Application Reference
Application Reference Copy: This HTML version is provided for reading and translation purposes only. To apply for housing, please complete and submit the official application PDF.
Affordable Housing Application
The Village at Hawk View
1500 Steelwood Lane
Reno, NV 89512
P: 775.398.5319
F: VHV.EBMCPORTALS.COM
TTY: 711
OFFICE USE ONLY
Date Received: ____________________
Time Received: ____________________
Date Entered Into Yardi: ____________________
Prospect Code: ____________________
Unit Size: ☐ 0BR ☐ 1BR ☐ 2BR ☐ 3BR ☐ 4BR
Additional Adult Apps: YES ☐ NO ☐
Meets Occupancy: YES ☐ NO ☐
App Complete: YES ☐ NO ☐
*IF No, Enter in Yardi and reject application
Original Application: YES ☐ NO ☐
Updated Application: YES ☐ NO ☐
Sec 8 HVC HH: YES ☐ NO ☐
Total Income Declared:
504/RA Needed: YES ☐ NO ☐
Mgr. Initials: ____________________
Prequal AMI Status: EVLI ☐ VLI ☐ LI ☐
PLEASE READ INSTRUCTIONS BELOW BEFORE COMPLETING
Please complete the following application and RETURN IT TO THE PROPERTY. All Items must be complete in order to determine your eligibility. Failure to complete all sections will result in the application being rejected. Application must be completed using BLUE/BLACK ink. If an item does not apply to you, please check N/A next to the question. Do not use white-out. Please use one line on corrections and initial corrections made. Completed applications can be returned via email to TheVillageAtHawkview@ebmc.com, to the site directly, or via an email attachment to the site manager’s email above. If applying as SPOUSE OR ROOMMATES, individual applications are required for privacy protection and must be submitted simultaneously. CA only applicants: If SB267 is elected on Page 7, Option 2, your application will be incomplete until you provide all supporting documentation and will not be added to the waitlist until all supporting documentation is provided with the application.
NOTE: Wait lists are maintained by bedroom size. A separate application is required for different unit sizes.
APPLICANT INFORMATION
I/We are applying for a: ____________________ Bedroom Unit (Please indicate bedroom size).
Do You or a Member of Your Household Have a Verifiable Special Need?
If yes, List Need: __________________________________________
First Name: ____________________ Last Name: ____________________
Street Address: ____________________ City State Zip: ____________________
Mailing Address: ____________________ City State Zip: ____________________
Phone 1: ____________________ Phone 2: ____________________
Email 1: ____________________ Email 2: ____________________
PLEASE NOTE: The information you provide on the application will be treated as confidential. It includes both the information necessary for determining your eligibility for housing and information required for statistical purposes. The race, ethnicity and gender information are requested to assure the Federal government that Federal laws prohibiting discrimination against applicants 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. Any information found to be incomplete and/or falsified will cause the application to be denied and not processed.
For Marketing Purposes, Please Let Us Know How You Heard About Us:
☐ Newspaper Ad ☐ Drove By ☐ Word of Mouth ☐ Web Site ☐ Google Search
☐ Resident Referral ☐ Management Website ☐ Other: ____________________
State Your Current Living Situation:
☐ Own my Home ☐ Live with Family/Friend ☐ Renting ☐ Unhoused ☐ Fleeing Violence
HOUSEHOLD MEMBER INFORMATION
List below All of the People You Expect to Reside in Your Household at Move-In
RELATION
- HOH - Head of Household
- S-Spouse
- CH-Co-Head
- D-Dependent
- O-Other
CITIZENSHIP
Enter One of the Following for subsidy eligibility:
- EC-Eligible Citizen
- EN-Eligible Non-Citizen
- IC-Ineligible Child
- IN-Ineligible Non-Citizen
- IP-Ineligible Parent
GENDER
Male
Female
Leave Blank-if you choose not to report
STUDENT STATUS
- N= None
- PT= Part Time
- FT= Full Time
| FULL NAME | RELATION | CITIZENSHIP | GENDER | DATE OF BIRTH | SOCIAL SECURITY NUMBER | STUDENT STATUS |
|---|---|---|---|---|---|---|
| HOH | ||||||
☐ Unborn / Anticipated Delivery Date: ______________________________
RENTAL HISTORY (Last 3 years)
CURRENT Landlord/Contact Name
| CURRENT Landlord/Contact Name | |
|---|---|
| Address | |
| Phone | |
| Fax | |
| Move-In and Move Out Dates | |
| Reason for Moving Out |
PRIOR Landlord/Contact Name
| PRIOR Landlord/Contact Name | |
|---|---|
| Address | |
| Phone | |
| Fax |
RENTAL HISTORY (Continued)
| Move-In and Move Out Dates | |
|---|---|
| Reason for Moving Out |
PRIOR Landlord/Contact Name
| PRIOR Landlord/Contact Name | |
|---|---|
| Address | |
| Phone | |
| Fax | |
| Move-In and Move Out Dates | |
| Reason for Moving Out |
HOUSEHOLD COMPOSITIONS and CHARACTERISTICS
1. ☐Yes ☐ No Are you expecting any future additions to your household due to pregnancy, adoption, foster child (ren) or custody of children? If yes, explain:
__________________________________________________________________________
2. ☐ Yes ☐ No Do you have any household members away at school, who will live at your residence during school recesses?
If yes, their name: __________________________________________
3. ☐Yes ☐ No Are any household members 18 years of age or older, that are Full-Time Students:
If yes, List Name and Age: __________________________________________
4. ☐Yes ☐ No Are there any family members who are temporarily absent from the household due to:
☐Employment ☐Military Service ☐Foster Care ☐Nursing Home ☐Hospital
5. ☐Yes ☐ No Are there any family members who are permanently confined in a nursing home?
If yes, will you still be including/counting this individual as part of the household? ☐ Yes ☐ N o
6. ☐Yes ☐ No Do you require a Live-In Attendant and have a doctor’s verification showing medical need?
7. ☐Yes ☐ No Are you or any household member currently in the US military or a US military veteran?
8. ☐Yes ☐ No Are you or any household member a Presidentially Declared Disaster victim?
9. ☐Yes ☐ No Do you or any household member currently live in, or have you ever lived in Public or HUD assisted housing or in HUD’s Housing Choice Voucher/Certificate Program? If yes, List below:
| Landlord and/or Complex Name | |
|---|---|
| Landlord Phone Number | |
| Property Address | |
| Move In Date | |
| Move Out Date |
10. ☐Yes ☐ No Do you or any household member owes any monies to HUD, an apartment community, and or previous landlord? If yes, provide:
| Landlord and/or Complex Name | |
|---|---|
| Landlord Phone Number | |
| Balance Due Landlord |
11. ☐Yes ☐ No Have you ever committed fraud in a HUD-assisted housing program, been asked to repay money for knowingly misrepresenting information, or been evicted from any rental?
If yes, explain: __________________________________________
12. ☐Yes ☐ No Are you or any household member subject to lifetime sex offender registration requirement any/a state? If Yes, Please Explain:
| Household Member Name | |
|---|---|
| State | |
| Registration Date | |
| Explanation |
14. List ALL States family members have lived in: __________________________________________
15. ☐ Yes ☐ No Do you or any household member have a criminal or juvenile record? If yes, Name(s) of Household Member (s) and Explain:
_____________________________________________________________________________________
16. ☐Yes ☐ No Have you or any household member ever been convicted or adjudicated of a misdemeanor/ felony or any other criminal activity, including a violation of the Controlled Substances Act. This also includes harassment, sexual assault, drug abuse, & any other crimes. If yes:
| Household Member Name | |
|---|---|
| Explanation | |
| Household Member Name | |
| Explanation |
IF you answered “YES” to any questions listed above in the Criminal Background Section of this application, please provide an explanation below. Include the date, circumstances, and nature of the offenses, as we verify criminal record in the following jurisdictions: AL, AK, AZ, AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, & WY
Explanation:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
17. ☐Yes ☐ No Are you or any household member a current user of a non-prescribed controlled substance, including any marijuana substances.
18. ☐Yes ☐ No Are you or any household member currently engaged or exhibit a pattern of alcohol abuse, which may threaten the health & safety of residents or staff or hinders the peaceful enjoyment of the housing premises.
19. ☐Yes ☐ No Have you or any household member ever used any other name, alias and/or social security number, other than the one listed on this application? If yes, Name(s) Used and by Which Household Member, Social Security Number Used and Explain:
_____________________________________________________________________________________
DISABLED HOUSEHOLDS and REASONABLE ACCOMODATIONS
Elderly families are defined by HUD as families where the head, spouse, or co-head is 62 years of age, or 18 years of age and a person with disabilities. If you wish to be considered as an elderly family due to a disability, HUD requires that we receive your consent to verify your disability. In addition, persons with disabilities have the right to request reasonable accommodations, which include changes, exceptions, or adjustments to a program, service, building, dwelling unit, or workplace that -will allow a qualified disabled person to participate fully in a program, take advantage of a service, live in a dwelling, or perform a job. Please complete both questions below.
20. ☐Yes ☐ No Are you 18 years of age, considered a disabled person, and give consent to have your disability verified?
21. ☐Yes ☐ No Do you or any household member require any special accommodations in your unit?
22. ☐Yes ☐ No Do you require a unit with accessible features?
If yes to 21 and/or 22, Please explain:
_____________________________________________________________________________________
EXPENSES/ALLOWANCES
23. ☐Yes ☐ No Do you have expenses for childcare of an aged 12 or younger? If yes, what are your out-of-pocket childcare costs?
☐ Weekly
| Provider | |
|---|---|
| Provider Address | |
| Provider Phone | |
| Provider Email |
24. ☐Yes ☐ No Do you pay for a care attendant or for any equipment for any handicapped or disabled household member(s) that are necessary to permit that person or someone else in the household to work? If yes, provide information, what are your out-of-pocket expenses?
☐ Weekly
| Type of Equipment | |
|---|---|
| Name of Company | |
| Address | |
| Phone | |
25. ☐Yes ☐ No Are any of the above expenses paid for or reimbursed by an outside agency? If yes, provide information: Amount reimbursed, frequency and which expense
| Type of Agency | |
|---|---|
| Name of Company | |
| Address | |
| Phone | |
| Monthly Reimbursement |
26. ☐Yes ☐ No Do you or any household member(s) pay for Medicare?
If Yes, Monthly Amount Paid
27. ☐Yes ☐ No Do you or any household member(s) have any other type of medical insurance?
If Yes, Monthly Amount Paid
| Name Of Carrier/Company | |
|---|---|
| Address | |
| Phone Number | |
| Policy Number |
28. ☐Yes ☐ No Do you or any household member have any outstanding medical bills?
If Yes, please provide a list
_____________________________________________________________________________________
_____________________________________________________________________________________
29. ☐Yes ☐ No Do you or any household members expect to incur any medical expenses within the next 12 months?
If Yes, please explain
_____________________________________________________________________________________
_____________________________________________________________________________________
30. ☐Yes ☐ No Do you or any household member use a pharmacy on a regular basis?
If Yes, Pharmacy __________________________________________
Phone Number __________________________________________
Address __________________________________________
TOTAL HOUSEHOLD INCOME
PLEASE REPORT FOR ANY HOUSEHOLD MEMBER:
30. ☐Yes ☐ No Employed? If Yes: Lists Below & Check Employment Status
| Full Name | Full Time | Part Time | Seasonal Work |
|---|---|---|---|
| ☐ | ☐ | ☐ | |
| ☐ | ☐ | ☐ | |
| ☐ | ☐ | ☐ | |
| ☐ | ☐ | ☐ |
31. ☐Yes ☐ No Expect to work ANY period during the next 12 months?
If Yes, please explain __________________________________________
32. ☐Yes ☐ No Work for someone who pays in CASH?
If Yes, please explain __________________________________________
33. ☐Yes ☐ No Does anyone regularly give the household cash or any other financial help?
34. ☐Yes ☐ No Does anyone regularly pay any of the household’s bills; such as rent, utilities, phone, etc.?
If Yes, please explain __________________________________________
35. ☐Yes ☐ No Do you receive death benefits under someone else’s social security number?
If Yes, Social Security / ITIN number __________________________________________
Below list ALL money earned or received by each member of your household, such as wages, self-employment, unemployment, child support, alimony, family financial support, Social Security/SSI, Workman's Compensation, retirement benefits, pensions, trusts, annuities, AFDC, Welfare, Veterans benefits, Military Pay, insurance benefits, etc.
| HOUSEHOLD MEMBER NAME | INCOME SOURCE (S) | HOURLY | WEEKLY | MONTHLY | ANNUALLY |
|---|---|---|---|---|---|
TOTAL HOUSEHOLD ASSETS
36. ☐Yes ☐ No Do you or any household member (including children) have Assets such as Cash, Checking, Savings, CD’s, 401K, Trusts, etc.? If Yes, List information below.
| ACCOUNT TYPE | HOUSEHOLD MEMBER NAME | ACCOUNT NUMBER | BANK/ INSTITUTION NAME | CURRENT VALUE | ANNUAL INCOME FROM ASSET |
|---|---|---|---|---|---|
| Cash/Deposit Box | $ | $ | |||
| Pre-Paid Debit Card (Visa/MC) | $ | $ | |||
| EBT/Welfare/CalWORKs | $ | $ | |||
| Checking | $ | $ | |||
| Savings | $ | $ | |||
| Money Market | $ | $ | |||
| Unemployment Card | $ | $ | |||
| CD’s Stocks Bonds | $ | $ | |||
| Trusts | $ | $ | |||
| Retirement/Pension Fund | $ | $ |
TOTAL HOUSEHOLD ASSETS (Continued)
| ACCOUNT TYPE | HOUSEHOLD MEMBER NAME | ACCOUNT NUMBER | BANK/ INSTITUTION NAME | CURRENT VALUE | ANNUAL INCOME FROM ASSET |
|---|---|---|---|---|---|
| Life Insurance (Whole/Universal) | $ | $ | |||
| Funeral/Burial Insurance/Account | $ | $ | |||
| Real Estate | $ | $ | |||
| Bitcoin | $ | $ | |||
| Cash App: | $ | $ | |||
| Venmo | $ | $ | |||
| Chime | $ | $ | |||
| Other | $ | $ | |||
| Other | $ | $ |
37. ☐Yes ☐ No Have you or any household member disposed of or given away any asset(s) for less than fair market value during the past two years?
If yes, asset disposed of
_____________________________________________________________________________________
_____________________________________________________________________________________
Fair Market Value
Sales Price (if applicable)
38. ☐Yes ☐ No Have you or any household member sold any real estate (U.S.A. or Another Country) in the last two years?
If yes, describe
_____________________________________________________________________________________
_____________________________________________________________________________________
Address
Sales Price
39. ☐Yes ☐ No Do you or any household member own or have an interest in any real estate or mobile home (U.S.A. or Another Country)?
If yes, describe
_____________________________________________________________________________________
_____________________________________________________________________________________
Address
Fair Market Value
HOUSEHOLD VEHICLES
| MAKE | MODEL | YEAR | COLOR | TAG/EXP | STATE | VEHICLE INSURANCE COMPANY | VEHICLE INSURANCE POLICY # |
|---|---|---|---|---|---|---|---|
40. ☐Yes ☐ No Do you have any pets?
If yes, describe
_____________________________________________________________________________________
_____________________________________________________________________________________
Emergency Contacts
In cases of emergency, management requests that you provide the information below. An emergency is broadly defined as a case where management feels a resident's well-being is threatened and/or where management feels a resident's actions/conduct appear to be a lease violation. Some examples of this type of emergency are non-payment of rent; perceived criminal activity against persons\property; perceived abuse of an illegal substance; behavior violating the quiet enjoyment of other residents; and, housekeeping that violates safe and sanitary rules. An emergency is also defined as an urgent need for assistance or relief, or when there are unforeseen circumstances that call for immediate action.
FIRST FAMILY MEMBER/FRIEND TO NOTIFY IS:
| Full Name | |
|---|---|
| Relationship | |
| Address | |
| City State Zip | |
| Phone 1 | |
| Phone 2 | |
SECOND FAMILY MEMBER/FRIEND TO NOTIFY IS:
| Full Name | |
|---|---|
| Relationship | |
| Address | |
| City State Zip | |
| Phone 1 | |
| Phone 2 | |
Please describe any other information that will help us to process this application (add additional sheet if necessary):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
CA Applicants/Residents Only: SB267: Review & Choose Option 1 or Option 2.
ALL OTHER Applicants, choose Option 1 ONLY
Each CALIFORNIA applicant must select one of the two options referenced above next to their signature below. If you choose OPTION 2, your application must accompany verifiable alternative evidence of the ability to pay at time of application submission.
| Applicant Signature | Option |
|---|---|
| ________________________________________ | ☐ Option 1: Consideration of Credit ☐ Option 2: Alternative Evidence |
Certification and Consent to Release of Information
NOTE: All household members 18 and older must sign this Application. By signing this application, I/We certify the accuracy of the information contained herein. I/WE understand that the Department of Housing and Urban Development (HUD)/United States Department of Agriculture or other state and/or local affordable program is authorized to collect this information. This application will be used to determine eligibility, appropriate bedroom size, and the amount my family will pay for rent. I/We also understand that this will be my only residence.
I/We authorize management to contact my present/prior landlords for information regarding my tenancy, and to access records pertaining to me which may be on file with credit bureau authorities.
I/We authorize a criminal background check and a check of the state/national sex offender registry for all adult family members. I/We understand that all information I have listed is subject to verification and that a final decision on eligibility cannot be made until all verifications are complete.
I/We understand that it is a crime to knowingly provide false information for the purpose of obtaining or maintaining occupancy in and/or, for the purpose of securing a lower rent in a subsidized housing unit, and that the penalty for knowingly providing false information is up to five years in prison and/or $10,000 fine upon conviction and will cause an automatic denial of this application.
I/We hereby do swear and attest that we have read and reviewed the Resident Selection Plan for The Village at Hawk View and all the information herein about me is true and correct. I understand that if no unit is currently available and I/We are placed on the waiting list, I/We must update all information abo ut me should it change or management require it to be updated. I/We understand my household at the tim e a unit becomes available and is offered may require to be updated.
| Applicant Signature | Date |
|---|---|
☐ This application is submitted with my Spouse/Roommate(s). Other household member(s):
________________________________________________________________________________
Received by:
| Owner/Agent Signature | Date |
|---|---|
**EXCEPTIONS TO DISCLOSURE OF SOCIAL SECURITY NUMBER - The Social Security Number requirements do not apply to: Individuals aged 62 or older as of January 31, 2010, whose initial determination of eligibility was begun before January 31, 2010, and not contesting eligibility.
Managing Agent's Fair Housing and Section 504 Designated Representative: It is the policy of this company to provide housing on an equal opportunity basis. We do not discriminate on the basis of race, color, national origin, ancestry, sex, age, disability, religion, familial status, marital status, sexual orientation, gender identity, or medical condition. If you feel you have been discriminated against in the processing of this application, please call the following representative of this company: EBMC 504 Coordinator at Compliance@Ebmc.com.
Language Identification Flashcard
The Village at Hawk View
1500 Steelwood Lane
Reno, NV 89512
P: 775.398.5319
F: VHV.EBMCPORTALS.COM
TTY: 711
☐ English Is My First Language - No Other Translation Required, or
Circle below the language of preference.
2004 Census Test — Language Identification Flashcard
| Selection | Language |
|---|---|
| ☐ | 1. Arabic |
| ☐ | 2. Armenian |
| ☐ | 3. Bengali |
| ☐ | 4. Cambodian |
| ☐ | 5. Chamorro |
| ☐ | 6. Simplified Chinese |
| ☐ | 7. Traditional Chinese |
| ☐ | 8. Croatian |
| ☐ | 9. Czech |
| ☐ | 10. Dutch |
| ☐ | 11. English |
| ☐ | 12. Farsi |
Language Identification Flashcard (Continued)
| Selection | Language |
|---|---|
| ☐ | 13. French |
| ☐ | 14. German |
| ☐ | 15. Greek |
| ☐ | 16. Haitian Creole |
| ☐ | 17. Hindi |
| ☐ | 18. Hmong |
| ☐ | 19. Hungarian |
| ☐ | 20. Ilocano |
| ☐ | 21. Italian |
| ☐ | 22. Japanese |
| ☐ | 23. Korean |
| ☐ | 24. Laotian |
| ☐ | 25. Polish |
Language Identification Flashcard (Continued)
| Selection | Language |
|---|---|
| ☐ | 26. Portuguese |
| ☐ | 27. Romanian |
| ☐ | 28. Russian |
| ☐ | 29. Serbian |
| ☐ | 30. Slovak |
| ☐ | 31. Spanish |
| ☐ | 32. Tagalog |
| ☐ | 33. Thai |
| ☐ | 34. Tongan |
| ☐ | 35. Ukrainian |
| ☐ | 36. Urdu |
| ☐ | 37. Vietnamese |
| ☐ | 38. Yiddish |
LANGUAGE PREFERENCE ACKNOWLEDGEMENT:
☐ Our Household Has NO Need of Translations
☐ I Prefer the Landlord/Agent to provide me with an interpreter free of charge.
☐ I prefer to use my own interpreter (interpreter must be 18 years or older):
| Name of Interpreter | |
|---|---|
| Signature of Interpreter | |
| Relationship of Interpreter |
If available, do you want copies of written translations for documents you read/filled out today?
Choose One ☐ YES ☐ NO
I understand that all tenant file forms must be signed in English and that any translations provided to me are solely for my understanding of the contents of the form. If I disagree with the language services provided, I may contact Compliance@ebmc.com or call 916.443.6637 for my dispute. By signing this form, I affirm that all the information is true and accurate.
| Resident Signature | |
|---|---|
| Date |
Race and Ethnic Data Reporting Form
U.S. Department of Housing and Urban Development
Office of Housing
OMB Approval No. 2502-0204
(Exp. 06/30/2017)
| Property Name | The Village at Hawk View |
|---|---|
| Owner Agent | Eugene Burger Management Corporation, Agent |
| Type of Assistance | |
| Head of Household | |
| Resident Address | |
| Unit |
Household Members
| Household Member 1 | |
|---|---|
| Household Member 2 | |
| Household Member 3 | |
| Household Member 4 | |
| Household Member 5 | |
| Household Member 6 | |
| Household Member 7 | |
| Household Member 8 | |
| Household Member 9 |
Please select the corresponding self-identification(s) for each corresponding household member below:
| ETHNIC CATEGORY (select one) |
HH1 | HH2 | HH3 | HH4 | HH5 | HH6 | HH7 | HH8 | HH9 |
|---|---|---|---|---|---|---|---|---|---|
| Hispanic | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Non-Hispanic | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Declined to Report | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| RACIAL CATAGORIES (select all that apply) |
|||||||||
| American Indian/Alaskan Native | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Asian | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Black/African American | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Native Hawaiian or Other Pacific Islander | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| White | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Other | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Declined to Report | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| SIGNATURE OF HEAD OF HOUSEHOLD | Date |
|---|---|
Applicant/Tenant Release and Consent
The Village at Hawk View
1500 Steelwood Lane
Reno, NV 89512
P: 775.398.5319
F: VHV.EBMCPORTALS.COM
TTY: 711
THIS SECTION TO BE COMPLETED BY THE APPLICANT/TENANT
I/We __________________________________________
the undersigned hereby authorize all persons or companies in the categories listed below to release information regarding employment, income, assets, and/or student status for purposes of verifying information on my/our application for housing. I/we authorize the release of this information without liability to the property listed above.
INFORMATION COVERED
I/We understand that previous or current information regarding me/us may be needed. Verification and inquiries that may be requested include but are not limited to: personal identity, student status, employment, income, assets, and medical or childcare allowances. I/We understand that this authorization cannot be used to obtain any information about me/us that is not pertinent to my/our eligibility for and continued participation as a qualified tenant.
GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information include, but are not limited to:
| Past and Present Employers | Residences and Rental Activity | Support and Alimony Providers |
| Welfare Agencies | State Unemployment Agencies | Social Security Administration |
| Credit Agencies | Veterans Administration | Retirement System |
| Banks and Other Financial Institutions | Medical and Child Care Providers | Utility Companies |
| Foster Care Agencies | Educational Institutions | Credit and Criminal Activity |
| Public Housing Authorities | Sex Offender Screening |
CONDITIONS
I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will stay in effect for a year and one month from the date signed. I/We understand I/we have a right to review this file and correct any information that is incorrect.
| Applicant/Tenant Signature | Printed Name | Date |
|---|---|---|
NOTE: This general consent may not be used to request a copy of a tax return. If a copy of a tax return is needed, IRS Form 4506-T, "Request for Copy of a Tax Form" must be prepared and signed separately.
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 use 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). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).
Race and Ethnic Data Reporting Form
U.S. Department of Housing and Urban Development
Office of Housing
OMB Approval No. 2502-0204
(Exp. 06/30/2017)
| Property Name | The Village at Hawk View |
|---|---|
| Owner Agent | Eugene Burger Management Corporation, Agent |
| Type of Assistance | |
| Head of Household | |
| Resident Address | |
| Unit |
Household Members
| Household Member 1 | |
|---|---|
| Household Member 2 | |
| Household Member 3 | |
| Household Member 4 | |
| Household Member 5 | |
| Household Member 6 | |
| Household Member 7 | |
| Household Member 8 | |
| Household Member 9 |
Please select the corresponding self-identification(s) for each corresponding household member below:
| ETHNIC CATEGORY (select one) |
HH1 | HH2 | HH3 | HH4 | HH5 | HH6 | HH7 | HH8 | HH9 |
|---|---|---|---|---|---|---|---|---|---|
| Hispanic | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Non-Hispanic | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Declined to Report | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| RACIAL CATAGORIES (select all that apply) |
|||||||||
| American Indian/Alaskan Native | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Asian | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Black/African American | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Native Hawaiian or Other Pacific Islander | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| White | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Other | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| Declined to Report | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
| SIGNATURE OF HEAD OF HOUSEHOLD | Date |
|---|---|