Preliminary Rental Application

Preliminary Rental Application

Rural Development Financed Properties

Please note that this is a preliminary application and gives no lease or rent rights.

Would you or a member of your household benefit from the design features of a barrier free unit? Yes No

Applicant’s History

If you have resided at additional addresses within the past five (5) years, please attach Previous Address Information on a separate sheet.

The information contained in this application is treated confidentially. No information will be revealed to anyone without the express written consent of the applicant.

Employment

Assets and Household Information

Have you disposed of any assets in the last two years? Yes No

Are you a student? Yes No If yes: Part-time student Full-time student

Are any members of your household full-time students? Yes No

Have you or any member of your household lived in subsidized housing? Yes No

Have you ever committed fraud in a subsidized housing program or been requested to repay money for knowingly misrepresenting information for such housing programs? Yes No

ADJUSTMENTS FOR INCOME

Do you qualify for any of the following:

Are you disabled or over the age of 62 years? Yes No

If yes, do you have medical expenses that are not covered by insurance? Yes No

Do you pay childcare expenses that allow you to work or attend school? Yes No

Do you pay expenses for care of an individual with disabilities that allow you to work? Yes No

Personal References

Applicant’s certification that the unit applied for will be the applicant household’s primary residence and it does/will not maintain a separate subsidized rental unit in a different location.

I fully understand that Title 18, Section 1001 of the United States Code states that a person is guilty of a felony for knowingly and willfully making false or fraudulent statements to any department or agency of the United States. I therefore, certify that the foregoing information is true and complete to the best of my knowledge. I authorize inquiries to be made to verify the statements above. Falsified statements shall be grounds for eviction.

I/We certify that the rental unit which I/We will occupy will be my/our primary residence and further certify that I/We do not and will not maintain a separate subsidized rental unit in a different location. I acknowledge that I am responsible to inform the office of any changes to any part of this application (i.e. address, phone, income).

Additional information will be required at a later date to complete the processing for residency.

Race and Ethnic Data Reporting

The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age, and disability 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. However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.

Fair Housing Reporting Act and Authorization

KMG Prestige, Inc., Affinity Property Management, LLC. and/or Apartments is requesting a copy of your Consumer Report or Credit Report to assist it in its consideration for:

Employment purposes, or

Housing at Apartments

I have read the foregoing information referred to as a Fair Credit Reporting Disclosure and now hereby authorize KMG Prestige, Inc., Affinity Property Management, LLC., and/or Apartments to obtain a Consumer Report, Credit Report or Investigative Report on me from a consumer reporting agency or company for:

Employment purposes

Housing purposes

Both

I acknowledge that I have received a copy of this document for my records.

Authorization for Criminal History Check

NOTICE TO APPLICANTS: The information requested below is for the sole purpose of conducting a background investigation, which includes, among other things, a criminal conviction check.

I expressly authorize all personnel, schools, companies, corporations, credit bureaus and law enforcement agencies to supply any and all information concerning my qualifications for employment positions applied for and the information given by me herein. This authorization is good for one year from the date of signing.

Things You Should Know About USDA Rural Rental Housing

Don’t risk losing your chances for federally assisted housing by providing false, incomplete, or inaccurate information on your application or recertification.

The remaining pages of the document contain informational notices, grievance procedures, and discrimination statements without additional form fields.