Rental Application - Usda/hud Properties Only Page 3
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10USDA/HUD HOUSING APPLICATION
Have you or any member of your household ever committed any fraud in a Federal assistance housing
program or been requested to repay money for knowingly misrepresenting information for such housing
programs? Yes No If yes, explain:
____________________________________________________________________________________
Do you have any pets? Yes No If, yes, what kind and size:_______________________________
Are you or any other household members a current user of illegal drugs? Yes No
Do you or any other household members abuse alcohol to the extent that you/they are a danger to others,
health, safety, or right to peaceful enjoyment? Yes No
Have you or any household member ever been convicted of any drug offense? Yes No
If yes, who:__________________________________________________________________________
Explain:_____________________________________________________________________________
Have you or any household members ever been convicted of a felony? Yes No
If yes, who: _________________________________________________________________________
Explain: ____________________________________________________________________________
Have you or any household members ever been evicted from a subsidized housing program for drug
related or criminal activity in the last 3 years? Yes No If yes, who: ____________________
Explain: ____________________________________________________________________________
Are you or any household members listed on the application on a state or federal sex offender registry?
Yes No
For each household member 18 years or older, please list all states in which you have lived since 1996:
Name: _______________________ States: __________________________________________
Name: _______________________ States: __________________________________________
Name: _______________________ States: __________________________________________
Name: _______________________ States: __________________________________________
LANDLORD INFORMATION
Present Housing: Own ______ Rent ______ Other ______ Monthly Amount $________________
Landlord’s Name:______________________________________________________________________
Landlord’s Address: ____________________________________________________________________
Street City State Zip Code
Landlord’s Telephone: ________________________ Dates of Residency: _______________________
(Mo./Yr.) to (Mo./Yr.)
If related to Landlord, state relationship: _________________________
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