PLEASE PROVIDE THE FOLLOWING DOCUMENTS WITH YOUR HOUSING APPLICATION

Transcription

1 A UNITED WAY COMMUNITY PARTNER Crispus Attucks Husing Department 613 Suth Gerge Street Yrk, PA (717) X 253 Fax (717) PLEASE PROVIDE THE FOLLOWING DOCUMENTS WITH YOUR HOUSING APPLICATION STATE ISSUED IDs - required fr all adults. SOCIAL SECURITY CARDS - required fr all family members PROOF OF ALL INCOME is als required: EIGHT (8) PAY STUBS f yur current emplyer(s) UNEMPLOYMENT COMPENSATION LETTER CHILD SUPPORT / Dmestic Relatins Curt Order dcuments SOCIAL SECURITY AWARD LETTER DEPARTMENT OF WELFARE Cash Benefits SIX (6) mst recent BANK STATEMENTS ***************************************************************** POR FAVOR PROPORCIONE LA SIGUIENTE INFORMACION CON SU SOLICITUD PARA VIVIENDA IDENTIFICACION DEL ESTADO CON FOTO para tds ls adults en su familia LAS TARJETAS DEL SEGURO SOCIAL para tds ls miembrs de su familia Prueba de TODOS LOS INGRESOS TAMBIEN SE REQUIERE OCHO (8) TALONARIOS de pag de su empleadr actual PRUEBA de la COMPENSACION POR DESEMPLEO PENSION PARA SUS HIJOS (Child Supprt) LA CARTA DE ADJUDICACION del Segur Scial CARTA de sus beneficis del DEPARTAMENTO DE WELFARE SEIS (6) ESTADOS DE CUENTA mas recientes DE SU BANCO

2 613 Suth Gerge St. Yrk, PA (717) United Way Agency GENERAL INFORMATION: RENTAL APPLICATION INFORMATION ON ALL PERSONS TO RESIDE IN APARTMENT: Last Name First Name MI f Birth Sc.Sec. #M/F Last Name First Name MI f Birth Sc.Sec. #M/F Last Name First Name MI f Birth Sc.Sec. #M/F Last Name First Name MI f Birth Sc.Sec. #M/F Last Name First Name MI f Birth Sc.Sec. #M/F Last Name First Name MI f Birth Sc.Sec. #M/F Last Name First Name MI f Birth Sc.Sec. #M/F **Scial Security cards must be presented fr all persns n the applicatin, if nt it will hld up the applicatin prcess. Husing must make a phtcpy f each card. Husehld Head's Driver's License r I.D. #:_ Spuse's Driver's License r I.D. #: Phne Number: ( ) Message Phne Number: ( ) Size f unit yu wuld like t rent? Bedrms WHAT IS YOUR HOUSEHOLD'S TOTAL GROSS MONTHLY INCOME FROM ALL SOURCES? $ D yu have a Sectin 8 Certificate? 0 Yes 0 N If yes, wh is yur casewrker? Phne number ( ) Hw did yu hear abut ur Husing Prgram? (Please indicate) 0 Newspaper Advertisement 0 Friend, relative, neighbr 0 Smene wh rents frm us EQUAL HOUSING OPPORTUNITY Spnsred by the City f Yrk Crispus Attucks Assciatin, Inc. prvides services fr everyne regardless f race, clr, religius creed, disability, ancestry, natinal rigin, age r sexual rientatin.

3 RENTAL INFORMATION: YOU MUST PROVIDE CONTINUOUS AND CORRECT RESIDENCE INFORMATION FOR THE PAST 3 YEARS. If infrmatin is incrrect r incmplete yur applicatin will be rejected immediately: Current Address: City/State/Zip: Owner/Landlrd's Name: Owner/Landlrd's Phne: ( ) Owner/Landlrd Address: Current Rent Yu Pay: $ Number f bedrms in unit Yu Lived Here Since (Mnth & Year): Why d yu want t mve? Next Prir Address: City/State/Zip Owner/Landlrd's Name: Owner/Landlrd's Phne ( ) Owner/Landlrd Address: When did yu live here? Frm: T: Rent: $ Why did yu mve? Next Prir Address: City/State/Zip Owner/Landlrd's Name: Owner/Landlrd's Phne:( ) Owner/Landlrd's Address When did yu live here? Frm: T: Rent: $ Why did yu mve? Next Prir Address: Owner/Landlrd's Name: Owner/Landlrd's Phne:( ) When did yu live here? Frm: T: Rent: $ Why did yu mve: City/State/Zip: Have yu ever been evicted? Yes0 N0 If yes, explain: Have yu ever mved ut wing the landlrd mney? Yes0 N0 If yes, Why? CONDITION OF CURRENT HOUSING: What is the cnditin f yur current husing? Plumbing/Kitchen 0; Currently Withut Husing 0. Standard 0; Unsafe r Unhealthy 0; N Indr FELONY RECORD: Have yu ever been cnvicted f a felny? Yes0 N0 If yes, explain: Have yu r any ther member f the applicant s husehld had any prblems with substance abuse currently r in the past 4 years? Yes0 N0 If yes, explain:

4 Student Status Are yu a full- time student (in cllege)? Yes / N Is yur c-applicant r spuse a full-time student (in cllege)? Yes / N Is there anyne in yur husehld that is 18 year and ver wh is a full time student (in cllege)? Yes / N Grants r Schlarships: Yes N Amunt: $ EMPLOYMENT HISTORY: Emplyment (Head f Husehld): Hurly Rate: $ Hurs Wrked per Week Mthly Amunt: $ Emplyer: Address: Phne :( ) Fax Number: ( ) Were yu hired thrugh a temp agency? Yes0 N0, Temp Agency Name Jb Title(s): Emplyed Since: Reasn(s) Fr Leaving: What shift d yu wrk? 0 1st Shift (7a-3p) 0 2nd Shift (3p-11p) 0 3rd Shift (11p-7a) Spuse's r C-Applicant's Current Emplyer: Name f applicant wh wrks here Address Phne ( ) Fax ( ) Were yu hired thrugh a temp agency? Yes0 N0, Temp Agency Name Jb Title Emplyed Since What (s) Hurly Rate $ Hurs wrked per week Reasn(s) Fr Leaving: What shift d yu wrk? 0 1st Shift 0 2nd Shift 0 3rd Shift If yu have been emplyed at yur current jb fr less than 6 mnths, please fill in: Previus Emplyer(s) (Head f Husehld): Phne: ( ) Fax: ( ) Address: Emplyed Between What (s): Were yu hired thrugh a temp agency? Yes0 N0, Temp Agency Name Hurly Rate $ Hurs wrked per week Reasn(s) Fr Leaving: _ Previus Emplyer (Spuse's/CApplicant) Name f applicant wh wrks here: Phne: ( ) Fax: ( ) _ Address Emplyed Between What s: Were yu hired thrugh a temp agency? Yes0 N0, Temp Agency Name _ Hurly Rate $ Hurs Wrked per week Reasn(s) Fr Leaving

5 STUDENT INFORMATION: **The fllwing Sectin shuld be cmpleted fr anyne wh is 16 years f age r lder and is nt a full time student. **Nn-Student Current Emplyer Phne ( ) Fax ( ) Are yu emplyed thrugh a temp agency? Yes0 N0 Temp Agency Name Hurly Wage $ Hurs wrked per week Hw lng have yu been emplyed? If n lnger emplyed with cmpany, give reasn fr departure INCOME INFORMATION: 0 Pensins: Surce(s): Mthly Amunt(s): $ 0 Unemplyment Benefits: Ttal Mthly Amunt f Check(s):$ 0 Welfare Cash Asst: Mthly Amunt f Check: $ Casewrker: 0 Scial Security/SSI/SSD: Ttal Mthly Amunt: $ Name f Recipient: 0 Veterans' Benefits: Ttal Mthly Amunt f Check: $ _ Address Other Incme: D yu receive any f the fllwing surces f ther incme? 0 AFDC: Mthly Amunt: $ Casewrker: 0 Alimny/Child Supprt: Mthly Amunt: $ Name f individual wh pays the supprt Case N. 0 Grants r Schlarships: Mthly Amunt: $ 0 Interest frm Bank Accunt(s): Mthly Amunt: $ 0 Wrkers Cmpensatin/Disability Insurance: Mthly. Amunt: $ 0 Other: Mthly Amunt: $ Have yu dispsed f (sld) r given away assets (Cash, Prperty, Real Estate etc) fr mre than $1,000 belw their fair market value? 0 Yes 0 N, If yes, please explain: Hw lng have yu been receiving any f the surces f incme nted abve? D yu have any assets such as real prperty, stcks, bnds, certificates f depsits, inheritances, bank checking r savings accunts r ther types? 0 Yes 0 N, If yes, list all assets and amunts: Bank Name Address Accunt Number Type f Accunt Balance Bank Name OR: Address Accunt Number Type f Accunt Balance I/We DO NOT have any assets at this time. (Signature) (Signature)

6 PERSONAL REFERENCES AND EMERGENCY CONTACT: Persnal Reference - CANNOT BE A RELATIVE: Name: Phne :( ) Relatinship: Hw lng has he/she knwn yu? : Address Nearest Relative t Ntify in an Emergency - This infrmatin MUST be prvided: Name: Phne :( ) Relatinship: Address I/we hereby CERTIFY that the infrmatin stated abve is true, crrect and cmplete t the best f my/ur knwledge. I/we further understand and agree that if any f the infrmatin I/we have prvided in this applicatin is fund t be incmplete, incrrect r false, it will be grunds fr denial f this applicatin r terminatin f my/ur tenancy. I/we als hereby authrize the agents fr Crispus Attucks Cmmunity Develpment Crpratin and its subsidiaries t verify the freging incme, emplyment and asset infrmatin; t cnduct a check fr prir evictins; t cnduct a plice recrd check; and t verify any ther infrmatin I/we have prvided n this applicatin. Signature Signature EQUAL HOUSING OPPORTUNITY Spnsred by the City f Yrk Crispus Attucks Assciatin, Inc. prvides services fr everyne regardless f race, clr, religius creed, disability, ancestry, natinal rigin, age r sexual rientatin.

7 613 Suth Gerge St. Yrk, PA (717) United Way Agency RELEASE OF VERIFICATION I,, SS# Hereby authrize the release f infrmatin relative t the applicatin fr a residential husing unit managed by the Crispus Attucks Assciatin r relative t my annual recertificatin during my residency with the Crispus Attucks Assciatin and its subsidiaries. The infrmatin is required by the Internal Revenue Service (IRS) and the Federal Law gverning the requesting agency. THIS INFORMATION WILL BE KEPT IN STRICT CONFIDENCE. Herein, I authrize the release f any infrmatin pertaining t, but nt limited t, the cmpsitin f my husehld such as rental histry, depsitry, credit histry, any infrmatin related t incme, emplyment, Scial Security payments, child r spusal supprt payments and lan verificatins. This frm will remain in effect thrughut the duratin f my husing ccupancy with the Crispus Attucks Assciatin. (Applicant/Resident Signature) (Crispus Attucks Assciatin Prperty Mnr)

8 613 Suth Gerge St. Yrk, PA (717) United Way Agency RELEASE OF VERIFICATION I,, SS# Hereby authrize the release f infrmatin relative t the applicatin fr a residential husing unit managed by the Crispus Attucks Assciatin r relative t my annual recertificatin during my residency with the Crispus Attucks Assciatin and its subsidiaries. The infrmatin is required by the Internal Revenue Service (IRS) and the Federal Law gverning the requesting agency. THIS INFORMATION WILL BE KEPT IN STRICT CONFIDENCE. Herein, I authrize the release f any infrmatin pertaining t, but nt limited t, the cmpsitin f my husehld such as rental histry, depsitry, credit histry, any infrmatin related t incme, emplyment, Scial Security payments, child r spusal supprt payments and lan verificatins. This frm will remain in effect thrughut the duratin f my husing ccupancy with the Crispus Attucks Assciatin. (Applicant/Resident Signature) (Crispus Attucks Assciatin Prperty Mnr)

9 613 Suth Gerge St. Yrk, PA (717) United Way Agency CONSUMER NOTICE This is nt a cntract LOURDES ZAYAS, hereby states that with respect t prperties wned by Crispus Attucks Assciatin, Crispus Attucks CDC, 400 Suth Gerge Street Partnership, Suth East Neighbrhd, Sutheast Histric Partnership, SKW Partnership and YrkBuild, I am acting in the fllwing capacity (check ne): Owner/Landlrd; X Direct Emplyee f the wner/landlrd An agent f the wner/landlrd pursuant t a Prperty Management r exclusive Leasing Agreement I hereby acknwledge that I have received this Ntice: Signature Signature EQUAL HOUSING OPPORTUNITY Spnsred by the City f Yrk Crispus Attucks Assciatin, Inc. prvides services fr everyne regardless f race, clr, religius creed, disability, ancestry, natinal rigin, age r sexual rientatin

10 Unit # Resident Name: In accrdance with the data cllectin infrmatin requested by the Department f Husing and Urban Develpment (HUD) please prvide the fllwing infrmatin fr the head f husehld. Ethnicity Hispanic r Latin Yes N Gender (M) Male (F) Female Race: (Select all that apply.) American Indian r Alaska Native Asian Black r African American Native Hawaiian r ther Pacific Islander White Resident signature I have prvided the abve infrmatin. I decline t prvide this infrmatin. Resident Signature