For Office Use Only
Date Received:
Time Received:
Received by:
□ Original □ Updated □ Add-on
If updated, use original date and time stamps.
HOH Name :____________________________
Use to link multiple apps due to addt’l adults
MERCY HOUSING MANAGEMENT
HOUSING APPLICATION
PROPERTY NAME: Reynoldstown Senior Residences___________PROPERTY TELEPHONE #404-975-4291
NOTICE: Discrimination Prohibited: The landlord will not discriminate based upon race, color, religion, creed, national origin, sex, age,
familial status, or disability. In addition, our housing programs are open to all eligible persons regardless of sexual orientation,
gender identity, marital status, and ancestry. Anyone who wishes to be admitted to the property or placed on a property’s waiting list
must complete an application. In addition to providing applicants the opportunity to complete applications at the project site, owners
may also send out and receive applications by mail. Owners shall accommodate persons with disabilities who, as a result of their
disabilities, cannot utilize the owner’s preferred application process by providing alternative methods of taking applications.
The information you provide on this application will be treated as confidential. This application gives no lease or rental rights. It
includes both information necessary for determining your eligibility for housing and information required for statistical purposes. If
you and your household appear to be eligible, you will need to submit additional information to complete the processing of this
application. All information you provide will be verified by Mercy Housing Management Group. Incomplete and/or falsified
information will cause the application to be denied and not processed.
It is the policy of Mercy-managed properties to take reasonable steps to provide meaningful access to limited English proficient (LEP) individuals
applying or residents at our apartment communities, or otherwise encountering our property’s facilities, programs, and activities. The policy is to
ensure that language will not prevent staff from communicating effectively with LEP residents, applicants, and others to ensure safe and orderly
operations, and that limited English proficiency will not prevent applicants from participating in the application process, or residents from accessing
important programs and information, understanding rules and regulations, and participating in meetings, events or activities.
MARKETING:
Please let us know how you heard of us:
Newspaper Ad Drove by Resident Referral Web Site Other:
Please provide the following information for all persons that will live in the household
ALL AREAS MUST BE COMPLETED IN ITS ENTIRETY
Date of Application: Unit Size Needed:
Applicant Name: Applicant Name:
Applicant SS#: Applicant SS#:
Applicant Date of Birth: Applicant Date of Birth:
Gender*: Gender*:
Applicant Race*:__________ Ethnicity*:_______________ ApplicantRace*:___________
Ethnicity*:_________________
*Race Options: American Indian/Alaska Native Asian African American/Black Native Hawaiian/Other Pacific Islander White Other:
*Ethnicity Options: Hispanic/Latino or Non-Hispanic/Latino
*This information is requested by the apartment owner in order to assure the Federal Government, acting through federal, State and local agencies
that Federal Laws prohibiting discrimination against resident applicants. 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.
X____________________________________ X____________________________________
I decline to provide my race and ethnicity data I decline to provide my Race and Ethnicity data
General Information:
Page 1 of 9
Please complete each field below. Answer each question as completely as possible. Enter N/A for all blank fields.
GENERAL INFORMATION
Applicant Applicant
Full Name (First, Middle, Last):
Mailing Address:
City, State, Zip:
County:
Home Phone:
Work Phone:
Alternate Phone:
Marital Status (circle one): Single, Separated, Married, Divorced, Widowed Single, Separated, Married, Divorced, Widowed
Applicant Applicant
Yes No Yes No Are you a student enrolled in an institute of higher education?
Yes No Yes No Are all household members U.S. Citizens? (N/A for PRAC 202/811 & Tax Credit)
Yes No Yes No Do you anticipate a change in household composition (i.e., addition of adult household
member, household member moving out, birth or adoption of child, etc.) in the next
twelve months? Explain: -
______________________________________________________
Yes No Yes No Have you or any household member disposed of, sold, donated, or gifted any assets
(including cash) for less than fair market value during the last two (2) years?
Explain: _____________________________________________________________
Yes No Yes No Have you ever been convicted of a felony or do you have a criminal history? If yes,
when and what were the circumstances?
Yes No Yes No Do you or any household member currently engage in the illegal use of drugs or
your/their behavior from this illegal use interferes with the health, safety, and right to
peaceful enjoyment of the property by other residents?
Yes No Yes No Have you been evicted in the last three years from federally-assisted housing for drug-
related criminal activity?
Yes No Yes No Have you or anyone in your household’s behavior, from abuse or pattern of abuse of
alcohol, interfered with the health, safety, and right to peaceful enjoyment by other
residents?
Yes No Yes No Has your tenancy or government assistance in a subsidized housing program ever been
terminated for fraud, non-payment of rent, or failure to comply with recertification
procedures?
Yes No Yes No Are you or anyone in your household subject to a nationwide Sexual Offender’s
Registration?
Yes No Yes No Will this apartment be your sole place of residency?
Yes No Yes No Have you been involuntarily displaced by Government Action or Natural Disaster?
Yes No Yes No Are you a U.S. Veteran and/or in Active Duty? (Optional)
Yes No Yes No Do you have an existing Section 8 voucher?
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Employment Status:
Please answer each applicable question if you are currently employed or have been employed within the last year. Enter N/A for fields that do
not apply. If you have been unemployed over the last year or have never worked, enter N/A in ALL fields.
EMPLOYMENT STATUS
Applicant Applicant
Are you currently employed? If yes, where?
If employed, what is your occupation?
If employed, list current wage and frequency:
If employed, is there any expected change in rate
of pay, hours worked or employment status? If
yes, explain.
If unemployed within last year, enter last day
worked. Otherwise enter N/A.
If unemployed, did you receive layoff notice?
Are you receiving unemployment benefits?
If unemployed, have you received any
employment income in the past 12 months? If
yes, from what source(s)?
If unemployed, why?(IDAHO only)
Otherwise, enter N/A here:
Income/Cash Benefits:
Please enter dollar amounts as estimated GROSS monthly figures for all sources of income. Please round your figures to the nearest dollar amount.
For income that does not apply, enter zero (0) in each field. Do not use N/A in this section.
INCOME/CASH BENEFITS
Applicant Applicant
Alimony $ $
Business/Self-Employment - NET $ $
Child Support Income $ $
Employment Wage Earnings $ $
Pension Income $ $
Recurring Assistance from Others $ $
Retirement Income $ $
School Financial Assistance $ $
Social Security Benefits $ $
SSI Benefits $ $
TANF/AFDC/Monetary Public Assistance $ $
Tribal per Capita Income $ $
Unearned Income for Members Under18 $ $
Unemployment Benefits $ $
Veterans Benefits $ $
Other Income $ $
TOTAL MONTHLY INCOME $ $
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Assets:
List each household member (including minors) & indicate assets held for each member in the asset table below. *Type of assets to include:
checking, savings, money market, house, land, stocks, bonds, certificates of deposit, retirement, pension funds, insurance policies, trusts,
annuities, pay cards, prepaid debit cards, cash or other forms of capital investments. DO NOT LIST THE VALUE OF PERSONAL
AUTOMOBILES OR HOUSEHOLD FURNISHINGS. [NOTE: Each member must be listed. Enter member name in designated field followed
by “None” in the Type of Asset field for those who do not have any. Otherwise, list assets held per member & value]
HOUSEHOLD ASSETS
Household Member’s Name Type of Asset* Value ($)
Household Composition:
In the table below, list the additional household members who will reside in the household not already listed on page 1 or on an additional
application. Include total number of household members in field at bottom of table to include members who may be listed on an additional
application. Please also include any “unborn” children.
HOUSEHOLD COMPOSITION
Grade Do you If not, list
Name Gender Birth percentage Last 4#s of Race Ethnicity
Age in have full
(First/Last) M/F date of custody Social (See Pg 1) (See Pg 1)
School custody?
a.
b.
c.
d.
e.
f.
Total # of HH Members
Include Members on page one
Household Member #: a. , b. , c. , d. , e. , f.
I decline to provide my race and ethnicity data (Each Household Member has the option to sign if they’re declining to provide this information.)
Special Needs (Optional):
Please answer the following questions.
Are you or another household member disabled? Yes No
Do you or a household member require a special accommodation in your unit or need accessible features in the unit?
Yes No
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Special Needs (Optional) Continued:
If yes, select applicable accessibility needs below:
Accommodation
Wheelchair Accessible
Walker/Cane Accessible
Other Mobility Impairment Accessible
Other Vision Impairment Accessible
Other Hearing Impairment Accessible
Other Permanent Disability Accessible
Accessible Parking Space
Live-in Attendant
If attendant is needed, please give name of attendant & ordering physician:
_______________________________________________
Name of Live-in Attendant Name and Phone Number of Physician
Emergency Contact (Optional):
Please list the name and phone number of the person we should contact if we cannot reach you in the event of an emergency.
First/Last Name Phone Number
Expenses (HUD-assisted units only):
Please enter dollar amount as estimated monthly figure for all applicable expenses. For fields that do not apply, enter zero (0). Do not use N/A in
this section.
EXPENSES
Applicant Applicant
Caregiver/Caregiver Duties $ $
Child Care $ $
Companion Animal Related $ $
Dependent Care $ $
Disability Related Equipment $ $
Disability Related- Other $ $
Health Insurance Related- Other $ $
Medical Related- Other $ $
Medicare Premium $ $
Other Anticipated Medical $ $
Over-the-Counter Medication Approved by Physician $ $
Prescription Medication $ $
Service Animal Related $ $
TOTAL MONTHLY EXPENSE $ $
Residential History:
Please provide consecutive residential history. This includes the addresses for family/friends you reside with, whether or not you pay rent,
current/previous landlords & homeless shelters.
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RESIDENTIAL HISTORY
Applicant Applicant
Name of CURRENT Housing Provider
OR Property:
List affiliation (circle one): Family/ Friend/ Landlord/ Owned/Shelter Family/ Friend/ Landlord/ Owned/Shelter
Address of Provider:
Address of Applicant (if different):
Provider/Property Phone Number:
Dates of Occupancy :
(mm/yy – mm/yy)
Did you pay rent? If so, how much per
month?
Where you evicted or is eviction
pending? If so, why?
Applicant Applicant
Name of PREVIOUS Housing Provider
OR Property:
List affiliation (circle one):
Family/ Friend/ Landlord/ Owned/Shelter Family/ Friend/ Landlord/ Owned/Shelter
Address of Provider:
Address of Applicant (if different):
Provider/Property Phone Number:
Dates of Occupancy:
(mm/yy – mm/yy)
Did you pay rent? If so, how much per
month?
Were you evicted or is eviction pending?
If so, explain why:
Applicant Applicant
Name of PREVIOUS Housing Provider
OR Property
List affiliation (circle one): Family/ Friend/ Landlord/ Owned/Shelter Family/ Friend/ Landlord/ Owned/Shelter
Address of Provider:
Address of Applicant (if different):
Provider/Property Phone Number:
Dates of Occupancy:
(mm/yy – mm/yy)
Did you pay rent? If so, how much per
month?
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Were you evicted or is eviction pending?
If so, explain why:
Please list all states and counties you have resided in:
Applicant 1:
ST: _______________ ST: ________________ ST: ________________ ST: _________________ ST: _________________
COUNTY: _________ COUNTY: __________ COUNTY: ___________ COUNTY: _________ COUNTY: ___________
Applicant 2:
ST: _______________ ST: ________________ ST: ________________ ST: _________________ ST: _________________
COUNTY: _________ COUNTY: __________ COUNTY: ___________ COUNTY: _________ COUNTY: ___________
POLICY STATEMENT & CERTIFICATION
Any general information included as part of an individual household member’s records will be made accessible between departments. Other
information not routinely in a household’s records may be shared between professional staff on a need-to-know basis at the discretion of the
department or site head staff person. Information, which involves criminal acts, including use of physical force, offenses against other persons, child
abuse and neglect, etc., will be automatically reported to appropriate authorities as required by law.
I/We am/are applying for housing and state that all information provided herein is true, accurate, and complete to the best of my knowledge and
belief. Application includes pages 1 through 6 of this application. The information obtained will be used for management purposes only and will be
held in confidence.
Acknowledgment of being informed of the above:
Signature of Applicant Date
Signature of Applicant Date
ACKNOWLEDGEMENT
Any changes to your income, assets, household composition or student status from the date you signed your application up to your move in
date, must be reported to Mercy Housing Management. Failure to do so could result in denial of your move in. If after move in we discover
that changes were not reported, Mercy Housing Management may be required to take steps that could result in eviction.
_______ ________
Initials Initials
PENALTIES FOR MISUSING THIS CONSENT
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of
the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use
of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any
person, who knowingly or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a
misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and
seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty
provisions for misusing the social security number are contained in the **Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as
violations of 42 U.S.C. 408 (a) (6), (7) and (8) **. 6/29/2007
APPLICATION CLARIFICATION NOTES
This section is to be used only to clarify items listed on the application itself.
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Item:
Item:
Item:
Item:
Item:
Item:
Discrimination Prohibited: The landlord will not discriminate based upon race,
color, religion, creed, national origin, sex, age, familial status, or disability.
Page 8 of 9 Eff 3/2016
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NOTICE OF RIGHT TO
REASONABLE ACCOMMODATION/MODIFICATION
If you have a disability and as a result of your disability you need . . .
• a change in the rules or policies or how we do things that would give you an equal opportunity to use
and enjoy the housing and facilities at this housing development or take part in programs on site,
• a change or repair in your apartment or a special type of apartment that would give you an equal
opportunity to use and enjoy the housing and facilities at this housing development or take part in
programs on site,
• a change or repair to some other part of the housing site that would give you an equal opportunity to use
and enjoy the housing and facilities at this housing development or take part in programs on site.
If you can show that you have a disability and if your request is reasonable (*does not pose “an undue
financial or administrative burden”), we will try to make the changes you request.
We will give you an answer in 10 working days unless there is a need for verification of the request. In that
case, the response time is 15 working days unless there is a problem getting the information we need or unless
you agree to a longer time. We will let you know if we need more information or verification from you or if we
would like to talk to you about other ways to meet your needs.
If we turn down your request, we will explain the reasons and you can give us more information if you think
that will help.
If you need help filling out a REASONABLE ACCOMMODATION/MODIFICATION REQUEST FORM or
if you want to give us your request in some other way, we will help you.
You can get a REASONABLE ACCOMMODATION/MODIFICATION REQUEST FORM at the
Property office
Or by emailing 504adacoordinator@mercyhousing.org
Fax: (877)-245-7121
(800) 855-2880 TTY
NOTE: All information you provide will be kept confidential and be used only to help you have an equal
opportunity to use and enjoy your housing and the common areas.
* This legal phrase means if it is not too expensive and too difficult to arrange.
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