Employees

Application

There is no application fee. Fax application to 765-807-3099 or e-mail to livingdowntown@insightbb.com.

PROPERTIES MANAGED BY CITY AGENCY, LLC

P.O. BOX 86 APPLICATION FOR

Lafayette, IN 47902 OCCUPANCY

PHONE: 765-714-2425

FAX: 765-807-3099

E-MAIL hlm@hlmohler.com

COMPLETE THIS APPLICATION IN FULL. ANSWER ALL THE QUESTIONS. COMPLETE ANSWERS TO THE QUESTIONS WILL DETERMINE YOUR PRIORITY FOR HOUSING.

SECTION A - APPLICANT

Applicant’s Name:

Present Address: Apt. No.:

City: State: Zip Code:

Permanent Address: Apt. No.:

City: State: Zip Code:

E-mail address:_____________________________________

Phone Day: Night:

SECTION B - HOUSEHOLD (COMPOSITION & CHARACTERISTICS)

LIST ALL HOUSEHOLD MEMBERS WHO WILL BE LIVING IN THE APARTMENT. (Include yourself as HEAD)

No.	Name	Relationship to Head	Birth Date	Sex M/F	Social Security Number
1.		Head
2.
3.
4.
5.
6.

SECTION C - LANDLORD/CHARACTER REFERENCES

Landlord - List most current landlord information first. List information for the past four years.

DATES OCCUPIED	APARTMENT BUILDING INFORMATION	LANDLORD INFORMATION
From: To: Rent Amt.: Utilities included: Y/N	Apt. Name: Address: Phone: ( )	Name: Address: Phone: ( )

From:

To:

Rent Amt.:

Utilities included: Y/N

Apt. Name:

Address:

Phone: ( )

Name:

Address:

Phone: ( )

SECTION D - INCOME INFORMATION

Applicant’s Employer: Other Household Member’s Employer:

Name/Company: Name/Company:

Address: Address:

Phone No.: Phone No.:

Length of Employment: From to . Length of Employment: From to .

Answer each question for household members. For each question answered yes, provide the monthly gross amount received.

DOES YOUR FAMILY/HOUSEHOLD RECEIVE OR EXPECT TO RECEIVE… ?	YES	NO	GROSS MONTHLY AMOUNT	FROM WHOM
Wages, salaries (includes overtime, tips, bonuses, commissions, self employment)?
Does anyone work for someone who pays them cash?
Regular pay for a member of the Armed Forces?
Public Assistance, General Relief or TANF?
Workman’s Compensation?
Unemployment benefits?
Child support or alimony?
Social Security payments?
Pensions?
Veterans Administration benefits?
Death benefits?
Annuities or life insurance dividends?
Lump sum payments (includes inheritances, insurance settlements, lottery winnings, capital gains)?
Regular cash contributions or gifts from individuals not living in the unit?
Are you or any member of the household a full-time student or plan on becoming a full-time student in the next 12 months?
Do you or any household members expect any changes to your income in the next 12 months?

　

SECTION E - ASSET INFORMATION

ALL INFORMATION WILL BE VERIFIED BY A THIRD PARTY.

DO YOU HAVE OR OWN… ?	YES	NO	CURRENT BALANCE	VALUE	WITH WHOM
1. Checking Accounts
2. Savings Accounts
3. Bonds/Stocks/Treasury Bills
4. Certificates of Deposit (CD)
5. Securities/Trusts/Funeral Trust
6. Money Markets
7. IRA/KEOGH/401K
8. Real Estate
9. Contract for Deed (Land Contract)
10. Rental Income
11. Assets Disposed of Within Last 2 Years
12. Personal Property Held as Investment - Describe:

SECTION F - GENERAL

1. When would you be available to move?

2. What size unit are you applying for: _____ 1 Bedroom _____ 2 Bedroom _____ 3 Bedroom?

Would you be willing to accept a smaller unit, if available? No _____ Yes _____ Size __________

3. Do you expect any additions to the household within the next twelve months? Yes____ No_____

Name and Relationship:__________________________________________________________________

Explanation:___________________________________________________________________________

4. Has your housing ever been terminated for fraud, non-payment of rent, or any other reason?

Yes _____ No _____ If yes, explain:

5. Do you have a pet? Yes _____ No _____ If yes, what kind:

Not all communities accept pets. Please verify if pet is allowed.

6. Race: (Optional - For Statistical Information Only)

White _____ Black _____ American Indian/Alaskan Native _____ Asian/Pacific Islander _____

Other _____

What is your credit score? ________________

Do you have any unsatisfied Civil or IRS Judgements recorded in Court or the Public Record?

yes or no _______

If yes, explain.___________________________________________________________________________

Do you have any Criminal Convictions on your record?_____________________________________

Are you on Police Records as a Sex Offender? ____________________________________________

SECTION G - EMERGENCY CONTACT

LIST NAME, ADDRESS, AND PHONE NUMBER TO CONTACT IN CASE OF EMERGENCY.

Name: Phone Number: Relationship:

Address: City, State: Zip Code:

READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING THIS APPLICATION.

APPLICANT CERTIFICATION & CREDIT INFORMATION: I understand that the above information is being collected to determine eligibility and resident selection criteria. I authorize City Agency, LLC to verify all information provided on this application and to contact previous and current landlords, sources of credit, and verification information which may be released to appropriate Federal, State, or local agencies. I understand that credit checks will be completed while I am an applicant and throughout my residency. I certify that the statements made in this application are true and complete to the best of my knowledge and belief. I understand that false statements, perjury or false information are punishable under Federal Law. I understand that false or misleading or incomplete information may result in the termination of the lease agreement. I understand that it is my responsibility to inform management of any changes on this application within 14 days. THIS APPLICATION IS NOT A RENTAL CONTRACT, CONTRACT OR LEASE. ALL APPLICATIONS ARE SUBJECT TO THE APPROVAL OF THE OWNER OR MANAGING AGENT.

Applicant Signature Date