No Credit Check Apartments Houston by ofy11631

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									       Pear Grove Apartments - Application Package Checklist
Please return this Fonn with all listed documents properly completed and signed. Application
Packages, which are incomplete, will not be processed for consideration of residency at the
property.



Applicant Name                                              Date

              Application for Rental

              Mental HealthlMental Retardation Provider(s) (doctors/clinics/centers) and
              Hospitalization Histories with addresses and dates for last five (5) years
              Letter from your current Psychiatriston his/her letterhead indicating length of
              treatment & confinnation you have a Chronic Mental Illness/Developmental
              Disability and whether you have been compliant with your treatment plan
              Copy of treatment plan
              Activity Plan reviewed & approvedby mental health/retardation professional

              Copy of Birth Certificate for all household members
              Copy of valid Driver's License or State Issued Identification for all adults
              Copy of current Social Security award letter indicating your benefits

              Copy of your current Lease or Letter from shelter or parents stating tenns of your
              living arrangement, amount paid, etc. if residing at shelter or with parents.
              Provide a housing history for at lease the last five (5) years with complete
              Landlord contact infonnation which includes the landlord name, full address, city,
              state, and zip code, phone & fax number & complete dates at each location.
              Copy of any and all evictions, landlord vacate/violations/damage letters/notices

               Copy of Credit Report if available
               Copy of Criminal History or Police Report(s) for any/all criminal history/arrests

               Copy of Food Stamp Letter if currently receiving this benefit
               Copy of AFDC or any other income or benefits documents
               Copy of current bank/brokerage statement(s) for all such accounts
               Copy of pay stubs for the last 2 months & W2 for last year, if working
               Copy of IRS tax return for the last 2 years if you filed a return

               Copy of divorce decree or separation documents if divorced or separated

               Referral Letter(s) (doctor, agency, etc.)

               Other Relevant Infonnation (please describe)

All of the above information and forms must be complete, signed and legible. Do not leave any
spaces blank. Insert a check mark for provided documents or insert none or N/A.
        (1212007)
                                 Basic Criteria/Requirements
           Minimum income: $500/ month ($6,OOO/year)
  .
  ~



  .
           Maximum income: $1,779/month ($21,350/year) one person household

  .
  .
           Stable/acceptable housing history past five years
           Acceptable credit and payment history
           Ability to live independently or demonstrate independent living skills
  .
  .        Maxi~um: 2 persons - one bedroom unit
           Ability to obtain and maintain electrical service for the unit
  .        Be able to keep the unit clean with or without assistance
  .        Able to provide documentation of a chronic mental illness or developmental disability
  e        Under the care of a mental health/retardation provider(s)
  .        Compliant with treatment plan
  .        History of compliance with treatment plan


                                      Unacceptable History
  .        Eviction(s) or non-renewal(s) or asked to move out
  .        Owe debt to former or present landlords, housing authorities, public housing, or HUD
           subsidized or assisted properties
  .        Felony conviction(s)
  .        Sexual offenders (i.e. registered sex offenders, etc.)
  .        Pyromaniacs (pyromania)
      .    Drug offense(s), substance/alcohol abuse(s) and/or conviction(s) (acceptability win be
           reviewed on case by case basis depending on the type, degree,date, etc.)
      .    Violence and/or assault with or without a weapon
      .    Nonpayment ofrent(s) and/or damage(s)
      .    Threatening behavior(s) and/or action(s) - disrupting other tenants quiet, and peaceful
           enjoyment of the property or threatening property staff or similar action
      .
      .
      4t
           Eviction, non-renewal, asked to move out of another HUD Section 811 property
           Repeated Lease and/or House Rule violations
           Misdemeanorconviction(s)and/or indictmentswill be reviewedand determinedacceptable
            on a case by case basis depending on the type, degree, date of incident, circumstances and
            other factors

NOTE: These are just some of the basic requirements andunacceptablehistory criteria
for eligibility and admissibility for tenancy at the property and are not intended to be
inclusive of all the property requirements.
<><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><><

I have read the above Basic Criteria/Requirements    and Unacceptahle History and
believe that I qualify and do not have any of the unacceptable history,


Applicant Signature                                             Date
                                              PEAR GROVE, INC.
                                             Application For Rental
                                            Please print or write legibly in blue ink

Date received:                                          Time received:                                   Bedroom size:

1)       Head of Household - Full Name (exactly as shown on your driver's license or government issued ID)

         Your street address, city, state, and zip code (exactly as shown on your driver's license or government issued ID)

         Driver's License # and state OR government issued photo ID card:
         Former Last Names (maiden, married, or changed):
         Age -       Birthdate:                  Social Security #                             Height:              Weight:    -
         Eye Color:              Hair Color:                      Do you or any occupantsmoke?                  Yes            No
         Are you a U.S. Citizen?         Yes                      No Please attach a copy of birth certificate to this application.
         Marital Status: Married                        Single                    Divorced                      Widowed-

         Spouse or other occupant(s)    -   Full Name (exactly as shown on your driver's license or government issued ID)

         Your street address, city, state, and zip code (exactly as shown on your driver's license or government issued ID)

         Driver's License # and state OR government issued photo ID card:
         Former Last Names (maiden, married, or changed):
         Age     -   Birthdate:                  Social Security #                             Height:              Weight:-
         Eye Color:              Hair Color:                      Do you or any occupantsmoke?                   Yes           No
         Are you a U.S. Citizen?         Yes                      No Please attach a copy of birth certificate to this application.
         Marital Status: Married                        Single                    Divorced                      Widowed-

         Other occupant(s) - Full Name (exactly as shown on your driver's license or government issued ID)

         Your street address, city, state, and zip code (exactly as shown on your driver's license or government issued ID)

         Driver's License # and state OR government issued photo ID card:
         Former Last Names (maiden, married, or changed):
         Age -      Birthdate:                Social Security #                           Height:              Weight:-
         Eye Color:                  Hair Color:               Do you or any occupantsmoke?                  Yes            No
         Are you a U.S. Citizen?             Yes               No Please attach a copy of birth certificate to this application.
         Marital Status: Married                     Single                    Divorced                      Widowed-

         Will you or any occupant have a pet or service animal? -             Yes            No Type pet:
         Kind, weight, height, breed, age:                                           Bitten OR attacked anyone?

2)       Race of Head of Household - Check one (this information is required by HUD)
         White            Black           Native American             Asian or Pacific Islander                     Other
         Hispanic         Non-Hispanic

3)       Current Address:
                              (Address)                                 (City)            (State)           (Zip)
         Home Phone No.                                          Work Phone No.
         How long have you lived there?                -         No. Bedrooms -             Monthly Rent $:
         Number of persons in household                List and Describe all pets:
         Present Landlord's Name                                                   Landlord's Phone
         Landlord's Address
         Reason for moving?
         Have you ever been displaced?                 If so, from where and when?
         Have you ever applied for a government-subsidized unit before?
         Where?

         If you, your spouse, or any occupant listed:

Pear Grove Apartments - Rental Application         Page lof6                                              12/2007
       <>are currently receiving or have received housing assistance, has it ever been terminated for fraud, non-payment,
       or anyotherreason? Yes             No -      If"Yes", please explain:

       <>ever been evicted, had eviction proceedings brought against you, asked to leave or had a Lease not renewed? Yes.
                  No -      If yes, please explain:
       <>ever moved out ofa dwelling before the end of the lease term without owner/landlord's consent? Yes -      No-
       If yes, please explain:
       <>declared bankruptcy? Yes -           No -   If yes, please explain:
       <>been sued for rent? Yes               No -  If yes, please explain:
       <>been sued for property damage? Yes -        No -       If yes, please explain:
       <>been charged, detained, or arrested for a felony or sex crime that was resolved by conviction, probation, deferred
       adjudication, court-ordered community supervision, or pretrial diversion? Yes - No -      If yes, explain:

       <>been charged, detained, or arrested for a felony or sex-related crime that has not been resolved by any method?
       Yes -   No -     If yes, please explain:
       <>owe money to any housing authority, HUD subsidizedor mortgaged property? Yes - No -             If yes, explain: -

       <>Please indicate below the date, location, type of each felony, misdemeanor, sex crimes, or any other criminal
       matter you, your spouse, or any occupant listed had/have/or is about to be charged, arrested, indicted, dismissed,
       acquitted, pardoned, or convicted. If none, put none:



4)      Residences for past five years (start with current place and go back five (5) years):

        ADDRESS                              LANDLORD                               PHONE        FROM <<»            TO

        n Apartment       name - .                             , # and street -
             Apt. # - -'     City -                            ,State--                          , Zip Code -
             Landlord Name - -                                 , # and street -
             Office # - -'   City -                            , State - .                       , Zip Code -
             Landlord Phone # -                                ., Fax # -                        , Move in date -
             Move out date -                  , Names on Lease-

        n Apartment       name   -                            , # and street -
             Apt. # - -,     City -                           , State - -                        , Zip Code -
             Landlord Name - -                                , # and street -
             Office # - -,   City -                           , State -                          , Zip Code -
             Landlord Phone # -                               , Fax # -                          , Move in date -
             Move out date -                  , Names on Lease-

        ;nApartment name - .                                  , # and street -
             Apt. # - -'     City -                           , State - -                         , Zip Code -
             Landlord Name - -                                , # and street -
             Office # - -,   City -                           , State -                           , Zip Code -
             Landlord Phone # -                               , Fax # -                           , Move in date -
             Move out date -                  , Names on Lease-

         1} Apartment name -                                  , # and street -
            Apt. # - -,     City -                            , State--                           , Zip Code -
            Landlord Name -                                    , # and street -
            Office # - -,   City -                             , State - .                        , Zip Code -
            Landlord Phone # -                                 , Fax # -                          , Move in date -
            Move out date -                   , Names on Lease -

         ~    Apartment   name - .                               , # and street -
              Apt. # - -'    City -                              ,State--                         , Zip Code -
              Landlord Name - -                                  , # and street -
              Office # - -'  City -                              , State -                        , Zip Code -
              Landlord Phone # -                                 , Fax # -                        , Move in date -

 Pear Grove Apartments - Rental Application       Page 2 of6                                       12/2007
              Move out date -                , Names on Lease-

5)      Starting with head of household, list LEGAL NAMES of all members who will live in this apartment (indicate under
        OCCUPATION if full-time student):

        DOB            FULL LEGAL NAME                RELATIONSHIP         SEX AGE        OCCUPATION                  SS #
        L
        b
        3.

        Is any addition to the family expected? If so, explain:
        Does anyone live with you now who is not listed above? If so, explain:
6)      How did you hear about the apartments?

7)      Why do you want to live here?

8)      Cunent Source of Income:

        Head of Household Employer

        Name/Company               Address            Phone No.         Hours Worked       Gross Income/-             # Years
                                                                                           (week/month)               Worked
        Spouse Employer

        Name/Company               Address            Phone No.         Hours Worked       Gross Income/-             # Years
                                                                                           (week/month)               Worked

        List all income sources for all household members. This includes, but is not limited to, full and/or part-time
        employment, all income from welfare agencies, Social Security, Pension, SSI, Disability Compensation, Armed
        Force Reserves, unemployment compensation, baby-sitting, care-taking of elderly and disabled, alimony, child
        support, educational loans, scholarships and grants, income from rental property, interest on assets, dividends,
        annuities, bonds, mutual funds, scholarships, lump sum payments (i.e. inheritance, insurance, lottery winnings,
        capital gains), trust funds, regular contributions from people not residing with you, or other financial assistance.
        CURRENT EMPLOYER OR AGENCY PROVIDING INCOME FOR THE LAST THREE YEARS

        Company                    Address            Phone No.         HouseholdMember        Hrs. Worked Gross Income
        L
        b
        .1,

9)      Assets (List all assets, which include, but are not limited to, sums in checking accounts, savings, safe deposit boxes,
        trust funds and cash on hand; stocks and bonds; certificates of deposit; real estate; other investments.

        Checking Acct: Bank                                   Acct. #                              Amt. $
        Address: -
        Savings Acct:       Bank                              Acct. #                              Amt.$
        Address: -
        Certificates        Bank                              Acct. #                              Amt. $
        Address: -
        Credit Union shares: Name                             Address -                            Amt.$
        Stocks and Bonds (Value): $                           Savings/War Bonds (Value): $
        Mutual Funds:                                 Value:
        Do you now own real estate? Yes                      No
        If yes, give full address of property:
        Have you disposed of any assets for less than Fair Market Value in the past two- (2) years? Yes-              No-

        Open Credit Accounts:
                FIRM                                  ADDRESS                              AMT. OF MONTHLYPAYMENT
        L
        b
        3.

Pear Grove Apartments - Rental Application       Page 3 of 6                                         12/2007
       Past credit problems you want to explain:



10)    Child care expenses:
       Do you pay for baby-sitting due to employment? Yes                                 No
       If yes, child care provider's name:
       Provider's address:
       Cost: Per Week $                    or Per Month $

11)    Medical Expenses:

       Are you covered by Medicare or Medicaid:
       Do you pay for any medical insurance/hospitalization, such as Blue Cross, etc.? (Do not include life insurance
       policies) Yes                         No
       Name of Insurance Company:                                                       PolicyNo.
       If paid directly to you, indicate amount of premium and how often paid:
       Do you take prescription drugs on a regular basis: Yes        No -      If "Yes", mthly. cost
       Do you anticipate any health care related expenses for the next 12 months, which are not covered by health
       insurance? -         If yes, explain:


12)     HandicaplDisability Information - Optional

        NOTE: YOU ARE NOT REQUIRED TO DISCLOSE INFORMAnON              PRETAINING TO A
        HANDICAPIDIABILITY STATUS, EITHER FOR YOURSELF OR FOR A FAMILY MEMBER. HOWEVER,
        THIS INFORMATION MAY HAVE A BEARING ON YOUR ELIGIBILITY FOR ASSISTANCE, MAY
        INFLUENCE YOUR MONTHLY RENTAL RESPONSIBILTY, AND MAY OR MAY NOT QUALIFY YOU
        FOR AN ACCESSIBLE UNIT.

        Do you or any family members on this application for rental have a condition, which may be considered a physical
        or mental disability or handicap? Yes                        No

        Please list names           Relationship                Does this condition require an accessible apartment unit?




        Do you pay for any care or apparatus required by a handicapped or disabledindividual?Yes -            No-
        If yes, explain and indicate cost:
        Cost per week                                         or Cost per month

 13)    Have you ever been indicted, charged, arraigned, cited or convicted of any criminal or civil matters or complaints
        for acts and/or action against people, property, or any other criminal or civil laws, ordinances, codes, or regulations?
        Yes-               No-               If "Yes", where?
        Date                City                                County                               State
        Details
        Date -              City                                County                               State
        Details

 14)     Have you ever been arrested, put on deferred adjudication and/or probation,or incarcerated?
         Yes-            No-                If"Yes", where?
         Date             City                                 County                             State
         Details
         Date -           City                                 County                             State
         Details

 15)     Are you currently or have in the past engaged in the illegal use of any drugs or controlled substances:
         Yes -             No -               If "Yes", where?
         Date              City                                  County                               State
         Details
         Date              City                                  County                               State

 Pear Grove Apartments - Rental Application        Page 4 of6                                         12/2007
       Details

       Have you been in the past or are you currently undergoing rehabilitative treatment for drug, alcohol, or substance
       abuse/addition? Yes -             No -              If "Yes", please provide name of treatment center and
       attending physician:

          (Treatment   Center)                                    (Physician's   Name)


16)    Have you ever been cited, arrested, or convicted for Driving While Intoxicated (DWI), Driving Under the Influence
       (DUI), or driving while impaired?
       Yes-              No-              If "Yes", where?
       Date              City                                County                            State
       Details
       Date -                    City                              County                          State
       Details

                 PLEASE PROVIDE A COpy OF DOCUMENTS ON ANY YES RESPONSES ON# 13-16.

17)    Please provide three business/professional   references:

       il Reference name -                                     , # and street -
          Ste.# -                , City -                      , State -                          , Zip Code -
          Phone# -                                    , Relationship -                            , # years known -

        n Reference      name     -                            , # and street -
          Ste. # -               , City -                      , State -                          , Zip Code -
          Phone # -                                   , Relationship -                            , # years known -

        J} Reference name -                                    , # and street -
           Ste. # -     , City -                               , State -                          , Zip Code -
           Phone # -                                  , Relationship -                            , # years known -

18)     Monthly payments you must make:

        Name & Address of Company                                 Account Number                  Monthly Payments
        1,
        b
        3.

19)     Automobiles:

        Make                     Model                 Year                      License No.       TDL#
        Make                     Model                 Year                      License No.       TDL#

20)     Please provide three personal references who are NOT relatives:

        il Reference name -                                    , # and street -
           Ste.# -               , City -                      , State -                          , Zip Code -
           Phone# -                                   , Relationship -                            , # years known -

        n Reference       name -                                 , # and street -
           Ste. # -              , City -                        , State -                         , Zip Code -
           Phone # -                                   , Relationship -                            , # years known -

        J} Reference name -                                      , # and street -
           Ste. # -     , City -                                 , State -                         , Zip Code -
           Phone # -                                   , Relationship -                            , # years known-

21)     In case of an emergency, please notify (must have two adult contact persons who will not be residing in the unit):

        il Name -                                                  , # and street -

Pear Grove Apartments - Rental Application      Page 5 of6                                          12/2007
          Ste.# - -,        City -                               , State -                             , Zip Code -
          Phone# -                                      , Relationship-                                ., # years known -

        ~ Name -                                                  , # and street -
          Ste. # - -,       City -                                >State -                             )   Zip Code -
          Phone # -                                     , Relationship -                               , # years known   -
        If you die or are seriously ill, missing, hospitalized or in jail or penitentiary or not locatable according to an
        affidavit by one or more of the above person(s) or your spouse, or parent, or child, we may allow such person(s) to
        enter your dwelling to remove all contents, as well as, your property in the mailbox, storeroom, and common areas.
        If you are seriously ill or injured or emotionally or mentally ill/distraught, you authorize us to call EMS or send for
        an ambulance or other medical/mental health professional or law enforcement at your expense. We are not
        obligated to do so. Please initial to the right you are acknowledging our right(s):

NOTE:

(a)     The units at this property are restricted to individuals with a document able chronic mental illness and other
        requirements including but not limited to income restrictions, ability to live independently, acceptable credit and
        housing history, compliance with treatment plan, acceptable criminal history if any, etc.

(b)     Copies of birth certificates, driver license or official identification and social security card need to be attached to this
        application for all household members. Other documents, releases, etc. will be required, in addition to an interview
        at a later date to deternrine the applicant's admissibility and eligibility for a unit at the property.

(c)     Our consent necessary for guests staying longer than 7 day. This application may be attached & made part of Lease.

        ACKNOWLEDGEMENT. You hereby certify and affirm that all statements in this application
        are true and complete. You, the applicant(s), agree to authorize us to investigate and verify same
        through any and all means to determine eligibility and admissibility including but not limited to
        consumer reporting agencies, other rental housing owners, credit bureaus, law enforcement
        organizations or other organizations deemed necessary. You understand that false statements or
        misrepresentation of information or omissions are serious criminal offenses punishable under
        Federal Law. You further understand and agree that false statements or misrepresentations on
        this form is grounds for denial of housing or basis for eviction, increase in HOD approved rents,
        or loss of financial assistance as the HOD regulations may require. In lawsuits relating to the
         application or Lease Contract, the prevailing party may recover from the non-prevailingparty all
         attorneys' fees and litigation costs. We may at any time furnish information to consumer
         reporting agencies and other rental housing owners regarding your performance of your legal
         obligations, including both favorable and unfavorable information about your compliance with
         the Lease Contract, rules, and financial obligations. Faxed signatures are legallybinding.

                                                                   /
         Signature of Head of Household                                Date

                                                                   /
         Signature of Spouse or Co-Applicant                           Date

              COMPLETE               AND LEGIBLE APPLICATIONS CAN BE MAILED TO:
                                               Pear Grove Apartments
                                           c/o MHMRA of Harris County
                                          7011 Southwest Freeway, 6thFioor
                                                Houston, Texas 77074
                                                 Attn: Samuel Home
                                         713-970-7448 foradditionalinformation


 Pear Grove Apartments - Rental Application        Page 60f6                                                12/2007
 Mental Health/Retardation and Hospitalization - Notification and History

This is written notification that Pear Grove Apartments need a complete list of your mental health and/or
retardation provider(s) (i.e. psychiatrist, counselor, case manager and/or case worker, therapist, etc.) for the
last five (5) years to confirm and determine if you have had consistent and continuous mental health and/or
mental retardation treatment since one of the criteria for a unit at this property is to have a chronic mental
illness of long duration or a developmental disability. Please be aware that if we are not able to obtain this
information and/or verification of your illness or developmental disability that we may not be able to
complete processing your application which can delay it and/or result in you not being approved for a unit.
---------------------------------------------------------------------------

Mental Health and/or Mental Retardation Treatment Provider for the past five years:
.!l Clinic, Provider, Doctor -                                             , Doctor's Name -
Title Provider -                               , # & street address -                                                      >Ste. # -
City -                                         , State -          , Zip Code -               , Phone # -
Fax # -                      , Begin treatment date -                               , End treatment date -

n Clinic, Provider,    Doctor -                                               , Doctor's Name -
Title Provider -                                  , # & street address -                                                   >Ste. # -
City -                                            , State -          , Zip Code -                 , Phone # -
Fax # -                         , Begin treatment date -                                , End treatment date -

;nClinic,Provider, Doctor -                                                       , Doctor's Name -
Title Provider   -                                    , # & street address -                                               >Ste. # -
City -                                                , State -          , Zip Code -              , Phone # -
Fax # -                         , Begin treatment date -                                         , End treatment date -

11Clinic, Provider,    Doctor    -                                                      , Doctor's Name   -
Title Provider -                                      , # & streetaddress-                                                 >Ste. # -
City -                                            , State -                   , Zip Code -                , Phone # -
Fax # -                         , Begin treatment date -                                         , End treatment date -

~ Clinic,Provider, Doctor -                                                   , Doctor's Name -
Title Provider -                                  , # & street address -                                                   >Ste. # -
City -                                            , State -          , Zip Code -               , Phone # -
Fax # -                         , Begin treatment date -                               , End treatment date -

Mental Health and/or Mental Retardation Hospitalization/Respite(s) for the last five years:
.!l Hospital -                                                  , # & street address -
City -                               , State -                  , Zip Code -                      , Phone # -
Fax # -                    , Begin treatment date -                                               , End treatment date -
Reason for Hospitalization -                                                            , Voluntary or Involuntary? -

n Hospital -                                                     , # & street address     -
City -                                    , State -              , Zip Code     -                , Phone # -
Fax # -                         , Begin treatment date -                                          , End treatment date -
Reason for Hospitalization       -                                                      , Voluntary or Involuntary? -

ACKNOWLEDGEMENT. You hereby certify and affirm that all statements on this form are true and complete.You
understand that false statements or misrepresentation of information or omissions are serious criminal offenses
punishable under Federal Law. You further understand and agree that false statements or misrepresentations on this
form are grounds for denial of housing or basis for eviction.



Signature of Applicant                                                                  Date


Printed Name                                                                                                                           12/2007
     Pear Grove Apart.- Activity Plan
NAME:                                                          DATE:

     Day       Time            Hours           Place           Activity           Goal

1)




2)




3)




4)




      ACKNOWLEDGEMENT. I am the mental health/retardationprovider for the above
      named individual and have reviewed the above activitieswith hirn/her and approved
      this Activity Plan. I also hereby certify and affirm that all statements and/or
      information on this Activity Plan are true, accurate and complete to the best of my
      knowledge. I understand that false statements or misrepresentationof information or
      omissions are serious criminal offenses punishable under Federal Law and anyone
      guilty of such acts may be sent to prison, or may face fines,other penalties or both.

Signature:                                                      Date:

Title:                                                          Telephone:

 WARNING Section 1001 of Title 18 of the U.S. Code states it is a criminal offense to make
 willful false statements or misrepresentations to any department or agency of the United States
 Government.
                                 PEAR GROVE, INC.
                              Criminal Record Declaration
                                                                         Date:

Dear Applicant:
The Tenant Selection Policy of Pear Grove Apartments obliges us to verify certain infonnation about all
members of families living in or applying for admissionto our apartments. Specifically,we wish to avoid
admitting a family in which anyone of whose members is involved in criminal activity, which would
adversely affect the health, safety, or welfare or other tenants. To comply with this requirement, we ask
your cooperation in listing any and all criminal activity on yourself as the applicant, spouses, children,
other occupants who will reside in the unit, and/or immediate family members or friends or relatives who
may periodically stay overnight at the property. Your prompt return of this infonnation will be greatly
appreciated. If you have any questions, please contactus at (713) 970-7448.

                                        CERTIFICATION LIST

Ap{>licant and Other Applicant Names and Pertinent Infonnation
  LAST NAME, FIRST, MI          DRIVER LIC. NO.        AGE & BIRTHDATE               SOCIAL SECURITY #
1                                                              /   /                     -    -
2                                                              /   /                     -    -
3                                                              /   /                     -    -
4                                                              /   /                     -    -
                                                                                                             =

I/we hereby certify the above and below infonnation are accurate and complete.

Applicant Signatures                             Date

u                                                /
~                                                /
1}                                               /
1}                                               /

                                               VERIFICATION

Please indicate whether and when any family members have been arrested, convicted or indicted of any
crimes related to the following:

          1) HomicidelMurder                      8) Drug trafficking/use/possession
          2) Rape or child molesting              9) Child abuse/domestic violence
          3) Burglary/robbery/larceny             10) Public intoxication/drunk & disorderly
          4) Threats or harassment                11) Receiving stolen goods
          5) Destruction of property              12) Fraud
          6) Vandalism                            13) Prostitution
          7) Assault or fighting                  14) Disorderly conduct

~ell1bers' ~arnes                SS#              Crill1e( )#
                                                         s          Date            Status/Disposition




 Declaration                                 Page 1 of 1                           Revised-OS/2007
           CRIMINAL AND CREDIT HISTORY - NOTICE


To:




From: Sam Home, Property Manager
      Pear Grove Apartments
      c/o MHMRA
      7011 Southwest Freeway, 6th Floor
      Houston, Texas 77074

Date:

This is written notification that Pear Grove Apartments will obtain verification from
appropriate law enforcement organization(s)/government entities AND credit bureau(s) it
deem necessary to obtain your criminal and credit backgroundhistory. HOD requires the
housing owner to verify all information including criminalbackground and credit history,
if any, on determining an applicant's eligibility and suitabilityfor housing at this project.



By signing below, you are acknowledging that you are aware Pear Grove
Apartments will obtain reports from any and all appropriate law enforcement
organizations, agencies or jurisdictions AND credit bureau(s) or credit sources on
the applicant and has no objection to them releasing any and all information they
may have on the applicant or any family members who will reside in this unit.

RELEASE: I HEREBY AUTHORIZE THE RELEASE OF THE REQUESTED
INFORMATION ON MY CRIMNIAL AND CREDIT HISTORY, IF ANY, FROM
ALL APPROPRIATE LAW ENFORCEMENT AGENCIES AND CREDIT
ORGANIZATIONS.



Signature of Applicant                                 Date

Printed Name
Driver License #
Date of Birth

								
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