PRELIMINARY RENTAL APPLICATION

EQUAL HOUSINGOPPORTUNITY

Sandalwood253 Sandalwood DriveLeechburg, PA 1.5656724,845.7358

I hereby apply for a rental housing living unit in this housing complex, and for rental assistance, if I ameligible and if it is available. I certify that this will be my permanent residence and I will not maintaina separate subsidized rental unit in a different location. I understand that this application will allow me tobe placed on the Waiting List and it is my responsibility to contact t'he Property every o months in order tokeep my place on the waiting list.

PRELIMINARY INFORMATION PERTAINING TO APPLICANT(S)

Appl i cant ' s Name :

Co-Applicant's Name:

Others Living in the Unit:

Name

Name

Name

SS#

SS#

SS#

SS#

SS#

Age :

Age :

Age:

Age:

Age:

Present Address:

Telephone Number: Annual Family Income: $

Source(s) of Income:

Are you a U. S. citizen? Yes/No

Are you a student under the age of 24? Yes/No

Do you request consideration for an income adjustment based on a /disability? Yes/No

Do you need special accommodations or modifications to the living unit based on a disability? Yes/No

SIGNED:

(Owner or Agent) (Applicant)

(Date Received) (Co-Applicant)

The information solicited on this application is requested by the apartment owner in order to assure theFederal Government, acting through HUD, that Federal Laws prohibiting discriminationagainst tenant applicants on the basis of race, color, national origin, religion, sex, marital status, age,and handicap are complied with. You are not required to furnish this information, but are encouraged to doso. This information will not be used in evaluating your application or to discriminate against you in anyway. However, if you choose not to furnish it, the owner (or managing agent) is required to note the race,ethnicity and sex of individual applicants on the basis of visual observation or surname.

HEAD OF HOUSEHOLD(check as appropriate)

Ethnicity Marital Status

American Indian / Alaskan Native Hispanic or LatinoAsian Not Hispanic or LatinoBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther

MarriedSeparatedUnmarried

MaleFemale

(FOR MANAGEMENT USE ONLY)

Eligibility Determination:

Date:

Eligible Unit size (s) :

(Attach copy of Notification Letter)

2 bdr. 3 bdr. 4 bdr. BBUf'l

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Have you, co-applicant, or any adult applicant included in this application, ever had a conviction of any of the following?

Answer "YES" to all that apply and the household member's name involved, and "NO" to those that do not apply:

Type of Charge

PLEASE RESPOND TO EACH LINE

Theft

Trespassing

Drug Use

Illegal Sale of Drugs or Drug Paraphernalia

Violent Acts to Persons or Property

Burglary

Criminal Mischief

Drug Possession

Sex Offense

DUIBad Checks

Other:

No Yes Household Member's Name Involved

Circle Each State You Have Ever Lived In:

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho

Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Mass. Michigan Minnesota Miss.

Missouri Montana Nebraska Nevada N. Hamps. N.Jersey N.Mexico New York N.Carolina N.Dakota Ohio Oklahoma

Oregon Penn. Rhode Is. S. Carolina S. Dakota Tenn. Texas Utah Vermont Virginia Washington W. Virginia

Wisconsin Wyoming

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Head of Household - Background Check

Please complete the information below to run the required background checks:

Name of Applicant - Head of Household:

Additional Names (aliases) - Head of Household:

Name on Driver's License - Head of Household:

Name on Social Security Card - Head of Household:

Social Security Number - Head of Household:

Date of Birth - Head of Household:

Most Recent Addresses (Current and previous) for the past three years - Head of Household:

Length of residency at current address - Head of Household: Monthly Rent $_

Number of months employed - Head of Household:

Monthly income - Head of Household:

I understand and authorize Sandalwood Holdings LP to do a credit, tenant, and criminal backgroundcheck.

Signature Date

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Other Adult Household Member - Background Check

Please complete the information below to run the required background checks:

Name of Applicant - Other Adult Household Member:

Additional Names (aliases) - Other Adult Household Member:

Name on Driver's License - Other Adult Household Member:

Name on Social Security Card - Other Adult Household Member:

Social Security Number - Other Adult Household Member: _

Date of Birth - Other Adult Household Member:

Most Recent Addresses (Current and previous) for the paSt three years - Other Adult Household

Member:

Length of residency at current address - Other Adult Household Member: Monthly Rent $

Number of months employed - Other Adult Household Member:

Monthly income - Other Adult Household Member:

I understand and authorize Sandalwood Holdings LP to do a credit, tenant, and criminal backgroundcheck.

Signature Date

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