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MHA Rental Application - Mutual Housing Association of Greater

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					                                                                                        Mutual Housing Association of Greater Hartford 1


                                    APPLICATION FOR HOUSING
                             Please complete this application completely and return to:

                  MUTUAL HOUSING ASSOCIATION OF GREATER HARTFORD, INC.
                                    95 Niles Street Hartford, CT 06105
                      Telephone (860) 296-1797 Fax (860) 524-8963 TTY: Dial 711
                                     Website: www.mutualhousing.org

                  PRINT HEAD OF HOUSEHOLD NAME                                          TELEPHONE NUMBER


                    HOUSING DEVELOPMENTS MANAGED BY MUTUAL HOUSING
Select a maximum of (4) properties per application. Please fill in all sections of the application completely.
Failure to do so will result in processing delays or rejection of your application. Should you need help in
completing this application, please contact Mutual Housing property management staff for assistance.

All applicants applying for Park Terrace I, Park Terrace II, Webster Street, Grove Street, Zion Street, Carter Court, Anvil
Place, Brick Hollow and Union Street must pay a non-refundable application fee of $40. The application fee must be
paid when you submit your application by money order or bank check only. No cash or personal checks will be
accepted. If you are interested in more than one property, only one $40 application fee is required. No application fee is
required for processing your application for Dart Gardens, Plaza Terrace or Willow Arms.


___Carter Court Cooperative – Glastonbury, CT 06033            ___Union Street Cooperative – Manchester, CT 06040
   1-56 Full Circle                                               1-63 Jennifer Way
   One, Two and Three Bedroom Units                               One, Two and Three Bedroom Units

___Dart Gardens – Hartford, CT 06106                           ___Webster Street – Hartford, CT 06114
   168 – 238 Dart St. & 615 - 637 Brookfield St.                  63-71 Webster Street
   One, Two and Three Bedroom Units                               Two and Three Bedroom Units

___Grove Street – Windsor Locks, CT 06096                      ___Willow Arms – Simsbury, CT 06081
   55 Grove Street                                                55 Elm Street - (16) of units Project Based Section 8
   Two and Three Bedroom Units                                    One and Two Bedroom Units

___Park Terrace I – Hartford, CT 06106                         ___Zion Street – Hartford, CT 06106
   222-248 Park Terrace                                           511-529 Zion Street
   One and Two Bedroom Units                                      Two and Three Bedroom Units

___Park Terrace II – Hartford, CT 06106                        ___Brick Hollow – Hartford, CT 06106
   459 Summit;264, 268, 278-308 Park Terrace and                  14-16 York Street & 555-609 Zion Street
   2-10 Hillside Avenue                                           Two and Three Bedroom Units
   One, Two, Three and Four Bedroom Units
                                                               ___Anvil Place – Senior Housing -55 years or older
___Plaza Terrace – All units Project Based Section 8
                                                                  51-55 West Main Street New Britain, CT 06051
   17-19 Martin Street Hartford, CT 06120
                                                                  One and Two Bedroom Units
   Two and Three Bedroom Units




                                                                                                                   REVISED 12/1/2012
                                                                                      Mutual Housing Association of Greater Hartford 2
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. 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 include copies of the following documents with your application for housing:
              Income statements or award letters showing all current household income
              If employed, attach copies of two current paystubs
              Copies of social security cards
              Birth certificates for all household members
              Picture identifications for all persons 18 years and older
Completed 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 all documents requested will result in processing delays or rejection of your application. The
applicant will be reviewed using the following criteria: verification of income source, credit history, rental history,
criminal history and housing program and project eligibility requirements.
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.

                                          A. GENERAL INFORMATION

Applicant Name:


Street & Apt #                             City                  State               Zip Code

Daytime phone                              Evening Phone                             Cell:

Email Address:                      Do you:  RENT or  OWN? (check one)
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? (Section 8 Voucher, RAP, etc....)?  Yes  No
HOW DID YOU KNOW ABOUT OUR APARTMENTS? ____________________________________________
(Craigslist, Infoline 211, CT Housing Search, Section 8 Agencies, Renter’s Directory, Mutual Housing Website,
Relative, Friend, Social Service Agency, Twitter, Facebook, Word of Mouth, etc.... )


                                                                                                                 REVISED 12/1/2012
                                                                                        Mutual Housing Association of Greater Hartford 3
                                    B. HOUSEHOLD COMPOSITION
                  List ALL persons who will live in the apartment. List the head of household first.

                                                                                                             Are you a
                                                                                                             Student?
                                                  Relation-                                                  Write Yes or
                                                   ship To
                                                   Head of                                                   No for each
                          Name                    Household        Birth Date              SS#               member below.
1. Head
                                                     SELF
2. 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
Are all of the persons in the household currently, will be or have been full-or part 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

EMPLOYMENT INCOME BY HOUSEHOLD MEMBER (Gross Income before Taxes)
Please indicate the gross income received by each member of your household. If you have additional
information, write it on a separate sheet of paper and attach to this application.

Member Name ____________________________________________________
Name of Present Employer___________________________________________ Telephone ______________
Address __________________________________________________________________________________
Years Employed ______ Position ______________________________ Current Salary $_________________
                                                                  [ ]weekly [ ]bi-weekly [ ]monthly

Member Name ____________________________________________________
Name of Present Employer____________________________________________ Telephone ______________
Address __________________________________________________________________________________
Years Employed ______ Position ______________________________ Current Salary $__________________
                                                                  [ ]weekly [ ]bi-weekly [ ]monthly

                                                                                                                   REVISED 12/1/2012
                                                                                   Mutual Housing Association of Greater Hartford 4
Member Name _____________________________________________________
Name of Present Employer____________________________________________ Telephone ______________
Address __________________________________________________________________________________
Years Employed ______ Position ______________________________ Current Salary $__________________
                                                                                [ ]weekly [ ]bi-weekly [ ] monthly

OTHER HOUSEHOLD INCOME
1. Do you receive alimony? [ ] Yes or [ ] No
Member Name _____________________________________________________
If yes, list amount you receive $______________ [ ]weekly [ ]bi-weekly [ ]monthly

2. Do you receive child support? [ ] Yes or [ ] No
Member Name _____________________________________________________
If yes, list amount you receive $______________ [ ]weekly [ ]bi-weekly [ ]monthly

3. Do you or other household member receive any other income not listed above? [ ] Yes or [ ] No
Member Name _____________________________________________________
If yes, list amount you receive $_________________ [ ]weekly [ ]bi-weekly [ ]monthly

4. List all other income such as TANF, Title IV, DSS, Social Security Benefits, SSI Benefits, Pensions,
   Disability Compensation, Unemployment Compensation, Interest, Annuities, Dividends, Income from Rental
   Property, Military Pay, Veteran Benefits, Scholarships, and/or Grants, Scheduled Payments from Investments,
   Contribution to the Household (monetary or not) and Long Term Care Medical Payment in Excess of
   $180/day:

Household Member Name                Type of Income           Gross Earnings
____________________           _______________________        $________per [ ]weekly [        ] monthly [       ]yearly
____________________           _______________________        $________per [ ]weekly [        ] monthly [       ]yearly
____________________           _______________________        $________per [ ]weekly [        ] monthly [       ]yearly
____________________           _______________________        $________per [ ]weekly [        ] monthly [       ]yearly
____________________           _______________________        $________per [ ]weekly [        ] monthly [       ]yearly

5. Do you anticipate any changes in the household income within the next 12 months?  Yes  No
   If yes, please explain _________________________________________________________

6. INCOME FROM TOTAL HOUSEHOLD ASSETS
Assets include Checking Accounts, Savings Accounts, Term Certificates, CDs, Money Markets, Stocks, Bonds,
IRA Accounts, Saving Bonds, Credit Union, Real Estate holdings and Cash Value of a Life Insurance Policy.
If you need additional space, please list the information on a separate sheet of paper and attach to the application.

Household Member Name                  Type of Asset          Interest Income Earnings
______________________         _______________________ $______per [ ] monthly [ ]yearly
______________________         _______________________ $______per [ ] monthly [ ]yearly
______________________         _______________________ $______per [ ] monthly [ ]yearly
______________________         _______________________ $______per [ ] monthly [ ]yearly
______________________         Life Insurance   Cash Value $ _____________________________
______________________         Life Insurance   Cash Value $ _____________________________
______________________         Savings Bonds Cash Value $______________________________
______________________         Real Estate Holdings Rental Income $______ per [ ] monthly or [ ] yearly


                                                                                                              REVISED 12/1/2012
                                                                                         Mutual Housing Association of Greater Hartford 5



Real Estate Property: Do you own any property?  Yes  No Market Value $_________________
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
Have you sold/disposed of any property in the last 2 years?  Yes  No
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
ADDITIONAL INFORMATION
1. Are you or any member of your family currently using an illegal substance?  Yes  No
2. Have you or any member of your family ever been convicted of a felony?  Yes  No If yes, please explain:
   _________________________________________________________________________
3. Have you or any member of your family ever been evicted from any housing  Yes  No
4. Will you take an apartment when one is available?  Yes  No
    Briefly describe your reason for applying. __________________________________________________

PETS are not allowed with the exception of service animals. Do you have a service animal? Yes
Please explain: _______________________________________________________________________

CURRENT LANDLORD REFERENCE
Name: _______________________________________ Address: _________________________________
City, State, Zip: ___________________________ Phone #: ___________________ How Long? _______

APPLICANT DEMOGRAPHICS (Optional Section)
(You are not required to furnish this information. This information will be used for fair housing programs only,
as required by State and Federal law.)
[   ]American Indian/Alaskan Native               [   ]Asian or Pacific Islander
[   ]Black(not of Hispanic origin)                [   ]Hispanic
[   ]White(not of Hispanic origin)                [   ]Other Race

                                      CERTIFICATIONS & CONDITIONS
I/We hereby certify that I/We do not and will not maintain a separate rental unit in another location. I/We further certify
that this will be my/our permanent residence and that the intended use is as a primary residence. I/We understand I/We
must pay a security deposit for this apartment prior to occupancy. I/We understand that my/our eligibility for housing will
be based on applicable income limits, housing program requirements and eligibility criteria and by management’s selection
criteria. 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. I/We hereby affirm that my/our answers to the questions on the application are true and correct
and that I/we have not knowingly withheld any fact or circumstance that would, if disclosed, affect my application
unfavorably. 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. I/We understand that all
information given in the application will be accessible to the owner and its agents assigned and housing authorities and
funders. I/We understand that all adult applicants, 18 or older must sign application.

    Applicant Signature:____________________________________________                       Date:___________

    Applicant Signature:____________________________________________                       Date:___________

    Applicant Signature:____________________________________________                       Date:___________


                                                                                                                    REVISED 12/1/2012
                                                                                       Mutual Housing Association of Greater Hartford 6




                             TENANT/APPLICANT RELEASE AND CONSENT

I/We, the undersigned, hereby authorize all persons, companies and agencies in the categories listed below to
release information regarding employment, income and/or assets for purposes of verifying information listed in
my/our application for housing and during the selection and tenant certification process. I/We authorize release
of information without liability to the Mutual Housing Association of Greater Hartford, Inc., agents, funding
sources, housing authorities and its assigns.

INFORMATION COVERED
I/We understand that previous or current information regarding me/us may be needed. Verifications and inquires
that may be requested include, but are not limited to: personal identity, employment, income, assets, medical or
child care allowances, student status, credit history, rental history, criminal history, family composition, marital
status, social security number and residences. I/We understand that this authorization cannot be used to obtain
information about me/us that is not pertinent to my eligibility for and continued participation as a qualified
applicant or tenant.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information may include, but are not limited to:

Past and Present Employers               Social Service Agencies          Veterans Administrations
Support and Alimony Providers            Educational Institutions         Retirement and Pension Providers
State Unemployment Agencies              Social Security Administration   Medical and Child Care Providers
Banks and other Financial Institutions   Previous/Current Landlords       Criminal Offenders Record (CORI)
Enterprise Income Verification System    Consumer Credit Agencies         Law Enforcement Agencies
Housing and Urban Development            State Department of Labor

CONDITIONS
I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this
authorization is on file. All information is regarded as confidential in nature. I understand that a photocopy of
this authorization is as valid as the original. Everyone 18 years or age and older must sign this form.
______________________________________________________________________________________________

SIGNATURES:
______________________________________        ________________________________ ________________
  Signature of Applicant/Resident               Printed Applicant/Resident Name      Date

______________________________________       ________________________________ _________________
  Signature of CO/Applicant Resident           Printed Co/Applicant/Resident Name   Date

______________________________________       ________________________________ _________________
  Signature of Adult Member                    Printed Adult Member Name            Date

______________________________________        ________________________________ _________________
  Signature of Adult Member                    Printed Adult Member Name             Date



                               THIS CONSENT IS VALID FOR A PERIOD OF
                               FIFTEEN MONTHS FROM THE DATE ABOVE



                                                                                                                  REVISED 12/1/2012
                                                                                                                                      Mutual Housing Association of Greater Hartford 7


                                                                EMERGENCY CONTACT FORM
  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.

   Applicant Name:

   Mailing Address:                                                                                    City, State, Zip:
   Telephone #:                                              Cell Phone #:                                          E-Mail Address:
   Name of Additional Contact Person or Organization:


   Address:                                                                                          City, State, Zip:
   Telephone No:                                                                         Cell Phone No:
   E-Mail Address (if applicable):
   Relationship to Applicant:
   Reason for Contact: (Check all that apply)

          Emergency                                                                          Assist with Recertification Process
          Unable to contact you                                                              Change in lease terms
          Termination of rental assistance                                                   Change in house rules
          Eviction from unit                                                                 Other: ______________________________
          Late payment of rent
   Commitment of Mutual Housing Association of Greater Hartford, Inc., its assigns or Owner: If you are approved for housing, this information
   will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or
   organization you listed to assist in resolving the issues or in providing any services or special care to you.

   Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
   applicant or applicable law.

   Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
   requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
   organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
   requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
   programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
   age discrimination under the Age Discrimination Act of 1975.

        Check this box if you choose not to provide the contact information.


                  Signature of Applicant                                                                                                             Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C.
3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604)
imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-
assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person
associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or
organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of
such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the
operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and
mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless
the collection displays a currently valid OMB control number. 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.




                                                                                                                                                                      REVISED 12/1/2012

				
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