Supportive Living Rental Application · Supportive Living Rental Application You must print out...

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 ________________________________________________________


Name of Bank __________________________________________________________

Address of Bank ________________________________________________________


3. Certificates of Deposits (CD’s)

Value _________________________________ Annual Interest __________________




4. Treasury Notes/Bonds





5. Stocks

Name _________________________________ Number of Shares ________________

Holding Company _______________________ Value __________________________









6. IRA/Keough Account


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 _________________


Address _________________________________________________________________




Address _________________________________________________________________



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)

Supportive Living Rental Application · Supportive Living Rental Application You must print out...

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