Affordable Housing Application

PLEASE SELECT THE PROPERTIES THAT YOU ARE APPYING FOR

Properties	Calkins	All Others
Family of 1	$46,080	$39,480
Family of 2	$52,640	$44,400
Family of 3		$65,760
Family of 4		$49,300
Family of 5	$59,200	$71,040
Family of 6		$76,320

Applicant Name:

Date

Managing Agent requires COPIES of the following documentation for ALL HOUSEHOLD MEMBERS and Application Fee

Social Security Cards
Certified Birth Certificates (Certified copies, not complimentary copies from the hospital) or CIBs for Native Americans.
Valid State-Issued IDs (for 18 years of age or older). Must be Colorado IDs at time of Lease signing.
$40.00 Application fee for each adult- Cashiers Check or Money Order (NO CASH)

BE CERTAIN TO SIGN AND DATE WHERE REQUIRED

Once your completed Application is received, you will be placed on the waiting list by the date and time the Application is received. Submitting an application does not guarantee housing.

Complete the Application and answer all questions. If the questions do not apply to you, state either NO, NONE or N/A. Every blank must be complete. Incomplete Applications Will Be Withdrawn.

Head of Household Name:

Phone

Email address:

Your Address:

City

State

Zip

Mailing Address:

City

State

Zip

How long have you lived at this address?

Landlord's Name:

Address

Phone

Previous Address

City

State

Zip

Landlord's Name

Address

Phone

How long were at this address?

Federal Law preempts State Laws when it comes to the use of Medical Mari juana, Initial e, Medical Mari juana users are prohibited into the Public Housing and the Housing Choice v vu\.ucr (Section 8) Programs, as well as any wtlts owned or managed by the Housing Authority of the County of Montezuma.

A. Federal Drug Laws Marijuana is categorized as a Schedule I substance under the Controlled Substances Act (CSA). See 21 US. C. 801 et seq. The Manufacture, distribution, or possession of mari juana is a federal criminal offense, and it may not be legally prescribed by a physician for any reason. See 21 USC. 841 (a)(]); 812(b)(l)(A)-(C)

By signing below, I/We acknowledge and understand that the use of controlled substances for recreational use or medicinal use is prohibited on all Housing Authority of the County of Montezuma property and the use, possession and distribution of a controlled substance will be a deciding factor in the decision to provide housing assistance to you or anyone in your household.

Head of Household/ Applicant Signature

Date

Do you have pets?

Yes No

How many?

Type:

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

Race: (Mark one or More)

Gender:

Female Male

"The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government that Federal Laws prohibiting discrimination against tenant Applications on the basis of race, color, national origin, religion, sex, familial status, gender identity (including gender expression), sexual orientation, age and disability 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 sex of the individual applicants on the basis of visual observation or surname."

Submitting an application does not guarantee housing

Initial

Are you a victim of domestic violence, dating violence or stalking?

Yes No

Initial

Is there an open Protection Order or Court Case regarding any household member?

Yes No

Name(s)

Initial

In accordance with the regulations at 24 CFR 5.856 and 5.905, O/As and PHAs must Initial perfonn necessary criminal history background checks to determine if any applicant, or member of an applicant's household, is subject to a lifetime registration requirement under a State or Federal sex offender registration program. This check must be carried out with respect to the State in which the housing is located and with respect to States where applicant and members of the applicant's household are known to have resided.

Are you or any member of your household subject to a lifetime state sex offender registration program in any State?

Yes No

Please be advised that it is your responsibility to notify the Housing Authority in writing, of any CHANGE OF MAILING ADDRESS. We must be able to contact you by your current mailing address at which time a Nationwide Criminal Background Check and Credit Report will be conducted on all applicants over the age of 18.

By qualifying and accepting a unit, you agree to pay a Security Deposit set forth for said unit. The managing Agent has the right to keep said deposit (tenant would forfeit deposit) if prospective Tenant does not give a minimum of a 30-day notice that they will not be moving into said unit.

if the proper notice is given to the Managing Agent, Managing Agent has 30 calendar day to return the Security Deposit, less any administrative fees, to the address provided.

I certify that the information present on this form is true and accurate to the best of my/our knowledge. The undersigned further understands that providing false presentations herein constitutes an act of fraud. False, misleading or incomplete information will result in the denial of Application.

Prospective Tenant

Date

Other Adult

Date

Move-in Application

Head of Household Name

Head of Household Address

City

State

current address [provide previous address(es) if less than two years]

dates of residency

rent or own?

monthly payment

landlord/mortgage co. name

current address [provide previous address(es) if less than two years]

dates of residency

rent or own?

monthly payment

landlord/mortgage co. name

current address [provide previous address(es) if less than two years]

dates of residency

rent or own?

monthly payment

landlord/mortgage co. name

current address [provide previous address(es) if less than two years]

dates of residency

rent or own?

monthly payment

landlord/mortgage co. name

part 3 household income

does your household have income, assistance, or benefits from the sources listed below?

Self employment (list nature of self employment)

Yes No

Self employment (list nature of self employment)

monthly income/ assistance amount

hh mbr #

Employment with a third-party receiving wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation.If yes, list the information in Part 4 below.

Yes No

hh mbr #

Unemployment benefits

Yes No

monthly income/ assistance amount

hh mbr #

Veteran’s Administration, GI Bill, or National Guard/military benefits/income

Yes No

monthly income/ assistance amount

hh mbr #

Educational assistance (for full and part time students) in the forms of grants, scholarships, or fellowships (exclude student loan awards which must be repaid)

Yes No

monthly income/ assistance amount

hh mbr #

Retirement benefits from Social Security

Yes No

monthly income/ assistance amount

hh mbr #

Supplemental Security Income (SSI) or Social Security Disability Income (SSDI)

Yes No

monthly income/ assistance amount

hh mbr #

Unearned income from family members age 17 or under (example: Social Security, trust fund disbursements, etc.)

Yes No

monthly income/ assistance amount

hh mbr #

Disability or death benefits other than Social Security

Yes No

monthly income/ assistance amount

hh mbr #

Public housing assistance/Rental assistance/Section 8 voucher. Housing authority providing the assistance:

Yes No

monthly income/ assistance amount

hh mbr #

I/we receive public assistance income (example: TANF)

Yes No

monthly income/ assistance amount

hh mbr #

Child support payments. If yes, for how many children do you receive support?

Yes No

Child support payments. If yes, for how many children do you receive support?

monthly income/ assistance amount

hh mbr #

I am entitled to receive child support payments and am currently making efforts to collect child support owed to us. Describe efforts being made to collect child support:

Yes No

monthly income/ assistance amount

hh mbr #

Alimony/spousal support payments

Yes No

monthly income/ assistance amount

hh mbr #

Periodic payments from trusts, annuities, inheritance, retirement funds or pensions, insurance policies or lottery winnings. If yes, list sources:

Yes No

monthly income/ assistance amount

hh mbr #

Income from real or personal property

Yes No

monthly income/ assistance amount

hh mbr #

Do your family, friends, or any other person or organization outside of your household help you meet needs by giving you cash assistance? If yes, who provides the cash assistance?

Yes No

If yes, who provides the cash assistance?

What is the average cash amount you receive?

How often do you receive the cash assistance?

Weekly Yearly Monthly

Do your family, friends, or any other person or organization outside of your household help you pay a bill or expense, such as for utilities, car, gas, insurance, bus pass, telephone, cable/internet, diapers, etc.?

Yes No

If yes, who helps you pay the bills or expenses?

What is the average amount of assistance you receive?

How often do you receive the cash assistance?

Weekly Yearly Monthly

part 4 current employment information (please attach a separate form for additional employment, if needed)

Resident Name

Occupation/Title

Employer Name

Contact Person

Employer Address

City

State

Zip Code

Date Hired

Salary/Rate of Pay

Hours Worked Per Week

Work Phone

Work Fax

Resident Name

Occupation/Title

Employer Name

Contact Person

Employer Address

City

State

Zip Code

Date Hired

Salary/Rate of Pay

Hours Worked Per Week

Work Phone

Work Fax

Resident Name

Occupation/Title

Employer Name

Contact Person

Employer Address

City

State

Zip Code

Date Hired

Salary/Rate of Pay

Hours Worked Per Week

Work Phone

Work Fax

part 5 previous employment information (not required for retired persons)

Resident Name

Occupation/Title

Employer Name

Contact Person

Employer Address

City

State

Zip Code

Date Hired

Salary/Rate of Pay

Hours Worked Per Week

Work Phone

Work Fax

Resident Name

Occupation/Title

Employer Name

Contact Person

Employer Address

City

State

Zip Code

Date Hired

Salary/Rate of Pay

Hours Worked Per Week

Work Phone

Work Fax

part 6 student status certification

Students include individuals attending public or private elementary schools, middle or junior high schools, senior high schools, colleges, universities, technical, trade or mechanical schools. Students do not include individuals participating in on-the-job training or correspondence courses

please choose one option below that best describes your household

The household contains at least one occupant who is not a student and has not been and will not be a student for five months or more out of the current and/or upcoming calendar year (months need not be consecutive).

List non-student here:

The household contains all students, but is qualified because at least one occupant is a part time student. Verification of part time student status is required.

List part time student here:

The household contains all students who were, are, or will be full time for five months or more out of the current and/or upcoming calendar year (months need not be consecutive). If yes, you must answer all five questions below.

Are the students married and entitled to file a joint tax return? (attach an affidavit or tax return)

Yes No

Is at least one student a single parent with child(ren), and this parent is not a dependent of someone else, and the child(ren) is/are not dependent(s) of someone other than the parent(s)?

Yes No

Is at least one student receiving Temporary Assistance to Needy Families (TANF)?

Yes No

Does at least one student participate in a program receiving assistance under the Job Training Partnership Act, Workforce Investment Act, or under other similar federal, state, or local laws? (attach verification of participation)

Yes No

Does the household consist of at least one student who was previously under foster care? (provide verification of participation)

Yes No

part 7 household asset information

do you have assets as listed below?

Yes No

Checking account(s). If yes, list bank(s).

hh mbr #

account #(s)

interest rate

cash value

do you have assets as listed below?

Yes No

Savings account(s). If yes, list bank(s).

hh mbr #

account #(s)

cash value

interest rate

do you have assets as listed below?

Yes No

Trust(s). If yes, please indicate which type (revocable or non-revocable), bank, and/or trustee’s name.

hh mbr #

account #(s)

cash value

interest rate

do you have assets as listed below?

Yes No

I/we own real estate (or hold a mortgage or Deed of Trust). If yes, provide description.

hh mbr #

account #(s)

cash value

interest rate

do you have assets as listed below?

Yes No

Personal property that is being held as an investment. If yes, describe:

hh mbr #

account #(s)

interest rate

cash value

do you have assets as listed below?

Yes No

Stocks, bonds, or Treasury bills. If yes, list sources/bank name(s).

account #(s)

hh mbr #

interest rate

cash value

do you have assets as listed below?

Yes No

Certificate(s) of Deposit (CD) or Money Market account(s). If yes, list source(s)/bank name(s).

account #(s)

hh mbr #

interest rate

cash value

do you have assets as listed below?

Yes No

IRA/Lump Sum Pension/Keogh Account/401k. If yes, list bank(s).

account #(s)

hh mbr #

interest rate

cash value

If forms are completed electronically, one of the following boxes must be checked:

This form was completed electronically by the resident Management or someone outside of household assisted completing the form electronically (Authorization to Assist is attached).

Signatures

Under penalties of perjury, I certify that the information presented on this form is true and accurate to the best of my/our 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.

Print Name of Applicant

Signature

Date

Print Name of Applicant

Signature

Date

Print Name of Applicant

Signature

Date

Print Name of Applicant

Signature

Date

Reviewed by (Signature of Owner/Representative)

Date

All household members ages 18 or over must sign and date.

After Hours Emergency

Hours

Office Location

Mailing Address