ESTATES OF MIDWEST CITY APPLICATION
APPLICATION & QUESTIONNAIRE
Low Income Housing Tax Credit Program

Date: 

Applicant:         Social Security #: 

Date of Birth:   Daytime Phone:    Evening Phone:  

Current Address:   City:    State:  Zipcode: 


Complete the following information for each household member that will occupy the unit at time of move-in.

Household Members Name(s)          Relationship            Sex            Social Security #     Date of Birth

         

         

         

         

         


Is there anyone other than those listed on this application whose credit may impact on yours?  Yes    No


Answer either Yes or No to each question.

Yes    No   1. Do you have a pet? 

Yes    No   2. Do you expect any additions to the household within the next twelve months?
 

Yes    No   3. Do you have full custody of your child(ren)?

Yes    No   4. Have you or anyone else named on this application ever filed bankruptcy?  

Yes    No   5.  Have you or anyone else named on this application ever been convicted of a felony?

 

RESIDENCE HISTORY

List the past THREE years of housing references. (If additional space is required use the back of this page.)  

1.  Landlords Name/Address:   

 Your Address:        Own  or Rent     

Dates:  From To  

 

2.  Landlords Name/Address:   

 Your Address:        Own  or Rent     

Dates:  From To  

 

3.  Landlords Name/Address:   

 Your Address:        Own  or Rent     

Dates:  From To  

 

Yes    No    Have you or anyone else named on this application ever been evicted for any reason?

PERSONAL REFERENCES

List a personal reference other than a relative.

Name/Address of Reference: 

 Phone:      Relationship:      Years known:  

 

VEHICLE IDENTIFICATION:

1. License #:    State Issued  Make/Model/Year:

2. License #:    State Issued:    Make/Model/Year:

 

EMERGENCY CONTACT:

Name/Address (If possible list someone in the area that is not listed on application.)

Phone:    Relationship:

INCOME INFORMATION:

 Include all income anticipated for the next 12 months.  Include all dollar amounts in the space provided. Check Yes or No to each question.

Do you or anyone in your household receive or expect to receive income from:  

Yes    No   1. Employment wages or salaries?  (Include overtime, tips, bonuses, commissions, and payments received in cash.)
Source                                                     Household Member                Amount  

   
   
    

Yes    No   2. Self-Employment?
Source                                                     Household Member                Amount  

   
   

Yes    No   3. Regular pay as a member of the Armed Forces? 
Source                                                     Household Member                Amount  

   
   

Yes    No   4. Unemployment benefits or workman’s compensation?  
Source                                                     Household Member                Amount  

   
   

Yes    No   5. Public Assistance, General Relief or Aid to Families with Dependent 
Source                                                     Household Member                Amount  

   
   

Yes    No   6. Child support or alimony?  (Any awarded amounts-collect or uncollected) 
Source                                                     Household Member                Amount  

   
   

Yes    No   7. Social Security, SSI, or any other payments from the Social     Security? 
Source                                                     Household Member                Amount  

   
   

Yes    No   8. Veteran’s benefits, pensions, retirement benefits, or annuities? 
Source                                                     Household Member                Amount  

   
   

Yes    No   9. Severance Payments?
Source                                                     Household Member                Amount  

   
   

Yes    No   10. Settlements? (Such as insurance settlements)
Source                                                     Household Member                Amount  

   
   

Yes    No   11. Disability, death benefits, or life insurance dividends? 
Source                                                     Household Member                Amount  

   
   

Yes    No   12. Regular gifts or payments from anyone outside of the household. (This includes anyone supplementing your income or paying any of your bills) 
Source                                                     Household Member                Amount  

   
   

Yes    No   13. Educational grants, scholarships, or other student benefits?
Source                                                     Household Member                Amount  

   
   

Yes    No   14. Lottery winnings or inheritances?
Source                                                     Household Member                Amount  

   
   

Yes    No  15. Payments from rental property, land contracts, or other forms of real estate? 
Source                                                     Household Member                Amount  

   
   

Yes    No   16. Any other income sources or types not listed? 
Source                                                     Household Member                Amount  

   
   

ASSET INFORMATION:

Include all assets held and the corresponding annual interest rate, dividends, or any other income derived from the asset.  An asset is defined as any lump sum amount that you hold and currently have access to.  Include the value of the asset and corresponding income from the asset in the space provided. Include all assets held by ALL household members including minors.

Do you or anyone in your household hold:

Yes    No   1. Checking, savings account or prepaid debit card?  
Source                                                     Household Member                Amount             Account #

     
     
     
 

Yes    No   2. CD’s, money market accounts, or treasury bills?   
Source                                                     Household Member                Amount             Account #

     
     

Yes    No   3. Stocks, bonds, or securities?   
Source                                                     Household Member                Amount             Account #

     
     

Yes    No   4. Trust Funds?
Source                                                     Household Member                Amount             Account #

     
     

Yes    No   5. Pensions, IRAs, KEOGH, or other retirement accounts?   
Source                                                     Household Member                Amount             Account #

     
     

Yes    No   6. Cash on hand over $500.00?

   

Yes    No   7. Real estate, rental property, land contracts/contract for deeds or other real estate holdings? (This includes your personal residence, mobile homes, vacant land, farms, vacation homes, or commercial property?)

Type                                                        Household Member               Value

     
     

Yes    No   8. Personal property as an investment? (this includes paintings, coin, or stamp collections, artwork, collector, or show cars, and antiques)

Source                                                     Household Member                Value

     
     

Yes    No   9. A safe deposit box?  

 

Yes    No   10. Have you or any household member disposed of or given away any asset(s) for LESS than fair market value within the past 2 years?    

   

ZERO INCOME VERIFICATION:

Yes    No   1. Are you or is any other adult member of your household claiming zero income? If so, who?

 

STUDENT INFORMATION:

 Are you or anyone in your household:  

Yes    No   1. Currently a full-time student, or planning to be one within the next 12 months?  

IF YES, student must continue on with the following questions:    You will need to provide verification of all items to which you answered yes.  

Yes    No    a. Are you married and currently filing a joint tax return?
Yes    No    b. Are you receiving AFDC (Aid to Families with Dependent Children?) 
Yes    No    c. Are you enrolled in the Job Training Partnership Act (JTPA) or another similar local, county, or state program?
Yes    No    d. Are you a single parent with child (ren) and neither you nor the child (ren) are dependents on anyone else’s tax return?
Yes    No    e. Will you be living with someone who is not a full time student?  If so, who?  

LIVE IN CARE ATTENDANT:

 Yes    No   1. Will you or anyone in your household require a live in care attendant?

 Name of Live in Care Attendant:   Relationship (If any): 

 SECTION 8 RENTAL ASSISTANCE:

 Yes    No   1. Will your household be receiving Section 8 rental assistance at time of move-in?  

Name of Agency:   Contact Person Name:

Yes    No   2. Will your household be eligible or are you applying to receive Section 8 rental assistance in the next 12 months?  

Explain:   Name of Agency: 

All questions that were answered Yes will be verified through the appropriate third-party source.  It will be your responsibility to provide management with all necessary information to properly process your application and verify your eligibility.  This will include names, addressed, phone and fax numbers, account numbers where applicable and any other information required to expedite this process.

SIGNATURE CLAUSE:

I understand that management is relying on this information to prove my household’s eligibility for the Low Income Housing Tax Credit Program.  I certify that all information and answers to the above questions are true and complete to the best of my knowledge.  I consent to release the necessary information to determine my eligibility.  I understand that providing false information or making false statements may be grounds for denial of my application.  I also understand that such action may result in criminal penalties.  

I authorize my consent to have management verify the information contained in this application for purposes of proving my eligibility for occupancy.  I will provide all necessary information and expedite this process in anyway possible.  I understand that my occupancy is contingent on meeting management’s resident selection criteria and the Low Income Housing Tax Credit Program requirements.

All ADULT household members names must be entered below;  Typing in the name and date is a signature.

Signature1:      Date: 

Signature2:      Date: 

Signature3:      Date: