Post on 27-Jul-2020
Supportive Living Rental Application
You must print out this application to complete it.
The completed application may be mailed or hand delivered to:
Office HoursM-F: 8:30 a.m.-4:30 p.m.Closed weekends & holidays
Joshua Arms Senior Residences1315 Rowell Ave.Joliet, IL 60433
1315 Rowell Ave.Joliet, IL 60433
TTY: 847.390.1460Phone: 815.727.6401 LSSI.org/JoshuaArms
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Joshua Arms of LSSI 1315 Rowell Avenue
Joliet, Illinois 60433
815-727-6401
TTY 847-390-1460
Joshua Arms of LSSI is a Smoke Free building
Rental Application
This facility is funded by the U.S. Department of Housing and Urban Development. In
accordance with their policy & procedures, all applicants are subject to the same application
process and criteria. A copy of the Tenant Selection Plan, AKA Admission Policy is kept on
site for review upon request. Failure to complete the application in its entirety will lead to its
return. Failure to disclose all requested information could lead to rejection of application. If
you need assistance with completing this application, please contact the office listed above. A
person may assist you in completing this application however they are not responsible for
obtaining the information. That is the responsibility of the applicant.
Eligibility
Occupancy of Joshua Arms will be limited to an elderly or disabled mobility impaired family as defined below:
1) “Elderly family”
a) families of two persons, one of who is 62 years of age or older;
b) the surviving member of any family described in subparagraph a) above, living in the assisted
unit with the deceased family member at the time of his or her death;
c) a single person who is 62 years of age or older; or
d) an elderly person or family and another person who are determined by HUD, based upon a
licensed physician’s certificate, to be essential to the older person’s care or well being.
2) “Disabled”
A certain number of units have been specially designated for persons who are disabled and mobility
impaired. Eligibility for these units requires the applicant to be 18 years of age or older; require the
special features of the unit; and, have a mobility impairment that;
a) is expected to be of long, continued and indefinite duration;
b) substantially impedes the person’s ability to live independently; and,
c) is such that the person’s ability to live independently could be improved by more suitable
housing conditions.
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Please Print
GENERAL INFORMATION Home Phone _______________
Full Name_____________________________________ Cell Phone ______
Last First Middle
Present Address _
No. Street City State Zip
Date of Birth ___________________ Email Address: __________________________
Gender: Male ____ Female ____ Prefer not to disclose ____
Social Security Number ___________________
Social Security Benefit Number if different than Social Security Number ______________
Are you a military veteran? Yes ___ No ____
If yes please specific which branch_____________________________________________
Please Check One
______________ Head of Household ______________ Other
Co-applicant or other:
Full Name_____________________________________ Home Phone__ ______
Last First Middle
Present Address _
No. Street City State Zip
Date of Birth ___________________
Gender: Male ____ Female ____ Prefer not to disclose ____
Social Security Number ___________________
Social Security Benefit Number if different than Social Security Number ______________
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Are you a military veteran? Yes ___ No ____
If yes please specific which branch_____________________________________________
Please Check One ______________ Head of Household
______________ Other
Have you been displaced by government action or a presidentially declared disaster?
Yes _______ No _______
If yes, please explain _______________________________________________________
HUD requires the building inquire if the displaced applicant is a military veteran
I am a military veteran ____
I am not a military veteran ____
Are you or any member of your household a Student in Higher Education?
Yes _______ No _______
If yes, please answer the following questions:
Is the student attending part-time or full-time? Part-Time_____ Full-Time__
Is the student under 24 years of age? Yes _______ No _______
Is the student a veteran? Yes _______ No _______
Is the student married? Yes _______ No _______
Does the student have a dependent child? Yes _______ No _______
Do you or any member of your household need an apartment with accessible features?
Yes_______ No_____
Type of Unit Requested
{ } One Bedroom (Standard) (one or two person unit)
{ } One Bedroom (Accessible - Barrier Free Unit) (one or two person unit)
Current/Previous Housing Information
{ } Rental { } Home Owner { } Other (Explain) ________________________
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If Rental was checked, please complete the area below for the last 5 years.
Name(s) on Lease Address of
apartment rented
City, State, Zip Date you moved in &
moved out
Landlord Information
Landlord’s Name Landlord’s
Address
Landlord’s
City, State, Zip
Landlord’s
Phone #
Move in &
move out date
IF more space is needed please attach the information on a separate sheet of paper.
Have you been evicted from your residence/apartment in the last five years?
Yes _______ No _______
Pets Do you own a pet? Yes _____ No _____ Type & Size _________________________
Type of Auto __________________ Make & Model _______________________________
Drive’s License Number _______________________ License Plate Number ___________
State Car is Registered in ______________________________________________________
Assets List value of all assets held by those expected to reside in the apartment:
1. Checking Account(s):
Name of Bank _________________________________________________________
Address of Bank: _______________________________________________________
Account Number(s): ____________________________________________________
Average Balance over last six months _______________________________________
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2. Savings/Money Markets Account(s):
Name of Bank __________________________________________________________
Address of Bank ________________________________________________________
Account number ________________________ Balance ________________________
Name of Bank __________________________________________________________
Address of Bank ________________________________________________________
Account number ________________________ Balance ________________________
Name of Bank __________________________________________________________
Address of Bank ________________________________________________________
Account number ________________________ Balance ________________________
3. Certificates of Deposits (CD’s)
Value _________________________________ Annual Interest __________________
Value _________________________________ Annual Interest __________________
Value _________________________________ Annual Interest __________________
Value _________________________________ Annual Interest __________________
4. Treasury Notes/Bonds
Value _________________________________ Annual Interest __________________
Value _________________________________ Annual Interest __________________
Value _________________________________ Annual Interest __________________
Value _________________________________ Annual Interest __________________
5. Stocks
Name _________________________________ Number of Shares ________________
Holding Company _______________________ Value __________________________
Name _________________________________ Number of Shares ________________
Holding Company _______________________ Value __________________________
Name _________________________________ Number of Shares ________________
Holding Company _______________________ Value __________________________
Name _________________________________ Number of Shares ________________
Holding Company _______________________ Value __________________________
Name _________________________________ Number of Shares ________________
Holding Company _______________________ Value __________________________
6. IRA/Keough Account
Value _________________________________ Annual Interest __________________
7. Whole Life Insurance
Name of Insurance Company ______________________________________________
Address _______________________________________________________________
Cash Value/Surrender Value ______________________________________________
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Dividend amount _______________________________________________________
Name of Insurance Company ______________________________________________
Address _______________________________________________________________
Cash Value/Surrender Value ______________________________________________
Dividend amount ________________________________________________________
8. Real Estate
Location/Type: _________________________________________________________
Remaining Mortgage: ____________________Estimated value _________________
9. Trusts/Annuities
Holding Company _______________________ Value _________________________
Address _________________________________ Interest Rate __________________
10. Personal Property being held as Investment, i.e. gems, coins, stamp collections, antiques etc.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
11. Other (i.e. cash not held in banks); _____________________________________________
(please specify)
Total Asset Value ________________________________
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I, or any member of my family, have { } or have not { } (check one) disposed of any assets the
previous two years. If assets have been disposed of, please list asset and approximate value.
_____________________________________________________________________________
_____________________________________________________________________________
Income List gross income from all those expected to reside in unit:
Monthly Income Source Head of Household Family Member 2
A. Social Security Retirement
B. Supplemental Security Income (SSI)
C. Social Security Disability
D. Public Aid (money only)
E. Pension/Annuities/Insurance
Benefits
F. Wage Salary/Self – employment
Income (including gratuities)
G. Interest from C.D.’s, Stocks, Bonds,
Savings (please list even if interest
rolls back into the account)
H. Income from Rental Property
I. Other – Please specify
Medical Expenses
Type of Expense Name of Company Payment Amount How often payment
is made?
Medicare N/A
Supplement
Pharmacy/
Prescriptions
Pharmacy/
Prescriptions
Doctor visits
Doctor visits
Doctor visits
Doctor visits
Outstanding medical
bills
Other
Other
Total Expenses
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Emergency Contacts Please list three family members or close friends to notify in case of
emergency:
Name _______________________________ Relationship _________________________
Address _________________________________________________________________
Street City State Zip
Telephone Number ____________________ Cell/business Number _________________
Name _______________________________ Relationship _________________________
Address _________________________________________________________________
Street City State Zip
Telephone Number ____________________ Cell/business Number _________________
Name _______________________________ Relationship _________________________
Address _________________________________________________________________
Street City State Zip
Telephone Number ____________________ Cell/business Number _________________
In accordance with U. S. Department of Housing and Urban Development policies, please
answer the following question completely. If applicable please complete the follow-up
information requested.
Have you have been convicted of a felony?
Yes _______ No _______
If Yes, Date __________________ State where convicted ______________________
Do you have a history of a pattern of alcohol abuse that would contribute to behavior that could
interfere with others’ health, safety, and/or right to peaceful enjoyment of the premises?
Yes _______ No _______
Do you have a history of a pattern of drug abuse that would contribute to behavior that could
interfere with others’ health, safety, and/or right to peaceful enjoyment of the premises?
Yes _______ No _______
Have you been evicted in the last three years from a federally assisted housing for drug-related
criminal activity?
Yes _______ No _______
If Yes, Date __________________ State where evicted ________________________
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In order to ensure this development complies with HUD’s requirement that the facilities funded
through HUD rejects any applicant(s) that are subject to State sex offender lifetime registration
requirement, please answer the following questions.
Are you required to register as a lifetime sex offender?
Yes________ No________
List what State(s) you have lived in. A multi-state screening is completed.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please explain how you became aware of the housing complex: (i.e. newspaper, relative, etc.)
_____________________________________________________________________________
_____________________________________________________________________________
Notice to Applicant
The information you used to complete this application will be verified in accordance with
Department of Housing and Urban Development’s policies and procedures. Each
application is processed in accordance with Joshua Arms’ Admission Polices/Tenant
Selection Plan. The Admission Policies/Tenant Selection plan is available for review
during normal business hours.
Please continue to the next page
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APPLICANT CERTIFICATION
I/we certify that if selected to move into this project, the unit I/we occupy will be my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility for section 8/236 assistance. I/we authorize the owner to verify all information provided on this application and to contact previous or current landlords or other sources for credit and verification information which may be released to appropriate federal, state or local agencies. I/we are aware of the fact a credit/criminal history will be processed and the State sex offender registries will be checked. I/we understand Lutheran Social Services of Illinois staff or other designated individual will complete a home visit. I/we certify that the statement made in this application are true and complete to the best of my/our knowledge and belief. I/we understand that false statement or information are punishable under federal law. APPLICANT SCREENING Verification of the applicant information and eligibility will be conducted. The applicant(s) release(s) Lutheran Social Services of Illinois (managing agent) and all persons who provide information from liability for actions taken or information supplied during the tenant selection process. Signature of Head of Household: DATE:
Signature of Family Member #2: DATE:
This application has been reviewed and appears complete.
MANAGEMENT: ________________
DATE RECEIVED: Time Received ______________________
TRACS 202D Revision: August 17, 2016
Joshua Arms of LSSI Supportive Living 1315 Rowell Avenue
Joliet, IL 60433 815-727-6401 ~ TTY 815-390-1460
Joshua Arms of LSSI is a Smoke Free building
Rental Preliminary Application for The Oaks Supportive Living Program
Applicant must be 65 years of age or older
Please Print Name (Head of Household): ____________________________________________ Birthdate: _________________ Name (Co-Applicant):__________________________________________________Birthdate:__________________ Address: ______________________________________________________________________________________ City:_____________________________________________________ State:________ Zip Code:_______________ Telephone: ____________________________________ Cell:___________________________________________ Social Security Number: _________________________________________________________________________ Contact Name:______________________________________________________Telephone:__________________ Relationship to Applicant(s): _____________________________________________________________________ Annual Household Income of Applicant(s): _________________________________________________________
Income includes all sources: Pension, Social Security, wages, IRA, annuity, interest, dividends, etc. Written verification will
be required with full rental application.
Signature Head of Household: ___________________________________________ Date: _____________________ Signature Co-Applicant: ___________________________________________________________ Date: ____________________ Please note: This is a preliminary application and is NOT a guarantee of admission.
Revised 10/4/2016
OMB Control # 2502-0581 Exp. (02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING This form is to be provided to each applicant for federally assisted housing
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: Telephone No: Cell Phone No:
Name of Additional Contact Person or Organization: Address: Telephone No: Cell Phone No: E-Mail Address (if applicable): Relationship to Applicant: Reason for Contact: (Check all that apply)
Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent
Assist with Recertification Process Change in lease terms Change in house rules Other: ______________________________
Commitment of Housing Authority 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.
Form HUD- 92006 (05/09)