LOW INCOME HOUSING TAX CREDIT RENTAL APPLICATION

All co-applicants, age 18 or older, including spouse, should complete a separate application.

We are pleased to consider your family as future residents of our rental community. The information you provide below will assist us in determining

your eligibility. All information will be kept confidential. Failure to provide the required information will prevent us from considering your

application. Misrepresentation of information is punishable by law.

Please answer all questions. Write N/A if a question is not applicable. Do not leave any questions blank or unanswered.

HOUSEHOLD COMPOSITION AND STATUS:

List the Head of Household (applicant) and all other persons who will be living in your unit. State the relationship of each family member to the Head. Choose only one member to be Head of Household. List all members you anticipate to live with you 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 temporally absent family members.

* A household member should be considered a full-time (FT) or part-time (PT) student if he/she has attended school in the current calendar year, is currently attending, OR plans to attend school in the next 12 months. Please include all school-age children, even if home-schooled as FT students.

Household Member’s Full Name

*

(first and last)

Relationship to Head

*

Date of Birth

*

Marital Status

Social Security Number

*

Is the household member a Student?*

Yes

No

Phone #

*

Email address

*

Are all household members full time students?*

Yes

No

INCOME SOURCES

I have or receive the following:

I have or receive Income from a Job (Employment)*

Yes

No

Employer Name

*

Monthly Amount

*

Notes

I have or receive Income from Self-Employment*

Yes

No

Includes sources such as and others: App Based Driving Services (e.g. Uber, DoorDash); Sales with E-Commerce (e.g. Shopify, Ebay, Etsy); Video platforms (e.g. YouTube)

I have or receive Income from Social Security*

Yes

No

I have or receive Income from Supplemental Security Income (SSI)*

Yes

No

I have or receive Income from Pension / Veteran’s Administration*

Yes

No

I have or receive Income from TANF / AFDC*

Yes

No

I have or receive Income from Trusts, Annunities, Inheritance, Pensions, Insurance Policies or similar Periodic Payments or Dispersements*

Yes

No

Source

*

Monthly Amount

*

Notes

I have or receive Income from Adoption Assistance*

Yes

No

I have or receive Income from Recurring, even if sporadic, non-monetary In-kind donations from outside the household*

Yes

No

I have or receive Income from Child Support *

Yes

No

I have or receive Income from Alimony*

Yes

No

I have or receive Income from Unemployment Benefits*

Yes

No

I have or receive Income from Educational Financial Assistance*

Yes

No

I have or receive Income from Military Pay*

Yes

No

Do you receive recurring payments from persons not living in the unit?*

Yes

No

Source

*

Monthly Amount

*

Notes

I have or receive other sources of income not listed above*

Yes

No

Source

*

Monthly Amount

*

Notes

ASSET SOURCES

Non-Necessary Personal Property

Do you have a Checking Account?*

Yes

No

Do you have a Savings/Holiday Account?*

Yes

No

Do you have a Certificates of Deposit (CD)?*

Yes

No

Do you have a Direct Express ® Card?*

Yes

No

(or any card where benefits or pay are deposited)

Do you have Cash on Hand?*

Yes

No

Do you have Cryptocurrency?*

Yes

No

(e.g. Bitcoin)

Do you have Internet Based Funding?*

Yes

No

(e.g. GoFundMe)

Do you have Stocks, Bonds, Revocable Trusts or Annuities?*

Yes

No

Do you have Money Market or Mutual Funds?*

Yes

No

Do you have Treasury Bills?*

Yes

No

Do you have a Safe Deposit Box?*

Yes

No

I have other non-necessary personal property, including but not limited to, recreational vehicles or boats not needed for day-to-day transportation, expensive jewelry without religious or cultural value or which does not hold family significance, collectibles such as coins or stamps, equipment or machinery that is not used to generate income for a business, or items such as gems/precious metals, antiques, artwork etc.*

Yes

No

Do not include necessary personal property such as, but not necessarily limited to, vehicles relied on for transportation, furniture, carpets, linens, kitchenware, common appliances, common electronics, clothing, personal effects that are not luxury items such as toys or books, wedding and engagement rings, jewelry used in religious/cultural ceremonies, medical equipment and supplies, health care-related supplies, musical instruments used by the family, personal computers or tablets, phones, professional tools of trade, educational materials, equipment to accommodate persons with disabilities, or exercise equipment.

Type

*

Cash Value

*

Have you received any Lump Sum Amounts?*

Yes

No

(e.g. inheritances, capital gains, lottery winnings, insurance settlements)?

Do you have Whole Life Insurance or Universal Life Insurance?*

Yes

No

Other*

Yes

No

Have you received a federal tax refund for refundable tax credit in the past 12 months?*

Yes

No

Do you own Real Property, e.g. a Home, Rental Property or other Capital Investments?*

Yes

No

Have you disposed of any assets for more than $1,000 below their Fair Market Value (FMV), given away or otherwise transferred ownership of assets within the last two years?*

Yes

No

Do not include separation, divorce, bankruptcy, or foreclosure.

Total Value of Non-Necessary Personal Property

*

RESIDENTIAL HISTORY

Please provide 3 years of housing history

Current Address

*

City/State/Zip

*

Do you

*

Date Moved In

*

Landlord Name/Mortgage Company

*

Rent/Mortgage

*

Phone

*

Reason for leaving

*

Do you have a previous address?*

Yes

No

Previous Address

*

City/State/Zip

*

Do you

*

Date Moved In

*

Landlord Name/Mortgage Company

*

Rent/Mortgage

*

Phone

*

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 crime?*

Yes

No

4. Will this be your only place of residence?*

Yes

No

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

Yes

No

6. Will you be receiving rental assistance while living at this community?*

Yes

No

7. Do you own any pets that would be moving with you into the community?*

Yes

No

OTHER INFORMATION

Do you have a vehicle?*

Yes

No

Type of Vehicle (car, truck, etc.)

*

License Plate #

*

Make/Model

*

Year

*

Color

*

EMERGENCY INFORMATION

In case of emergency, notify...

Name

*

Phone

*

Relationship

*

CERTIFICATION OF ACCURACY AND COMPLETENESS

I certify that all information provided in 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 tax credit program under which I applied. I further understand and

agree that the owner/management agent will use this information to investigate My credit worthiness through credit bureau, criminal

checks and landlord verification. I 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 understand that

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.

LOW INCOME HOUSING TAX CREDIT RENTAL APPLICATION

Household Member’s Full Name

Relationship to Head

Date of Birth

Marital Status

Social Security Number

Student Status

Phone #

Email address

INCOME SOURCES

Employer Name

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Source

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Monthly Amount

Notes

Source

Monthly Amount

Notes

Source

Monthly Amount

Notes

ASSET SOURCES

Current Balance

Interest Rate

Current Balance

Interest Rate

Cash Value

Interest Rate

Balance

Amount

Cash Value

Annual Earnings

Cash Value

Annual Earnings

Cash Value

Annual Earnings

Cash Value

Annual Earnings

Cash Value

Annual Earnings

Cash Value

What is held in the Box?

Type

Cash Value

Source

Date

Amount

Cash Value

Annual Earnings

Amount Received

Cash Value

Notes

Date

List items

Total Value of Non-Necessary Personal Property