Permanent Supportive Housing Program (Page 4 of 4) in pdf

Permanent Supportive Housing Program Page 4

Emergency Information

Name:

Address:

Phone Number:

Relationship:

Are you a veteran?

_____Yes

_____No

Accessibility (For Eligibility Purposes Only)

Are you or anyone in your household disabled/handicapped? If so, who?

Do you or any member of your household have a need for an accessible unit? If so, please describe the need for an

accessible unit:

Please describe your current River Edge outpatient services, frequency, and compliance level.

Please describe any physical health problems that you have.

Agreement and Authorization Signature

I affirm that the information given in this application is true and correct. I understand that if any of the

information provided is false, misleading or incomplete, management may decline my application, or if move-

in has occurred; terminate my lease and evict me and my household. Do not use white-out on this form, please

line through the error and initial the change. I understand that it is a crime to knowingly provide false

information for the purpose of obtaining or maintaining occupancy in and/or for the purpose of securing a

lower rent in a subsidized housing development. I authorize Management to make any and all inquiries to

verify this information either directly or through information exchanged now or later with rental and credit

screening services, previous and current landlords, law enforcement agencies or other sources of information

released to appropriate Federal, State, or local agencies. The applications selection process will be in

accordance with the Second Neighborhood Tenant Selection Plan. I affirm that the apartment unit applied for

will be my/our permanent residence. I affirm further that I do not and will not maintain a separate subsidized

rental unit in a different location.

Applicant’s Signature

Date

Co-Applicant’s Signature

Date

Permanent Supportive Housing Program Page 4