Evergreen Terrace Apartments

1360 Carpenter Street
Albany, OH 45710

(740) 698-0004

evergreenterrace@pmiohio.com

Please click here to download a printable version of the Premier Management, LLC. - Rental Application and fill out manually

Rental Application

General Information

Apartment Community
*
Number of individuals who will reside in the apartment
*
Number of bedrooms desired
Applicant First Name
*
Middle Initial
Last Name
*
Phone
*
2nd Phone
Maiden Name and/or any other names you have ever been known by
*
Co-Applicant Name
Phone
2nd Phone
Maiden Name and/or any other names you have ever been known by
How did you hear about this property?

Household Composition

Fill in the information requested below for each individual who will reside in the apartment (include the applicant and/or co-applicant):
Full Name
*
Relationship to Applicant
*
Gender
*
* Social Security Number
*
Birth Date
*
City & State of Birth
*
* List any household member, who was age 62 or older as of January 31, 2010, and who does not have a Social Security Number, who received HUD rental assistance at another location on January 31, 2010.
List all states in which any household member has resided
*

Whom?
*

References & Emergency Contact

Applicant

List 2 people (who are not related to you) as personal references AND list 1 person to be contacted in case of an emergency.

1st Personal Reference:

Name
*
Phone
*
Address
*
City
*
State
*
Zip Code
*

2nd Personal Reference:

Name
*
Phone
*
Address
*
City
*
State
*
Zip Code
*

Emergency Contact:

Name
*
Relationship to Applicant
*
Phone
*
Address
*
City
*
State
*
Zip Code
*

Co-Applicant

List 2 people (who are not related to you) as personal references AND list 1 person to be contacted in case of an emergency.

1st Personal Reference:

Name
*
Phone
*
Address
*
City
*
State
*
Zip Code
*

2nd Personal Reference:

Name
*
Phone
*
Address
*
City
*
State
*
Zip Code
*

Emergency Contact:

Name
*
Relationship to Applicant
*
Phone
*
Address
*
City
*
State
*
Zip Code
*

Income

Applicant

Amount
*
Hours Weekly
*
Employer Name
*
Phone Number
*

Monthly Amount
*

Worker’s Compensation Amount
*
Worker’s Compensation Pay Period
*

Unemployment Benefits Amount
*
Unemployment Benefits Period
*

Child Support or Alimony Amount
*
Child Support or Alimony Period
*

Monthly Amount
*

Monthly Amount
*

Monthly Amount
*

Monthly Amount
*

Amount
*
Other Income Pay Period
*
Source
*

Co-Applicant

Amount
*
Hours Weekly
*
Employer Name
*
Phone Number
*

Monthly Amount
*

Worker’s Compensation Amount
*
Worker’s Compensation Pay Period
*

Unemployment Benefits Amount
*
Unemployment Benefits Period
*

Child Support or Alimony Amount
*
Child Support or Alimony Period
*

Monthly Amount
*

Monthly Amount
*

Monthly Amount
*

Monthly Amount
*

Amount
*
Other Income Pay Period
*
Source
*

Assets

Applicant

Name of Bank
*
Phone Number
*

Balance
*
Interest Rate
*

Balance
*
Interest Rate
*

Balance
*
Interest Rate
*

Type of Account
*
Balance
*
Interest Rate
*

Balance
*

Cash Value
*
Dividend
*

Please describe it briefly
*

Please list items
*

Assets

Co-Applicant

Name of Bank
*
Phone Number
*

Balance
*
Interest Rate
*

Balance
*
Interest Rate
*

Balance
*
Interest Rate
*

Type of Account
*
Balance
*
Interest Rate
*

Balance
*

Cash Value
*
Dividend
*

Please describe it briefly
*

Please list items
*

Expenses

Applicant

Child Care Cost
*
Per
*
Number of Hours
*
Per
*
If you are 62 years of age or older or disabled, you are entitled to a $400.00 deduction from your annual income, and qualify to deduct any of the following medical costs.

Please indicate any medical costs paid on a recurring basis. (Indicate only amount for which you are not reimbursed from any source).

Monthly Premium
*

Premium
*
Premium Period
*
How many Doctor Visits do you make per year?
*
Cost Per Visit
*

Monthly Cost

Cost
*
Per
*
Type of Medical Expense
*

Expenses

Co-Applicant

Child Care Cost
*
Per
*
Number of Hours
*
Per
*
If you are 62 years of age or older or disabled, you are entitled to a $400.00 deduction from your annual income, and qualify to deduct any of the following medical costs.

Please indicate any medical costs paid on a recurring basis. (Indicate only amount for which you are not reimbursed from any source).

Monthly Premium
*

Premium
*
Premium Period
*
How many Doctor Visits do you make per year?
*
Cost Per Visit
*

Monthly Cost

Cost
*
Per
*
Type of Medical Expense
*

When?
*
Where?
*

When?
*
Where?
*

Residential History

Applicant

Please provide a period of at least 3 years of residential history.
Present Address
*
City
*
State
*
Zip Code
*
Length of Residency
*
Rent
*
Landlord’s Name
Landlord’s Phone
Landlord’s Address
City
State
Zip Code
Previous Address
*
City
*
State
*
Zip Code
*
Length of Residency
*
Rent
*
Landlord’s Name
Landlord’s Phone
Landlord’s Address
City
State
Zip Code

Residential History

Co-Applicant

Please provide a period of at least 3 years of residential history.
Present Address
*
City
*
State
*
Zip Code
*
Length of Residency
*
Rent
*
Landlord’s Name
Landlord’s Phone
Landlord’s Address
City
State
Zip Code
Previous Address
*
City
*
State
*
Zip Code
*
Length of Residency
*
Rent
*
Landlord’s Name
Landlord’s Phone
Landlord’s Address
City
State
Zip Code

Identification & Signatures

IDENTIFICATION IS REQUIRED. Please present your driver’s license or another form of identification, and READ THE FOLLOWING PARAGRAPH BEFORE SIGNING THIS APPLICATION:

By my signature below, I understand and agree that my credit and references will be checked and all other information provided on this application may be verified by a representative of this apartment community or Premier Management, LLC.

I certify that if I am accepted for residency in this apartment community, this will be my permanent residence and I will not maintain a separate residence in a different location.

I FURTHER CERTIFY THAT THE FACTS IN THIS APPLICATION ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT, FALSIFIED OR FRAUDULENT STATEMENTS MADE ON THE APPLICATION WILL LEAD TO THE REJECTION OF THIS APPLICATION. CREDIT INQUIRIES WILL BE PROCESSED THROUGH MERIT CHEQUE.

If yes, whom?
*

If yes, list County
*
State
*
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA  programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including
gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity  conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by
program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at  (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,  program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed  to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form,  call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office  of the Assistant Secretary for Civil Rights,1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202)  690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.

Applicant

Applicant’s Signature
*
Date
*
Please upload a picture of Driver’s License or other form of I.D.
*
License Number & Make of Automobile (s):
1st Auto
2nd Auto

Co-Applicant

Co-Applicant’s Signature
*
Date
*
Please upload a picture of Driver’s License or other form of I.D.
*
License Number & Make of Automobile (s):
1st Auto
2nd Auto

Statistical Info

The information regarding race, ethnicity and gender designation solicited on the application is requested in order to assure the Federal Government, acting through the Rural Housing Service that the Federal law prohibiting discrimination against tenant applications on the basis of race, color, national origin, sex, age, disability, religion and familial status are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and gender of the individual applicants on the basis of visual observation or surname.
Ethnicity
Gender
Race
Marital Status of Applicant
PENALTIES FOR MISUSING THIS CONSENT:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at **208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a) (6), (7) and (8).**
Equal Housing Opportunity
This institution is an equal opportunity provider and employer.
Handicap Accessible