Hoosier Uplands

Persimmon Park Apartments

406 Wade Street
Mitchell, IN 47446
npowell@hoosieruplands.org
(812) 849-4639

Rental Application RD

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 - RD
    Please click here to download a printable version of the Hoosier Uplands - Rental Housing Application - RD and fill out manually

    Rental Housing Application


    Name of the apartment complex you are applying for
    Persimmon Park Apartments
    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
    Choose...
    Marital Status
    Choose...
    Driver's License Number
    Driver's License State


    Rental History

    Last two years
    Current Address
    City
    State
    Zip
    Start Date of Occupancy
    End Date of Occupancy
    Monthly Payment
    Approximate monthly cost of utilities paid by you (excluding phone and TV):

    Reason for Moving

    How?
    Present Landlord Name
    Landlord Phone Number
    Previous Address
    City
    State
    Zip
    Start Date of Occupancy
    End Date of Occupancy
    Monthly Payment
    Approximate monthly cost of utilities paid by you (excluding phone and TV):

    Reason for Moving

    How?
    Previous Landlord Name
    Landlord Phone Number


    Household Composition

    List all persons that will be occupying the unit
    Full Name
    Relationship to Head of Household
    Date of Birth
    Social Security Number
    Total Annual Income

    Total Number of Occupants

    If yes, please explain


    GENDER / RACE / ETHNICITY STATUS

    The information regarding sex designation, race, and ethnicity are requested to assure the Federal Government, acting through the Rural Housing Service, that federal laws prohibiting discrimination against tenant applications on the basis on race, color, national origin, religion, sex, familial status, age, and disability are complied with. This information will not be used in evaluating your application or to discriminate against you in any way
    First Name
    Gender


    Disability Status

    If you require an accommodation, please list specific modifications needed:


    Attendant

    If a care attendant will be living with you permanently or on a periodic basis, please list:
    Name of Care Attendant:
    A criminal background check of the Attendant is required.
    Phone Number:


    Student Status

    If yes, please explain:


    General Questions

    Name and phone # of childcare provider

    (Not all properties allow pets and certain breeds may not be allowed)
    Please list breed and weight


    Character References

    Name
    Relationship
    Phone
    Name
    Relationship
    Phone


    Medical

    If you answer yes to either of the two questions below, you will be asked to complete Form #20A-Expense List.

    Elderly is defined as an individual who is 62 years old or older.


    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
  • 3 Hoosier Uplands - Background Check Release
If you are done filling out the forms, please click on the "Submit" button at the bottom of the screen.
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