OMB Control # 2502-0581

                                                                   Exp. (07/31/2012)

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

Instructions:  Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization.  This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require.  You may update, remove, or change the information you provide on this form at any time.  You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

  Check there if you choose not to provide the contact information.  

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.

Form HUD- 92006 (05/09)

CENTER CITY RENTAL APPLICATION

DATE APARTMENT NEEDED BY: _________________________________

 Name: ________________________________________________ Soc. Sec. #: __________________________________ 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? __________ * Marital Status: ______________ * Do you own a car? _________________

If yes, License plate# ________________ * 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: _____________________________________________________________

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 YRS OR OLDER MUST SIGN THE APPLICATION AND THE INFORMATION RELEASE FORM ATTACHED)

Name: ____________________________________________________ Relationship to you: _________________________________ Sex: _______

Date of Birth: ______________ Soc. Sec. #: ______________________________ Race/National Origin: ___________________________________

Name: ____________________________________________________ Relationship to you: _________________________________ Sex: _______

Date of Birth: ______________ Soc. Sec. #: ______________________________ Race/National Origin: ___________________________________

Name: ____________________________________________________ Relationship to you: _________________________________ Sex: _______

Date of Birth: ______________ Soc. Sec. #: ______________________________ Race/National Origin: ___________________________________

Name: ____________________________________________________ Relationship to you: _________________________________ Sex: _______

Date of Birth: ______________ Soc. Sec. #: ______________________________ 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: ________

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

$                                                                                                                                                                                                                                             

$                                                                                                                                                                                                                                             

$                                                                                                                                                                                                                                             

* This information is 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).

Name: __________________________________________________ Address: ________________________________________________________

City/State: __________________________________________________ Zip: ______________________ Phone: ____________________________

Name: __________________________________________________ Address: ________________________________________________________

City/State: __________________________________________________ Zip: ______________________ Phone: ____________________________

Name: __________________________________________________ Address: ________________________________________________________

City/State: __________________________________________________ Zip: ______________________ Phone: ____________________________

List Three (3) Personal References: NO RELATIVES (FAMILY) WILL BE ACCEPTED AS REFERENCES:

Name: __________________________________________________ Address: ________________________________________________________

City/State: __________________________________________________ Zip: ______________________ Phone: ____________________________

Name: __________________________________________________ Address: ________________________________________________________

City/State: __________________________________________________ Zip: ______________________ Phone: ____________________________

Name: __________________________________________________ Address: ________________________________________________________

City/State: __________________________________________________ Zip: ______________________ Phone: ____________________________

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?????

THANK YOU!!!

Return this application to:                                        CENTER CITY NEIGHBORHOOD DEVELOPMENT CORPORATION

                                                                                1824 MAIN STREET, NIAGARA FALLS, NEW YORK 14305

                                                                                                (716) 282-3738       FAX: 282-9607

                                                                DO NOT WRITE BELOW THIS LINE – OFFICE USE ONLY                                                                  

Date received: _____________________   Staff Person’s Initials: ______________________   Time received in Office: _______________________

ASSETS

LIST THE AREA BANKS YOU ARE PRESENTLY DOING BUSINESS WITH:

Do You have any of the following Yes (Y) or No (N). If so, attach statements.

Savings Bonds            (   )       Retirement Accounts   (   )      Credit Union Accounts (   )

Trust Funds     (   )       Certificates of Deposit (   )     Stock or Bonds             (   )

DEBTS

LIST ANY DEBTS YOU PRESENTLY OWE (car loan, credit cards etc):

LIST ALL OTHER BILLS - Utilities, Life Insurance, Auto Insurance, Health, Child Support, etc.

IF A ‘YES” ANSWER IS GIVEN TO ANY OF THE FOLLOWING QUESTIONS, PLEASE EXPLAIN ON THE BACK.

I (WE) CERTIFY THAT THE STATEMENTS CONTAINED HEREIN ARE TRUE, ACCURATE AND COMPLETE. I (WE) AUTHORIZE THE CORPORATION TO VERIFY ANY AND ALL STATEMENTS CONTAINED IN THIS APPLICATION, EVIDENCED BY MY (OUR) SIGNATURE'S BELOW:

APPLICANT ________________________________________________ DATE _________________

CO-APPLICANT _____________________________________________ DATE _________________