIOUS OR CURRENT LANDLORDS OR OTHER SOURCES FOR CREDIT, AND/OR CRIMINAL HISTORY VERIFICATION INFORMATION WHICH MAY BE RELEASED TO APPROPRIATE FEDERAL, STATE, OR LOCAL AGENCIES. I CERTIFY THAT THE STATEMENTS MADE IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF. I UNDERSTAND THAT ANY OMISSION, MISREPRESENTATION OR FALSE INFORMATION WILL BE CAUSE FOR REJECTION AND ARE ALSO PUNISHABLE UNDER FEDERAL LAW. I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO CONTACT EACH HOUSING COMMUNITY TO WHICH I AM APPLYING TO MAKE ANY NECESSARY CHANGES OR UPDATES TO MY APPLICATION. APPLICANT SIGNATURE DATE

STAFF USE ONLY: If the following information is required by the housing community you are applying for, a staff member will indicate to you if it needs to be filled out. Race/ethnicity and gender information is voluntary. Full Legal Name US Citizen Race/Ethnicity Gender Social Security # Veteran (circle one) Yes/No

Yes/No

Yes/No

Yes/No

This institution is an equal opportunity provider. For general questions, contact the Dwelling Place Main Office. Telephone: 616-***-****, 888-***-****, TDD: 7-1-1

www.dwellingplacegr.org

Name

Phone Number

Address

Relationship

Name and Company/Organization

Phone Number

STAFF USE ONLY

INITIALS

DATE

TIME

Contact this candidate