Scenic Hill Housing Application

We are pleased to consider your household as future residents.The information you provide below will be used to determine your eligibility. All information will be kept confidential. Failure to provide the required information will prevent us from processing your application. Misrepresentation of information is punishable by law. Please answer all questions.There is no smoking in these units and this is a pet free property.

APPLICANT INFORMATION

Last Name

*

First Name

*

Middle Initial

Date of Birth

*

Social Security Number

*

Present Address

*

(PO Box/Mailing Address)

City

*

State

*

Zip

*

Phone

*

Email

*

HOUSEHOLD COMPOSITION AND STATUS

List the Head of Household (applicant) and ALL other persons who will be living in your unit.

Chose only one member to be the Head of Household. State the relationship of each additional household member to the head.

List all members you anticipate to live in your unit at least 50% of the time in the next 12 months including anyone who is not currently a household member but is anticipated to become one in the next 12 months.

Include any temporarily absent household members.

Household Member’s Full Name

*

(first and last)

Relationship to Head

*

Date of Birth

*

Social Security Number

*

Has any member of the household used another name (for example, maiden name) or social security number?*

Yes

No

Do you expect any changes to the household in the next 12 months?*

Yes

No

Do you certify that this unit will be your permanent residence and that you will not/do not maintain a separate residence unit in a different location?*

Yes

No

Would you like to sign a release form for a person or agency to assist with your application process?*

Yes

No

Income Source

*

If Yes, Household Member

*

Monthly Gross Income

*

Other Assets not listed above?*

Yes

No

Please list below all former addresses within the past 7 years, starting with the present:

Current Address

*

Do you Rent or Own?

*

City

*

State

*

Zip

*

Landlord/Mortgage Company

*

Rent/Mortgage

*

Phone

*

Move In Date

*

Reason for Leaving

*

Previous Address

Do you Rent or Own?

City

State

Zip

Landlord/Mortgage Company

Rent/Mortgage

Phone

Move In Date

Move Out Date

Reason for Leaving

1. Have you ever been evicted from tenancy?*

Yes

No

2. Have you ever filed for bankruptcy?*

Yes

No

3. Have you ever been convicted of a felony?*

Yes

No

4. Are you subject to Sex Offender Registry requirements in any State?*

Yes

No

5. Do you have any drug related convictions?*

Yes

No

6. Have you lived outside of Wisconsin?*

Yes

No

7. Will you have 50% or more physical custody of all minor members in the household?*

Yes

No

9. Are household members U.S. Citizens or have Eligible Immigration Status?*

Yes

No

ALL ADULT HOUSEHOLD MEMBERS MUST SIGN THIS FORM

CERTIFYING ACCURACY AND COMPLETENESS OF INFORMATION PROVIDED

I/we certify that the information on this rental application is true and complete to the best of my knowledge and understand that this information will be used to verify income eligibility for the program that I/we have applied. I further understand and agree that the owner/management agent will use this information to investigate my/our credit worthiness through credit bureau, criminal checks and landlord verification. I/we further understand that any applicant who purposefully falsifies, misrepresents or withholds any information related to program eligibility or submits inaccurate and/ or incomplete information on this application will not be considered for housing. Furthermore, if such misrepresentation or omission is discovered after tenancy has begun, I/we understand that I/we may be subject to eviction or punishable by law.

Under penalty of perjury. I swear that I have read the above statement and I grant my consent for the release of information to all necessary third parties as needed for verification purposes.

Applicant Signature

*

Date

*

Scenic Hill Housing Application

APPLICANT INFORMATION

Last Name

First Name

Middle Initial

Date of Birth

Social Security Number

Present Address

City

State

Zip

Phone

Email

HOUSEHOLD COMPOSITION AND STATUS

Household Member’s Full Name

Relationship to Head

Date of Birth

Social Security Number

Please list details

Please list details

Income Information

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

If Yes, Household Member

Monthly Gross Income

Income Source

If Yes, Household Member

Monthly Gross Income

Please list the asset(s):

Please list below all former addresses within the past 7 years, starting with the present:

Current Address

Do you Rent or Own?

City

State

Zip

Landlord/Mortgage Company

Rent/Mortgage

Phone

Move In Date

Reason for Leaving

Previous Address

Do you Rent or Own?

City

State

Zip

Landlord/Mortgage Company

Rent/Mortgage

Phone

Move In Date

Move Out Date

Reason for Leaving

Please list details