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Black Realty Management, Inc.
Application for Affordable Housing
Parkview Apartments
313 Erie St.
Cheney, WA 99004
509.253.6910
Managed by Black Realty Management Company: 107 S. Howard St., Spokane WA 99201 (509) 623.1000
APPLICATION TO RENT Size of unit required □ 1BR □ 2BR
This apartment complex does not have any units that are designated as mobility accessible units.
Each adult over the age of 18 must complete a separate application.
All members 6 years old and older must provide a social security number to be eligible to apply.
Applicant’s Legal Name: □ Male □ Female
Social Security #: Birth Date: Driver’s License #:
Spouse/Co-Head Legal Name: □ Male □ Female
Other persons to occupy rental property:
Legal name: □ Male □ Female
Social Security #: Birth Date: Relationship:
Legal name: □ Male □ Female
Social Security #: Birth Date: Relationship:
Legal name: □ Male □ Female
Social Security #: Birth Date: Relationship:
Legal name: □ Male □ Female
Social Security #: Birth Date: Relationship:
Residence / Rental History
All rental history will be verified. Include rentals, living with friends/relatives, shelters, Institutions, group homes, hospitals
etc. Attach additional paper if necessary.
Applicant’s present address City, State Zip code
Applicant’s present phone # message
Present Landlord Landlord Phone #: Move-In date
Applicant’s previous address: City, State Zip code
Move-In date Move-Out date
Previous Landlord Landlord Phone #:
Applicant’s previous address: City, State Zip code
Move-In date Move-Out date
Previous Landlord Landlord Phone #:
Employment History / Gross Income
Applicant Employed by Salary/Wage $ #of Hrs/Week
Supervisor’s Name How long you worked years months
Address City, State, Zip Code
Phone # Occupation/Department
nd
Applicant Previous/2 job Salary/Wage $ #of Hrs/Week
Supervisor’s Name How long you worked years months
Address City, State, Zip Code
Phone # Occupation/Department
Additional Income – Monthly
Pension $ Social Security $ Social Security Disability $ SSI $
Unemployment $ Child Support $ Public Assistance $ Other $ Source
Assets
Name of Bank or Savings and Loan Address
City, State, Zip Code Checking Balance: $ Savings Balance $
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Black Realty Management, Inc.
CD’s $ Escrow Balance $ Stock Value $ Other $
Income (Interest/Dividends) earned from all assets per year $ Real Estate Holdings Market Value $
Important Information
Name of Nearest Relative/Friend Relationship Address
City, State Zip Code Phone #
Name of Nearest Relative/Friend Relationship Address
City, State Zip Code Phone #
Eligibility Determination
These questions are asked to determine for which community you would be eligible.
□ Yes □ No Are you currently receiving rental assistance from HUD (Tenant Based or Project Based?
□ Yes □ No Have you, or anyone who will be occupying the unit, ever been convicted of a criminal offence:
If Yes, City State Offence(s)
□ Yes □ No Are you, or anyone who will be occupying the unit required to register as a sex offender?
□ Yes □ No Have you, or anyone who will be occupying the unit, been evicted in the last 3 years from federally
assisted housing for drug related criminal activity?
□ Yes □ No Do you qualify for Senior Housing (62 years or over)?
□ Yes □ No Do you require a unit designed for Hearing □ or sight □ impaired?
□ Yes □ No Do you require the features of an accessible unit? This property does not have mobility accessible
units.
□ Yes □ No Are you currently an illegal user of a controlled substance?
□ Yes □ No Have you ever been convicted of the illegal manufacture or distribution of a controlled substance?
□ Yes □ No Has your assistance or tenancy in a subsidized housing program ever been terminated for fraud, non-
payment of rent or failure to cooperate with recertification procedures?
□ Yes □ No Are you currently a full time student?
□ Yes □ No Do you have a pet?
□ Yes □ No Do you have a service animal?
□ Yes □ No Are you or anyone who will be occupying the unit enrolled as a student in an institute of higher
education?
□ Yes □ No Have you been displaced by government action or by a presidential declared disaster?
□ Yes □ No Will this be your primary residence?
How did you learn about this housing?
NOTE: The application must be complete, signed by applicant, and returned to the complex before you can be
placed on a waiting list. To remain on a waiting list, you must make contact to the complex in which
you have applied every six months.
The applicant is not responsible for the screening fee.
In accordance with State and Federal laws you are hereby notified that an investigation may be made by The Information
Source, Inc. (MOCO, Inc.) of the information you provide on this Application, together with information as to your
character, general reputation, personal characteristics, and mode of living. You have the right to dispute the accuracy of
information provided by TIS or by the entities you have disclosed above, and, upon written request, the right to complete
and accurate disclosure of the nature and scope of the investigation and/or a written summary of your rights under the
WA Fair Credit Reporting Act. Direct all inquiries to: TIS, C/O MOCO, Inc., PO Box 2826, Seattle, WA 98111. I/We
certify that to the best of my/our knowledge all statements made herein are true and correct. I/We authorize TIS to obtain
such credit reports, character reports, verification of rental and employment history it deems is necessary to verify all
information set forth in the above Application, and provide an investigative report to the undersigned Landlord. I/We
further understand that false fraudulent or misleading information disclosed above may be grounds for denial of tenancy
or subsequent eviction.
I am aware that an incomplete application causes a delay in processing and may result in denial of tenancy.
Applicant’s Signature Date
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Black Realty Management, Inc.
Co-Applicant’s Signature Date
Black Realty Management Signature Date
Black Realty Management, Inc. does not discriminate against any person because of race, color, religion, sex,
familial status, national origin, martial, or handicap status in the admission or access to or treatment or
employment in their federally assisted programs and activities.
As such, we are required to provide reasonable auxiliary aids and services necessary for effective
communication with persons with disabilities when requested. The person named below has been designated
to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and
Urban Development’s regulations implementing Section 504 (24, part 8 dated June 2, 1988): Property Manager,
Jeff Swanson, 107 S. Howard St. Ste. 600, Spokane, WA 99201, (509) 622.3537, fax (509) 622.3500.
A copy of the Tenant Selection Plan for each property is available upon request.
EQUAL HOUSING OPPORTUNITY
FOR CORPORATE USE ONLY
When was application received:
Time Application was received:
Initials of whom received Application:
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Black Realty Management, Inc.
Owner’s Notice No. 1
Section 214 of the Housing and Community Development Act of 1980, as amended, prohibits the Secretary of
HUD from making financial assistance available to persons other than U.S. citizens or nationals, or certain categories of
eligible noncitizens, in the following HUD programs:
a. Section 8 Housing Assistance Payments programs;
b. Section 236 of the National Housing Act including Rental Assistance Payment (RAP); and
c. Section 101/Rent Supplement Program.
You have applied, or are applying for, assistance under one of these programs; therefore, you are required to
declare U.S. Citizenship or submit evidence of eligible immigration status for each of your family members for whom you
are seeking housing assistance. You must do the following:
1. Complete a Family Summary Sheet, using the attached blank format (**see
sample Family Summary Sheet in Exhibit 3-4**) to list all family members who
will reside in the assisted unit.
2. Each family member (including you) listed on the Family Summary Sheet must
complete a Citizenship Declaration. If there are 10 people listed on the Family
Summary Sheet, you should have 10 completed copies of the Citizenship
Declaration. The Citizenship Declaration has easy-to-follow instructions and
explains what, if any other forms and/or evidence must be submitted with each
Citizenship Declaration.
3. Submit the Family Summary Sheet, the Citizenship Declarations, and any other
forms and/or evidence to the onsite manager of the property you are certifying
with or to the address below:
_______Parkview Apartments
_______313 Erie St.__________________ _____
_______Cheney, WA 99004_________________
This Section 214 review will be completed in conjunction with the verification of other aspects of eligibility for
assistance. If you have any questions or difficulty in completing the attached items or determining the type of
documentation required, please contact On-site Manager. On-site Manager will be happy to assist you. Also, if you are
unable to provide the required documentation by the date shown above, you should immediately contact this office and
request an extension, using the block provided on the Citizenship Declaration Format. Failure to provide this information
or establish eligible status may result in your not being considered for housing assistance.
If this Section 214 review results in a determination of ineligibility, you will have an opportunity to appeal the
decision. Also, if the final determination concludes that only certain members of your family are eligible for assistance,
your family may be eligible for proration of assistance. That means that when assistance is available, a reduced amount
may be provided for your family based on the number of members who are eligible.
If assistance becomes available and the other aspects of your eligibility review show that you are
eligible for housing assistance, that assistance may be provided to you if at least one member of your
household has submitted the required documentation. Following verification of the documentation submitted
by all family members, assistance may be adjusted depending on the immigration status verified. You will be
contacted as soon as we have further information regarding your eligibility for assistance.
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Black Realty Management, Inc.
Citizenship Declaration
INSTRUCTIONS: Complete this Declaration for each member of the household listed on
the Family Summary Sheet
LAST NAME
FIRST NAME
RELATIONSHIP TO DATE OF
HEAD OF HOUSEHOLD SEX BIRTH ____ _________
SOCIAL ALIEN
SECURITY NO. REGISTRATION NO.
ADMISSION NUMBER__________________________if applicable (this is an 11-digit number
found on DHS Form I-94, Departure Record)
NATIONALITY (Enter the foreign nation or country to
which you owe legal allegiance. This is normally but not always the country of birth.)
SAVE VERIFICATION NO.
(to be entered by owner if and when received)
INSTRUCTIONS: Complete the Declaration below by printing or by typing the person's
first name, middle initial and last name in the space provided. Then review the blocks
shown below and complete either block number 1, 2, or 3:
DECLARATION
I, ____________________________________________________ hereby declare, under
penalty of perjury, that I am
(print or type first name, middle initial, last name):
______ 1. A citizen or national of the United States.
Sign and date below and return to the name and address specified in
the attached notification letter. If this block is checked on behalf of a
child, the adult who will reside in the assisted unit and who is
responsible for the child should sign and date below.
___________________________ ______________
_________
Signature Date
Check here if adult signed for a child: _______
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Black Realty Management, Inc.
______ 2. A noncitizen with eligible immigration status as evidenced by one of the
documents listed below:
NOTE: If you checked this block and you are 62 years of age or older, you need
only submit a proof of age document together with this format, and sign below:
If you checked this block and you are less than 62 years of age, you should submit
the following documents:
a. Verification Consent Format (**see Sample Verification Consent Form in
Exhibit 3-6**).
AND
b. One of the following documents:
(1) Form I-551, Alien Registration Receipt Card (for permanent resident
aliens).
(2) Form I-94, Arrival-Departure Record, with one of the following
annotations:
(a) "Admitted as Refugee Pursuant to section 207";
(b) "Section 208" or "Asylum";
(c) "Section 243(h)" or "Deportation stayed by Attorney General"; or
(d) "Paroled Pursuant to Sec. 212(d)(5) of the INA."
(3) If Form I-94, Arrival-Departure Record, is not annotated, it must be
accompanied by one of the following documents:
(a) A final court decision granting asylum (but only if no appeal is taken);
(b) A letter from an DHS asylum officer granting asylum (if application
was filed on or after October 1, 1990) or from an DHS district
director granting asylum (if application was filed before October 1,
1990);
(c) A court decision granting withholding or deportation; or
(d) A letter from an DHS asylum officer granting withholding of
deportation (if application was filed on or after October 1, 1990).
(4) Form I-688, Temporary Resident Card, which must be annotated "Section
245A" or "Section 210."
(5) Form I-688B, Employment Authorization Card, which must be annotated
"Provision of Law 274a.12(11)" or "Provision of Law 274a.12."
(6) A receipt issued by the DHS indicating that an application for issuance of
a replacement document in one of the above-listed categories has been
made and that the applicant's entitlement to the document has been
verified.
(7) Form I-151 Alien Registration Receipt Card.
If this block is checked, sign and date below and submit the documentation required above
with this declaration and a verification consent format to the name and address specified in
the attached notification. If this block is checked on behalf of a child, the adult who will
reside in the assisted unit and who is responsible for the child should sign and date below.
If for any reason, the documents shown in subparagraph 2.b. above are not currently
available, complete the Request for Extension block below.
________________________________________________ _________
Signature Date
Check here if adult signed for a child: ______
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Black Realty Management, Inc.
REQUEST FOR EXTENSION
I hereby certify that I am a noncitizen with eligible immigration
status, as noted in block 2 above, but the evidence needed to
support my claim is temporarily unavailable. Therefore, I am
requesting additional time to obtain the necessary evidence. I
further certify that diligent and prompt efforts will be undertaken to
obtain this evidence.
__________________________________________
_____________
Signature Date
Check if adult signed for a child: ______
______ 3. I am not contending eligible immigration status and I understand that I am not
eligible for financial assistance.
If you checked this block, no further information is required, and the person named above
is not eligible for assistance. Sign and date below and forward this format to the name and
address specified in the attached notification. If this block is checked on behalf of a child,
the adult who is responsible for the child should sign and date below.
__________________________________________ ___________
Signature Date
Check here if adult signed for a child: ______
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Black Realty Management, Inc.
Black Realty Management, Inc.
Statistical Questionnaire
Black Realty Management, Inc. manages apartment communities that obtain funding through various
sources. In order to keep the apartment communities affordable, Black Realty Management, Inc. has certain
statistical information that we are required to obtain for reporting purposes only. We would appreciate you
participation in providing this information.
Please complete one for each family member over the age of 18.
Minority & Ethnicity:
Minority: (Select one)
White Black Asian Pacific Islander Native American None
Ethnicity: (Select one)
Hispanic Non-Hispanic None
Special Needs Population (Check all those that apply)
The following information is voluntary and will not be used to determine eligibility or
suitability
Developmentally Disabled People Living with HIV/AIDS
Survivors of Domestic Violence Substance Abusers and People in Recovery
People Living with Chronic Mental Illness Physicall Challenged
Traumatic Brain Injured Veterans
Frail Elderly Population At-Risk of Homelessness
Mentally-ill, chemically addicted
Multiple Special Needs (Specify Needs)
Homeless Households Served: (Check all those that apply)
Homeless Families Served Homeless Individuals Served
Application number
(For Corporate use only)
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Black Realty Management, Inc.
APPLYING FOR HUD
HOUSING
ASSISTANCE?
THINK ABOUT THIS…
IS FRAUD WORTH IT?
Do You Realize…
If you commit fraud to obtain assisted housing from HUD, you could be:
• Evicted from your apartment or house.
• Required to repay all overpaid rental assistance you received.
• Fined up to $10,000.
• Imprisoned for up to five years.
• Prohibited from receiving future assistance.
• Subject to State and local government penalties.
Do You Know…
You are committing fraud if you sign a form knowing that you provided false or misleading
information.
The information you provide on housing assistance application and recertification forms
will be checked. The local housing agency, HUD, or the Office of Inspector General will
check the income and asset information you provide with other Federal, State, or local
governments and with private agencies. Certifying false information is fraud.
So Be Careful!
When you fill out your application and yearly recertification for assisted housing from
HUD make sure your answers to the questions are accurate and honest. You must include:
All sources of income and changes in income you or any members of your household
receive, such as wages, welfare payments, social security and veterans’ benefits,
pensions, retirement, etc.
Any money you receive on behalf of your children, such as child support, AFDC
payments, social security for children, etc.
Any increase in income, such as wages from a new job or an expected pay raise or
bonus.
All assets, such as bank accounts, savings bonds, certificates of deposit, stocks, real
estate, etc., that are owned by you or any member of your household.
All income from assets, such as interest from savings and checking accounts, stock
dividends, etc.
Any business or asset (your home) that you sold in the last two years at less than full
value.
The names of everyone, adults or children, relatives and non-relatives, who are living
with you and make up your household.
(Important Notice for Hurricane Katrina and Hurricane Rita Evacuees: HUD’s
reporting requirements may be temporarily waived or suspended because of your
circumstances. Contact the local housing agency before you complete the housing
assistance application.)
Ask Questions
If you don’t understand something on the application or recertification forms, always ask
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Black Realty Management, Inc.
questions. It’s better to be safe than sorry.
Watch Out for Housing Assistance Scams!
• Don’t pay money to have someone fill out housing assistance application and
recertification forms for you.
• Don’t pay money to move up on a waiting list.
• Don’t pay for anything that is not covered by your lease.
• Get a receipt for any money you pay.
• Get a written explanation if you are required to pay for anything other than rent
(maintenance or utility charges).
Report Fraud
If you know of anyone who provided false information on a HUD housing assistance
application or recertification or if anyone tells you to provide false information, report that
person to the HUD Office of Inspector General Hotline. You can call the Hotline toll-free
Monday through Friday, from 10:00 a.m. to 4:30 p.m., Eastern Time, at 1-800-347-3735.
You can fax information to (202) 708-4829 or e-mail it to Hotline@hudoig.gov.
You can write the Hotline at:
HUD OIG Hotline, GFI
451 7th Street, SW
Washington, DC 20410
December
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