Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Home Phone

(###)

###

####

Will you be the only person to occupy the unit? *

Yes

No

Size of unit requested: *

One Bed

Two Bed

Type of unit require: *

Barrier Free

Hearing Impairment

List yourself (head-of-household), and all other household members who will be living in the unit in the form below. Additionally, describe the relation of each member to the head. *

ANY APPLICANT WHO PURPOSELY FALSIFIES, MISREPRESENTS OR WITHHOLDS ANY INFORMATION RELATED TO PROGRAM ELIGIBILITY OR SUBMITS INACCURATE AND/OR INCOMPLETE INFORMATION ON APPLICATION WILL NOT BE CONSIDERED FOR HOUSING NOR PUT ON A WAITING LIST.

First Name

Last Name

Head of Household: *

First Name

Last Name

Birthday: *

MM

DD

YYYY

Eligibility *

Eligibility for some properties requires that the applicant be mobility impaired/live in a disabled household as certified by a credentialed medical practitioner. I am eligible for admission based on the definition of: "Mobility Impairment", a mobility impaired household with at least one disabled adult (over the age of 18) who is in need of a barrier-free unit. *

Yes

No

Does applicant or any household member need reasonable accommodation for a mobility accessible or hearing impairment unit? * *

Yes

No

Signatures *

I/WE UNDERSTAND THE INFORMATION IN THIS APPLICATION WILL BE USED TO DETERMINE ELIGIBILITY FOR HOUSING ASSISTANCE AND THAT THIS INFORMATION WILL BE VERIFIED. I/WE UNDERSTAND THAT ANY FALSE INFORMATION MAY MAKE ME/US INELIGIBLE FOR A UNIT. ​I/WE CERTIFY THAT ALL INFORMATION GIVEN IN THIS APPLICATIONS IS TRUE, COMPLETE AND ACCURATE. I/WE UNDERSTAND THAT IF ANY OF THIS INFORMATION IS FALSE, MISLEADING OR INCOMPLETE, MANAGEMENT MAY DECLINE OUR APPLICATION OR, IF A MOVE-IN HAS OCCURRED, WE CAN TERMINATE OUR LEASE AGREEMENT. ​I/WE AGREE TO NOTIFY MANAGEMENT IN WRITING REGARDING ANY CHANGES IN HOUSEHOLD ADDRESS, TELEPHONE NUMBERS, INCOME AND HOUSEHOLD COMPOSITION. BY MY/OUR SIGNATURES BELOW I HEREBY RELEASE ANY INDIVIDUAL OR INSTITUTION, INCLUDING ITS OFFICERS, EMPLOYEES, OR RELATED PERSONNEL, BOTH INDIVIDUALLY AND COLLECTIVELY, FROM ANY AND ALL LIABILITY FOR DAMAGES OF WHATEVER KIND, WHICH MAY RESULT TO ME BECAUSE OF COMPLIANCE WITH THIS AUTHORIZATION AND REQUESTED TO RELEASE INFORMATION OR ANY ATTEMPT TO COMPLY WITH IT. ​BY MY/OUR SIGNATURES BELOW I HEREBY RELEASE ANY INDIVIDUAL OR INSTITUTION, INCLUDING ITS OFFICERS, EMPLOYEES, OR RELATED PERSONNEL, BOTH INDIVIDUALLY AND COLLECTIVELY, FROM ANY AND ALL LIABILITY FOR DAMAGES OF WHATEREVER KIND, WHICH MAY RESULT TO ME BECAUSE OF COMPLIANCE WITH THIS AUTHORIZATION AND REQUEST TO RELEASE INFORMATION OR ANY ATTEMPT TO COMPLY WITH IT. I the applicant have read the terms of this application and hereby attest and agree.

First Name

Last Name

Date *

MM

DD

YYYY