Hoosier Uplands

Midtown Suites Apartments

122 N. 6th Street
Mitchell, IN 47446
npowell@hoosieruplands.org
(812) 849-4639

Rental Application

If you are done filling out the forms, please click on the "Submit" button at the bottom of the screen.
If you are done filling out the forms, please click on the "Submit" button at the bottom of the screen.
  • 1 Hoosier Uplands - Rental Housing Application
    Please click here to download a printable version of the Hoosier Uplands - Rental Housing Application and fill out manually

    Rental Housing Application

    Name of the apartment complex you are applying for
    Name of Applicant
    *
    (First, Middle Initial, Last)
    Name of Co-Applicant
    (if applicable - additional applicant must be completed)
    Applicant Email Address
    *
    Applicant Phone Number
    *
    Application Type
    Marital Status
    Driver's License Number
    Driver's License State

    Household Composition

    List all persons that will be occupying the unit
    Full Name
    Relationship to Head of Household
    Date of Birth
    Social Security Number
    Employed?
    Student?

    Rental History

    Last two years

    Present Landlord Name
    Present Landlord Phone
    Landlord Address
    City
    State
    Zip
    Start Date of Occupancy
    End Date of Occupancy
    Are you related to Landlord?
    How are you related to landlord?
    Please indicate how you are related to the landlord if applicable
    Previous Landlord Name
    Previous Landlord Phone
    Previous Landlord Address
    City
    State
    Zip
    Start Date of Occupancy
    End Date of Occupancy
    Are you related to Landlord?
    How are you related to landlord?
    Please indicate how you are related to the landlord if applicable

    General Questions

    Have you or any household member ever been convicted of a felony?
    Have you ever been evicted?
    Eviction Reason
    If you have ever been evicted, please explain
    Have you or any household member been arrested or convicted of a drug related crime?
    Does anyone not listed in the household composition section plan to live with you in the next 12 months?
    If yes, explain
    Will the Household be receiving Section 8 housing assistance?
    If yes, please list agency name, contact person and phone number
    Are there any absent household members who under normal conditions would live with you?
    Does an adult of this household have primary physical custody of every child listed on this application?
    Does your household have or anticipate having any pets other than those used as a service animal?
    Does anyone in your household have special needs?
    If yes, please explain

    Credit References

    Loans
    Credit Cards
    Other

    Character References

    Name
    Relationship
    Phone
    Name
    Relationship
    Phone

    Emergency Contact Number

    In case of emergency, please notify
    Name
    Home Phone
    Work Phone
    Applicant certifies the above information is true and accurate and understands that false or inaccurate information shall be cause for denial of this application or termination of any subsequent rental agreements. I/We are the only person(s) who will reside in the apartment if this application is approved. Apartment owner or agents may verify all information given directly or through reporting agencies. Acceptance of the application is not binding on apartment owner or agent until approved in writing.

    You have applied to live in an apartment that is governed by the Low Income Housing Tax Credit Program. This Program requires us to certify all of your income asset and eligibility information as part of determining your household’s eligibility. Program requirements state we must verify each income and asset source as well as other claims of eligibility. We must determine this prior to granting your eligibility and, if such eligibility is granted, each subsequent year you remain in the unit. The undersigned is the person(s) named above and hereby authorizes Apartment Credit Services to conduct a search of my Criminal Record, Police Record and Motor Vehicle Record information for the purpose of obtaining housing. Additionally, I authorize all companies and law enforcement agencies to release such information, and release them from any liability and responsibility from doing so. A faxed copy of this authorization shall be as valid as the original.

    If applicant cancels after two (2) days, all moneys deposited shall be forfeited to the apartment owner. If approved all moneys deposited with this application will be applied toward security deposit and/or processing fee at owner’s discretion. If an application is denied for ANY reason a 90-day wait period is required before reapplying to this property.
    Head Signature
    *
    Co-head Signature
    Co-Applicant Signature
  • 2 Hoosier Uplands - Authorization to Release Information
    Please click here to download a printable version of the Hoosier Uplands - Authorization to Release Information and fill out manually

    Authorization to Release Information

    Name of the apartment complex you are applying for
    Applicant Contact Information
    Applicant Name
    *
    (First, Middle Initial, Last)
    Email Address
    *
    Phone Number
    *
    The undersigned individual(s) has applied for residency at _PROPERTY_. The property is operated under federal affordable housing regulations, which require that we obtain written confirmation of the eligibility of all applicants and household members. In order to comply with federal regulations, please complete the following form in full and return it to the sender at your earliest convenience.

    Verifications and inquiries that may be requested include, but are not limited to:
    • Credit and Criminal Activity 
    • Identity and Marital Status 
    • Previous Residences and Rental Activity
    • Employment, Income, and Assets 
    • Medical Allowances 
    • Student Status
    The groups or individuals that may be asked to release/verify the above information (depending on program requirements) include, but are not limited to:
    • Courts and Post Offices
    • Law Enforcement Agencies
    • Medical Providers
    • Retirement Systems
    • Banks and Other Financial Institutions
    • Past and Present Employers
    • State Unemployment Agencies 
    • Veterans Administration
    • Social Security Administration 
    • Previous Landlords (Including PHA’s)
    • Utility Companies
    • Credit Providers and Bureaus 
    • Welfare Agencies
    • Internal Revenue Service

    I/we agree that a photocopy of this authorization may be used for the purposes stated above. The original signed copy of this authorization is on file in the management office and will stay in effect for two years from the date signed. I/we understand that I/we have a right to review my/our file and correct any information that can be proven incorrect. The undersigned hereby authorizes the release of any information requested in order to determine my/our eligibility for the federal affordable housing program.
    Applicant Signature
    *
    Applicant or Resident Name
    Last 4 Digits of Social Security Number
    Co-Applicant Signature
    Co-Applicant or Co-Resident Name
    Last 4 Digits of Social Security Number
  • 3 Hoosier Uplands - Background Check Release
    Please click here to download a printable version of the Hoosier Uplands - Background Check Release and fill out manually

    Applicant Criminal Background Check Release and Authorization Form

    Name of the apartment complex you are applying for
    Applicant Contact Information
    Applicant Name
    *
    (First, Middle Initial, Last)
    Email Address
    *
    Phone Number
    *
    I, {APPLICANT_NAME} hereby authorize Hoosier Uplands or other authorized representative of the apartment community bearing this release, or copy thereof, to obtain any information pertaining to criminal court records. I hereby direct you to release such information to Hoosier Uplands or other authorized representatives of the apartment community.

    I, {APPLICANT_NAME} hereby fully release and discharge Hoosier Uplands, and their employees, agents, attorney, and their respective affiliates from all claims and damages arising out of or relating to any investigations of my background for residency.
    Current Address
    City
    State
    Zipcode
    How long at this address?
    Previous Address (if less than one year at the above address):
    Street
    City
    State
    Zipcode
    Other Name, Alias, Maiden Name
    Date of Birth
    Social Security #
    Have you ever been convicted for any crime, including sex-related or child abuse related offenses?
    please provide detailed explanation

    Please sign your name below

    *

    11/21/2024

  • 4 Hoosier Uplands - Income Certification Questionaire
    Please click here to download a printable version of the Hoosier Uplands - Income Certification Questionaire and fill out manually

    Income Certification Questionaire

    (*Note: A separate questionnaire must be completed by each adult member of the household)
    Name of the apartment complex you are applying for
    Applicant Name
    *
    (First, Middle Initial, Last)
    Questionnaire Type
    Email Address
    *
    Phone Number
    *
    I receive Section 8 rental assistance
    If yes, list the housing authority
    Amount of monthly rental assistance

    Income Information

    Include all income sources, including unearned income of minors.
    I am self employed
    List nature of self-employment
    This includes but not limited to: Rideshare companies such as Uber/Lyft, multi-level marketing companies such as Mary Kay, Total Life Changes, 1099-contractors, etc.
    Monthly Gross Income
    (use net income from business)
    I have a job and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation
    List the businesses and/or companies that pay you:
    Name of Employer
    Monthly Gross Income
    I receive cash contributions of gifts
    including but not limited to: rent, utility payments, cell phone, transportation, etc. on an ongoing basis from persons not living with me.
    Monthly Gross Income
    I receive unemployment benefits.
    Monthly Gross Income
    I receive Veteran’s Administration, GI Bill, or National Guard/Military benefits/income
    Monthly Gross Income
    I receive periodic social security payments or Supplemental Social Security Income (SSI).
    Monthly Gross Income
    The household receives unearned income from family members age 17 or under
    (example: Social Security, Trust Fund disbursements, etc.)
    Monthly Gross Income
    I receive periodic payment from lottery winnings
    Monthly Gross Income
    I receive disability or death benefits other than Social Security
    Monthly Gross Income
    I receive Public Assistance Income
    (examples: TANF, AFDC) DO NOT INCLUDE FOOD STAMPS
    Monthly Gross Income
    I am entitled to receive child support payments through court order or other agreement
    If yes, how many orders/agreements do you have?
    amount ordered
    If yes, from how many persons do you receive support?
    amount received
    List the amount received if not receiving the full agreement amount
    I am entitled to receive alimony/spousal maintenance payments
    Monthly Gross Income
    I receive periodic payments from trusts, annuities, inheritance, retirement funds or pensions, insurance policies, lottery winnings, or donation banks
    donation banks such as plasma donations
    Source
    Monthly Gross Income
    I receive income from real or personal property
    Net Earned Income
    I receive student financial assistance (grants, scholarships, etc.) not including loans
    *NOTE: Count as income only if household receives Section 8 rental assistance.
    Monthly Gross Income
    per semester
    I am claiming zero income

    Asset Information

    Include all asset sources, including assets of minors
    I have a checking account
    Number of Checking Accounts
    Bank Name
    Interest Rate
    6 months average balance
    I have a savings account
    Number of Savings Accounts
    Bank Name
    Interest Rate
    Current balance
    I have a debit card, pay card for direct deposit of benefits, or prepaid debit card(s)
    Number of cards held
    Card Name
    Current balance
    I have revocable trusts
    Bank Name
    Interest Rate
    Current balance
    I own real estate
    Description of Real Estate Owned
    I intend to
    Value
    I own stocks, bonds, or Treasury Bills
    Source or Bank Name
    Interest Rate
    Cash Value
    I have Certificates of Deposit (CD) or Money Market Account(s)
    # of accounts held
    Source or Bank Name
    Interest Rate
    Cash Value
    I have an IRA/Lump Sum Pension/Keogh Account/401K
    Bank Name
    Interest Rate
    Cash Value
    I have a whole life insurance policy
    How many policies
    Insurance Company Name
    Cash Value
    I have cash on hand
    Cash Value
    I have received lottery winnings paid in one payment (not reoccurring periodic payments)
    I have disposed of assets (i.e. gave away money/assets) for less than fair market value in the past 2 years
    Item
    Date Disposed
    I have a safe deposit box at a financial institution
    Name of Institution
    Contents
    Cash Value
    I have other personal property held as an investment, other income from assets or sources other than those listed above
    Type
    Interest Rate
    Cash value
    UNDER PENALTIES OF PERJURY, I CERTIFY THAT THE INFORMATION PRESENTED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. THE UNDERSIGNED FURTHER UNDERSTANDS THAT PROVIDING FALSE REPRESENTATIONS HEREIN CONSTITUTES AN ACT OF FRAUD. FALSE, MISLEADING OR INCOMPLETE INFORMATION WILL RESULT IN THE DENIAL OF APPLICATION OR TERMINATION OF THE LEASE AGREEMENT.
    Printed Name of Applicant/Tenant
    *

    Please sign your name below

    *

    11/21/2024

If you are done filling out the forms, please click on the "Submit" button at the bottom of the screen.
Equal Housing Opportunity
We encourage and support the nation's affirmative housing program in which there are no barriers to obtaining housing because of race, color, religion, sex, national origin, handicap or familial status.
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