CENTER CITY RENTAL APPLICATION
DATE APARTMENT NEEDED BY: _____________________________________
Name: Social Security #: ____________________ Age:_____________
Address: _____________________________ City/State: ____________________ Zip : _____________
Phone: ___________________ Birth date: __________________Place of Birth :_________________
* Are you 60 or older? * Race/National Origin : __________________________ * Are you a female head of household ?________________?
* Are you handicapped/disabled? _________________________ * Are you pregnant? _________________________________
*Have you been displaced by fire/disaster? _________________ * If yes, give date:____________________________________
* Have you in the past, or are you expecting to be displaced by government action? _______ * If yes, give date:____________________________________
* Have you been displaced by a landlord?_________ * If yes, give date and explain: ________________________ ____________________________________________________________________________________________________________________________________
Do you own a car? ____________________________________ If yes, License plate#: ________________________________
List any other names you have been known by, ( i.e. nicknames, maiden names) : ____________________________________________________________
LIST ALL PERSONS WHO WILL ALSO OCCUPY THE APARTMENT: ( ANY PERSON 18 YEARS OR OLDER MUST SIGN THE APPLICATION AND THE INFORMATION RELEASE FORM ATTACHED)
Name: ____________________________ Relationship to you: _____________________ Sex:________
Date of Birth: __________ Social Security # : _______________ Race/National Origin: ________________
Name: ____________________________ Relationship to you: _____________________ Sex:________
Date of Birth: __________ Social Security # : _______________ Race/National Origin: ________________
Name: ____________________________ Relationship to you: _____________________ Sex:________
Date of Birth: __________ Social Security # : _______________ Race/National Origin: ________________
Name: ____________________________ Relationship to you: _____________________ Sex:________
Date of Birth: __________ Social Security # : _______________ Race/National Origin: ________________
LIST ALL THE PLACES YOU HAVE LIVED FOR THE PAST FIVE (5) YEARS: ( Including Landlord Information)
1. PRESENT Property Address: __________________________City/State: _________________Zip:_______
How long have you been a tenant? ___________ Reason for leaving: ________________________________
Current Rent: ________. If your rent includes any of the following, Circle: gas electric oil appliances
furniture laundry facilities other ____________.
Name of PRESENT Landlord: _________________________Address: _______________________________
City/State:____________________ Zip: ___________________________Phone: ______________________
2. PREVIOUS Property Address: ________________________ City/State: ______________________ Zip:_____
How long were you a tenant? ________________Reason for leaving : ________________________________
Rent:__________
Name of PREVIOUS Landlord: ________________________Address: ________________________________
City/State:____________________ Zip: ___________________________Phone: ______________________
3. PREVIOUS Property Address: ________________________ City/State: ______________________ Zip:_____
How long were you a tenant? ________________Reason for leaving : ________________________________
Rent:__________
Name of PREVIOUS Landlord: ________________________Address: ________________________________
City/State:____________________ Zip: ___________________________Phone: ______________________
EMERGENCY CONTACT PERSON : ______________________________RELATIONSHIP TO YOU: _________
Address: _____________________________________Phone:
_______________________________________
LIST GROSS AMOUNT OF INCOME RECEIVED BY EACH MEMBER OF THE HOUSEHOLD DURING THE PAST TWELVE MONTHS. ( INCLUDE WAGES, UNEMPLOYMENT, CHILD SUPPORT, MILITARY ALLOTMENTS, PUBLIC ASSISTANCE, SOCIAL SECURITY, ETC, )
MONTHLY GROSS AMOUNT TYPE OF INCOME NAME OF PERSON RECEIVING INCOME
$___________________________ ______________________________ _______________________________________
$____________________________ ______________________________ _______________________________________
$____________________________ ______________________________ _______________________________________
*Information used for state/federal reporting and for determining preference or priority for permanent housing placement. You may choose not to answer these questions, but you may forfeit a preference/priority for which you may be eligible.
INCOME INFORMATION:
Person Receiving Income: ________________________________Source/Employer:______________________________
Source/Employer= s Address: ______________________________City/State: ___________________Zip:_____________ Phone #: _______________Length of Employment/Income: ___________________Position Held: ____________________
Person Receiving Income: ________________________________Source/Employer:______________________________
Source/Employer= s Address: ______________________________City/State: ___________________Zip:_____________ Phone #: _______________Length of Employment/Income: ___________________Position Held: ____________________
IF SOCIAL SERVICES LISTED GIVE: PA # ___________________CASE WORKER:
____________________________________________IF PENSION LISTED, GIVE
Pension # __________________________Fund Name:___________________________________Address: _____________________________________________City/State: ___________________Zip:_____________
Phone #: ( )________________________________ __________ Person Collecting : ______________________________
The following information is required to properly assess your application. Please supply all information requested in full.
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.
List Three (3) Credit References. (If you have never had credit with a store or bank, list previous landlords or others to whom you have made payments to of any type).
1.Name: __________________________________Address:________________________________________________
City/State: _______________________________Zip: ________________Phone Number: _________________________
2.Name: ___________________________________Address:______________________________________________
City/State: _______________________________Zip: ________________Phone Number: _________________________
3.Name: ___________________________________Address:_______________________________________________
City/State: _______________________________Zip: ________________Phone Number: _________________________
List Three (3) Personal References:
NO RELATIVES ( FAMILY) WILL BE ACCEPTED AS REFERENCES:1.Name: ___________________________________Address:_______________________________________________
City/State: _______________________________Zip: ________________Phone Number: _________________________
2.Name: ___________________________________Address:_______________________________________________
City/State: _______________________________Zip: ________________Phone Number: _________________________
3.Name: ___________________________________Address:_______________________________________________
City/State: _______________________________Zip: ________________Phone Number: _________________________
Have you ever been convicted of a crime?________ If yes, give dates and type of conviction:________________________
Have you ever applied to Center City before? _____ If yes, give approximate date/year : ____________________________
Were you referred or recommended by someone to Center City ? Please give name: ______________________________
If you were not referred, how or where did you learn of Center City? ____________________________________________
This application creates no obligation. All information given is kept confidential. Submittal of this form authorizes Center City to verify any and all statements, sources named and references given. During the application process Center City may visit the applicant at their current residence. To secure an apartment, a personal interview must be held, the applicant must be accepted, security deposit must be made and lease signed, A credit report may be requested during the course of processing your application at no cost to you. By signing below you are giving Center City authorization to order such credit reports. In addition, all
ADULT household members MUST sign the attached information release form.DATE: _____________Your Signature: _______________________________________________________________
DATE: _____________Adult Member Signature: _______________________________________________________
PLEASE READ OVER THIS FORM CAREFULLY-HAVE YOU SUPPLIED ALL REQUESTED INFORMATION?????
Return this application to: CENTER CITY NEIGHBORHOOD DEVELOPMENT CORPORATION
1824 MAIN STREET,
NIAGARA FALLS, NEW YORK 14305
(716) 282-3738 FAX: 282-9607
Authorization for the release of Information
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Organization requesting release of information: CENTER CITY NEIGHBORHOODDEVELOPMENT CORPORATION 1824 Main Street Niagara Falls, NY 14305 (716) 282-3738 fax (716) 282-9607 DATE: Purpose The above named organization may use this authorization and the information obtained with to administer and enforce program rules and policies Authorization I authorize the release of any information (including documentation and other materials) pertinent to eligibility for or participation under any of the following programs: OMH Mentally III Homeless Program Low-Income Rental Public Housing Mutual Help Home ownership Opportunity Program Turnkey III Home ownership Opportunities Program Housing Trust Fund Rental Assistance Program Rent Supplement Section 8 Housing Assistance Payments Program Section 23 and 10 8 Leased Housing Section 23 Housing Assistance Payments Urban Initiatives Program I authorize the above-named organization or public housing authority to obtain information about me or my family that is pertinent to eligibility for or participation in assisted housing programs. I authorize Center City Neighborhood Development Corporation or a Public Housing Authority to obtain information on wages or unemployment compensation from State Employment Securities Agencies Information covered Inquiries may be made about: child care Expenses Credit History Criminal Activity Family Composition Medical Expenses Social Security Numbers Identity and Marital Status Residences/Rental History Employment, Income Pensions & Assets
Head of Household Signature
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This form cannot be used to request a copy of a tax return. Instead use form 506, Request For A Tax Return
Individuals of Organizations That May Release Information: Any individual or organization including any governmental organization may be asked to release information. For example, information may be requested from: Courts Credit Bureaus Employers, Past & Present Landlords Banks & financial Institutions Law Enforcement. Agencies Providers at: Alimony Credit Bureaus Child Care Medical Care Child Support Pensions/Annuities Schools/Colleges Utility Companies Welfare Agencies US Social Security Admin. Handicapped Assist. US Dept.Veterans Affairs Computer Matching Notice & Consent I agree that Center City Neighborhood Development Corporation or a Public Housing Agency may conduct computer matching programs with other governmental agencies including Federal, State, or local agencies. The governmental agencies may include: US Postal Service US Office of Personnel Management US Social Security Administration US Department of Defense State Employment Security Agencies
The match will need to verify information supplied by the family. Conditions: I agree that photocopies of this authorization may be used for the purposes stated above. If I do not sign this authorization, I also understand that my housing assistance may be denied or terminated.
Adult Member of Household
Date
Adult Member of Household
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