APPLICATION FOR HOUSING by 2915gx

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									                                                                         MHAGH Application for Housing 1


                           APPLICATION FOR HOUSING
                                         Please Print Clearly
                        APPLICANT NAME                                       TELEPHONE NUMBER



                                                             HOUSING DEVELOPMENTS
Please put a check mark next to the housing
                                                    ___Dart Gardens – Hartford, CT 06106
development for which you are applying.                168 – 238 Dart St. & 615 - 637 Brookfield St.
Check all properties in which you are interested.      One, Two and Three Bedroom Units
                                                    ___Park Terrace I – Hartford, CT 06106
All applicants applying for Park Terrace I, Park        222-248 Park Terrace
Terrace II, Webster Street, Grove Street, Zion          One and Two Bedroom Units
Street, Carter Court and Union Street must pay      ___Park Terrace II – Hartford, CT 06106
a non-refundable application fee of $40. The           459 Summit;264, 268, 278-308 Park Terrace and
application fee must be paid by money order            2-10 Hillside Avenue
or bank check only. No cash or personal                One, Two, Three and Four Bedroom Units
checks will be accepted. If you are interested      ___Plaza Terrace – Hartford, CT 06120
in more than one of these properties, only one         17-19 Martin Street
$40 application fee is required.                       Two and Three Bedroom Units
                                                    ___Webster Street – Hartford, CT 06114
                                                       63-71 Webster Street
Mutual Housing will provide help                       Two and Three Bedroom Units
with reviewing this document.                       ___Zion Street – Hartford, CT 06106
Should you need help in completing                     511-529 Zion Street
                                                       Two and Three Bedroom Units
this application, please contact the                ___Grove Street – Windsor Locks, CT 06096
property manager you received the                       55 Grove Street
application from or the Mutual                          Two and Three Bedroom Units
                                                    ___Willow Arms – Simsbury, CT 06081
Housing main office listed below. If                    55 Elm Street
necessary, persons with disabilities                    One and Two Bedroom Units
may ask for this application in large               ___Carter Court – Glastonbury, CT 06033
                                                        1-56 Full Circle
print type or other alternate formats.                  One, Two and Three Bedroom Units
                                                    ___Union Street – Manchester, CT 06040
                                                       1-63 Jennifer Way
                                                       One, Two and Three Bedroom Units



                           Please complete this application and return to:

             MUTUAL HOUSING ASSOCIATION OF GREATER HARTFORD
                           95 Niles Street, Hartford, CT 06105
                 (860) 296-1797     Fax (860) 524-8963 TTY: Dial 711
                            Website: www.mutuahousing.org
                                                 MHAGH Application for Housing 2


            Please indicate how you found out about us.
_ 211                             _ Housing Search.com
_ Airport News                    _ Radio (Please specify) __________________
_ Craigslist                      _ LinkedIn
_ CRT                             _ Manta
_ Facebook                        _ MHA Website
_ Google Ad                       _ Reminder News
_ Hartford Housing Authority      _ Renter’s Directory
_ HUD.gov                         _ Social Agency
_ Identidad Latina                _ Twitter
_ Imagineers                      _ Yankee Flyer
_ Hispanic Yellow Pages           _ Other (Please specify) __________________
                                                                    MHAGH Application for Housing 3


Resident Selection

I. MUTUAL HOUSING FAIR HOUSING STATEMENT
The Mutual Housing Association of Greater Hartford, Inc. (MHAGH) is a non-profit housing
development and management firm that works within the Mutual Housing model, as defined by
Connecticut law.
Essential to the organization’s mission is our commitment to diversity. The Association will not
discriminate against any applicant on the basis of race, sexual orientation, age, gender, religion,
political affiliation, national origin, physical or mental disability, marital status, learning
disability, lawful source of income, individuals with children, or any other status protected by
statute. In addition, the Association pledges to aggressively and affirmatively market available
units to qualified persons of all backgrounds.


II. APPLICATION
Please submit documents that will show all sources of income for each household member.
If employed, please attach at least one current pay stub. If receiving income from other
sources, please provide a copy of a payment statement or award letter showing current
income. Attach copies of social security cards and birth certificates for all household
members and picture identifications for all persons 18 and older.
All applicants applying for Park Terrace I, Park Terrace II, Webster Street, Grove Street, Zion
Street, Carter Court and Union Street must pay a $40 NON-REFUNDABLE application fee.
The application fee must be paid by money order or bank check only. No cash or personal
check will be accepted. If you are interested in more than one of these properties, only one $40
application fee is required.
Applications are placed in order of date and time received. Please fill in all sections completely.
For those questions or request for information that do not apply to you, please write in “NA”
which means not applicable. Failure to complete this application true and completely to the best
of your knowledge and belief and provide copies of social security cards and birth certificates
will result in processing delays or rejection of your application.
The applicant will be reviewed on the following criteria.
      Verification of income source
      Acceptable credit history
      Acceptable rental history
      Acceptable police report
      Housing Program Eligibility and Requirements
If an applicant is rejected, the applicant is informed in writing that the application has been
rejected and provided with the reasons for the rejection and an opportunity to appeal the
decision. If you need a reasonable accommodation to apply or live in our development, we will
consider your request. Please let us know what you need.
                                                                                     Revised 7/28/2011
                                                                    MHAGH Application for Housing 4




                                 A. GENERAL INFORMATION


Applicant Name (s):


Street & Apt #                          City                State                Zip Code

Daytime phone                           Evening Phone                            Cell:

No. of BR’s in current unit:            Do you:  RENT or  OWN? (check one)

Amount of current monthly rent or mortgage payment: $

If owned, do you receive monthly rental income from property?  Yes  No (check one)
Check utilities
paid by you:        Heat               Electricity      Gas             Other (specify)

Approximate monthly cost of utilities paid by you (excluding phone and cable TV) $
Bedroom size
requested:        One BR              Two BR            Three BR         Four BR

Does any member of your household need an accessible unit? Yes No 
Does any member of the household have any accessibility or reasonable accommodation requests or need
for changes in a unit or development? Yes No  If yes, please explain: ______________________
__________________________________________________________________________________
Does any member of the household have a reasonable accommodation request for an alternate way to
communicate with you? Yes No  If yes, please explain: _____________________________
__________________________________________________________________________________


DO YOU RECEIVE HOUSING ASSISTANCE?  Yes  No (If yes, attach a copy of the
voucher to the application)

HOW DID YOU KNOW ABOUT OUR APARTMENTS? _____________________________
_______________________________________________________________________________
                                                                                 MHAGH Application for Housing 5


                                    B. HOUSEHOLD COMPOSITION
                  List ALL persons who will live in the apartment. List the head of household first.


                                                    Relation-
                                                     ship To
                                                     Head of                                                     Student
                           Name                     Household         Birth Date                 SS#             Yes or No
Head

Co-Tenant

3.

4.

5.

6.

7.

8.


Have there been any changes in household composition in the last twelve months?  Yes  No
If yes, explain:
Do you anticipate any changes in household composition in the next twelve months?  Yes  No
If yes, explain:
Is there someone not listed above who would normally be living with the household?  Yes  No
If yes, explain:


                                                STUDENT STATUS
Will ALL of the persons in the household be or have been full-time students during five calendar months of this year or
plan to be in the next calendar year at an educational institution (other than a correspondence school) with regular faculty
and students?  Yes  No

      Are any full-time student(s) married and filing a joint tax return?             Yes      No
      Are any student(s) enrolled in a job-training program receiving
       assistance under the Job Training Partnership Act?                              Yes      No
      Are any full-time student(s) a TANF or a title IV recipient?                    Yes      No
      Are any full-time student(s) a single parent living with his/her minor
       child who is not a Dependant on another’s tax return and whose                  Yes      No
       children are not dependents of anyone other than a parent?

      Is any student a person who was previously under the care and
       placement of a foster care program (under Part B or E of Title IV of            Yes      No
       the Social Security Act)?
                                                                           MHAGH Application for Housing 6


                                                 C. INCOME
         List ALL sources of income as requested below. If a section doesn't apply, cross out or write NA.


Household Member Name                                Source of Income                      Gross Monthly Amount
                                      Social Security                                      $
                                      Social Security                                      $
                                      Social Security                                      $
                                                                                           $
                                      SSI Benefits                                         $
                                      SSI Benefits                                         $
                                      SSI Benefits                                         $


                                      Pension (list source)                                $
                                      Pension (list source)                                $


                                      Veteran’s Benefits (list claim #)                    $
                                      Veteran’s Benefits (list claim #)                    $


                                      Unemployment Compensation                            $
                                      Unemployment Compensation                            $


                                      Title IV/TANF                                        $

                                      Contributions to the Household (monetary or
                                      not)                                        $


                                      Full-Time Student Income (18 & Over Only) $
                                      Financial Aid (grants & scholarships                 $
                                      exceeding of the amount of tuition may
                                      have to be included in total income)


                                      Interest Income (source)
                                      Interest Income (source)                             $
                                                                                           $
                                      Long Term Medical Care Insurance
                                      Payments in excess of $180/day


                                      Scheduled Payments from Investment                   $
                                      S
                                                                            MHAGH Application for Housing 7




Household Member Name                               Source of Income                      Monthly Amount
                                       Employment amount                              $
                                       Employer:
                                       Position Held:
                                       How long employed:

                                       Employment amount                              $
                                       Employer:
                                       Position Held
                                       How long employed:

                                       Employment amount:                             $
                                       Employer:
                                       Position Held:
                                       How long employed:
                                       Alimony
                                       Are you legally entitled to receive alimony?        Yes  No
                                       If yes, list the amount you are entitled to
                                       receive.                                           $
                                       Do you receive alimony?                             Yes  No
                                       If yes, list amount you receive.                   $
                                       Child Support
                                       Are you legally entitled to receive child          Yes No
                                       support? the amount you are entitled to
                                       If yes, list
                                       receive.                                           $
                                       Do you receive child support?                       Yes  No
                                       If yes, list the amount you receive.               $
                                       Other Income                                       $
                                       Other Income                                       $
                                       Other Income                                       $

TOTAL GROSS ANNUAL INCOME (Based on the monthly amounts listed above x 12)                $
TOTAL GROSS ANNUAL INCOME FROM PREVIOUS YEAR                                              $
Do you anticipate any changes in this income in the next 12 months?                       Yes  No
Is any member of the household legally entitled to receive income assistance?             Yes  No
Is any member of the household likely to receive income or assistance (monetary or
not) from someone who is not a member of the household as listed on Page 2 etc)?          Yes  No
If yes to any of the above, explain:



Is the income received?                                                               Yes  No
                                                                           MHAGH Application for Housing 8

                                                D. ASSETS
             If your assets are too numerous to list here, please request an additional form.
                             If a section doesn't apply, cross out or write NA.
Checking Accounts #                         Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
Savings Accounts #                          Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
Trust Account         #                     Bank                                   Balance$
Certificates          #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance$
Credit Union          #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
                      #                     Bank                                   Balance $
Savings Bonds         #                     Maturity Date                          Value $
                      #                     Maturity Date                          Value $
                      #                     Maturity Date                          Value $
Life Insurance        #                                                            Cash Value $
Policy
Life Insurance        #                                                            Cash Value $
Policy
MUTUAL FUNDS
Name:                              # Shares:      Interest or Dividend $           Value $
Name:                              #Shares:       Interest or Dividend$            Value $
Name:                              # Shares:      Interest or Dividend $           Value $

STOCKS
Name:                              # Shares:       Dividend Paid $                 Value $
Name:                              # Shares:       Dividend Paid $                 Value $
Name:                              # Shares:       Dividend Paid $                 Value $

BONDS
Name:                              # Shares:       Interest or Dividends           Value $
Name:                              # Shares:       Interest or Dividends
Investment Property                                                                Appraised Value $
                                                                    MHAGH Application for Housing 9
Real Estate Property: Do you own any property?                                    Yes  No
If yes, Type of property:
Location of property:
Appraised Market Value:                                                          $
Mortgage or outstanding loans balance due:                                       $
Amount of annual insurance premium:                                              $
Amount of most recent tax bill:                                                  $

Does any member of the household have an asset(s) owned jointly with a
person who is NOT a member of the household as listed in this application?        Yes  No
If yes, describe:


Do they have access to the asset(s)?                                              Yes  No

Have you sold/disposed of any property in the last 2 years?                       Yes  No
If yes, Type of property:
Market value when sold/disposed:                                                 $
Amount sold/disposed for                                                         $
Date of transaction

Have you disposed of any other assets in the last 2 years (Example: Given away money to relatives, set
up irrevocable trust accounts)?  Yes  No
If yes, describe the asset:
Date of disposition:
Amount disposed:                                                             $
Do you have any other assets not listed above (excluding personal
property)?                                                                    Yes  No
If yes, please list:


                                  E. ADDITIONAL INFORMATION
Are you or any member of your family currently
using an illegal substance?                          Yes        No
Have you or any member of your family ever been
convicted of a felony?                               Yes        No
         If yes, describe:
Have you or any member of your family ever been
evicted from any housing?                            Yes        No
       If yes, describe:
Have you ever filed for bankruptcy?                  Yes        No
        If yes, describe:                           
Will you take an apartment when one is available?    Yes      No
Briefly describe your reasons for applying:

                                                                    MHAGH Application for Housing 10


                                    F. REFERENCES
        Current Landlord          Name:
                                  Address:
                                  Home Phone:
                                  Business
                                  Phone:
                                  How Long?
       Previous Landlord          Name:
                                  Address:
                                  Home Phone:
                                  Business
                                  Phone:
                                  How Long?



 Credit Reference #1:
 Address:
 Account #:                                   Telephone #:
 Credit Reference #2:
 Address:
 Account #:                                   Telephone #:


 Reference #1:
 Address
 Relationship:                                Telephone #:
 Reference #2:
 Address
 Relationship:                                Telephone #:


EMERGENCY CONTACT PERSON

Name of Contact Person:
Address:                                         City, State, Zip
Telephone #:                                    Cell Phone #:
E-Mail Address (if applicable):
Relationship to Applicant:
                                                                  MHAGH Application for Housing 11





                      G. VEHICLE AND PET INFORMATION (if applicable)
List any cars, trucks, or other vehicles owned. Parking is provided for one vehicle. Arrangements with
Management will be necessary for more than one vehicle.

Type of Vehicle:                               License Plate #:
Year/Make:                                     Color:
Type of Vehicle:                               License Plate #:
Year/Make:                                     Color:
Pets are not allowed with the exception of service animals. Do you have a
service animal?                                                            Yes  No
If yes, describe:


                                  Applicant(s) Demographics

The following information is requested by the State government to monitor compliance with FAIR
HOUSING regulations. You are not required to furnish this information. It is against the law
to discriminate if you do not give us the information or based on this information.
Applicant:                                              Co-Applicant:
I do not wish to furnish this information             I do not wish to furnish this information.
White                                                 White
Black or African American                             Black or African American
Asian                                                 Asian
Black or African American & White                     Black or African American & White
Asian & White                                         Asian & White
American Indian or Alaska Native                      American Indian or Alaska Native
American Indian or Alaska Native & White              American Indian or Alaska Native &
White
American Indian or Alaska Native &                    American Indian or Alaska Native &
    Black or African American                             Black or African American
Native Hawaiian or Other Pacific Islander             Native Hawaiian or Other Pacific Islander
Other Multi Racial                                    Other Multi Racial

Hispanic  Yes No (check one)                          Hispanic  Yes No (check one)

Female        Male                                   Female        Male
                                                                        MHAGH Application for Housing 12



          GENERAL AUTHORIZATION FOR RELEASE OF
                      INFORMATION
CONSENT
I/We give consent to Mutual Housing Association of Greater Hartford and Housing Program
Funders to use any information received in administering and enforcing housing
requirements, rules and policies. I/We also consent for either entity to release information from
my/our file about rental history to credit bureaus, collection agencies or future landlords.
PURPOSE
Mutual Housing Association of Greater Hartford may use this authorization to obtain information as
part of the resident application, selection process, and tenant certification. All information is
regarded as confidential in nature.

INFORMATION COVERED
Verifications and inquiries that may be requested include but are not limited to:
Identity                Marital Status          Employment               Income
Assets                   Medical Allowances         Child Care Expenses Residences
Rental History           Credit History             Criminal Activity        Family Composition
Federal, State, Tribal or Local Benefits            Social Security Number
INDIVIDUAL OF ORGANIZATIONS THAT MAY RELEASE INFORMATION
Any individual or organization including any government organization may be asked to
release information. For example, information may be released from:
Banks & Other Financial Institution        Courts          State Dept. of Labor     Credit Bureaus

Law Enforcement Agencies                   Landlords       Employers (Past & Present)
Providers of: Alimony, Child Care, Credit, Medical Care, Social Security, Veteran's Benefits,
Pensions and Welfare.
CONDITIONS
I agree that a photocopy of this authorization may be used for the purposes stated above. The
original authorization will remain on file in the management office.

ALL ADULT HOUSEHOLD MEMBERS, 18 YEARS OR OLDER, MUST SIGN, PRINT
NAME AND DATE BELOW:

1._____________________________________________________________________________
Applicant Signature                        Print Name                               Date

2._____________________________________________________________________________
Applicant Signature                        Print Name                               Date

3._____________________________________________________________________________
Applicant Signature                        Print Name                               Date

4._____________________________________________________________________________
Applicant Signature                        Print Name                               Date
                                                           MHAGH Application for Housing 13



                 CERTIFICATIONS & CONDITIONS
1. I/We hereby certify that I/We do not and will not maintain a separate subsidized
   rental unit in another location.

2. I/We further certify that this will be my/our permanent residence and that the
   intended use is as a primary residence.

3. I/We understand I/We must pay a security deposit for this apartment prior to
   occupancy.

4. I/We understand that my eligibility for housing will be based on applicable income
   limits, housing program requirements and eligibility criteria and by management’s
   selection criteria.

5. I/We certify that all information in this application is true to the best of my/our
   knowledge and I/We understand that false statements or information are punishable
   by law and will lead to cancellation of this application or termination of tenancy after
   occupancy.

6. I/We hereby affirm that my answers to the questions on the application are true and
   correct and that I have not knowingly withheld any fact or circumstance that would, if
   disclosed, affect my application unfavorably.

7. I/We hereby authorize you to verify any and all information contained in this
   application. I release all concerned parties from any liability in connection with any
   information that they may provide.

8. I/We understand that all information given in the application will be accessible to the
   owner and its agents, various housing authorities, housing program funders and the
   owner’s property management company.


9. I/We understand that all adult applicants, 18 or older must sign application.

Signature(s):

Applicant #1:______________________________________              Date:___________

Applicant #2:______________________________________              Date:___________

Applicant #3:______________________________________              Date:___________

Applicant #4:______________________________________              Date:___________
                                                                               Revised 7/28/2011

								
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