Rental Application Form And Applicant/resident Release And Consent Form (Page 3 of 3) in pdf

Income & Asset Disclosure Statement

Please include the amount for each “yes” answer.

INCOME SOURCE

Employment Income (Gross Amount)

( )Yes

( )No

Military Pay

( )Yes

( )No

Self Employment Income

( )Yes

( )No

Social Security Income (Gross Amount)

( )Yes

( )No

Social Service Income

( )Yes

( )No

Disability Income

( )Yes

( )No

Unemployment Income

( )Yes

( )No

Worker’s Compensation

( )Yes

( )No

Pensions

( )Yes

( )No

Rental Income from Property Owned

( )Yes

( )No

Section 8/ Housing Voucher____________________ ( )Yes_______ _( )No______ _ _$____________________________

Welfare Assistance (AFDC/TANF)

( )Yes

( )No

Child Support

( )Yes

( )No

Alimony

( )Yes

( )No

Recurring Monetary Gifts

( )Yes

( )No

Veterans Administration Benefits

( )Yes

( )No

Income from any source not mentioned(i.e.2

job)

( )Yes

( )No

(List information on 2

job on back of page)

Employment:

Circle all applicable:

Employed full time

Employed part time

Self-employed

Non-employed

Unemployed

Current

Employer:

Position:

Date Hired:

Address:

Supervisor:

Phone:

Current Wages: $

per: hour

week

month

year (circle one)

Do you expect to earn substantial overtime?

( )Yes

( )No

If so, how much?

Assets:

Dollar Value

Name of Institution

Do you have any of the following? If yes, indicate the value.

Checking Account (average 6 month balance)

( )Yes

( )No

Savings Account

( )Yes

( )No

Certificates of Deposit

( )Yes

( )No

Stocks or Bonds

( )Yes

( )No

IRA’s or Retirement Funds

( )Yes

( )No

Mutual Funds

( )Yes

( )No

Trust Accounts

( )Yes

( )No

Whole or Universal Life Insurance (not Term)

( )Yes

( )No

Personal Property held as an investment

( )Yes

( )No

Real Estate

( )Yes

( )No

Any Assets not listed above

( )Yes

( )No

Have you disposed of any assets in the

Previous 24 months?

( )Yes

( )No

I hereby apply to lease the above described premises on substantially the terms set forth herein. As an inducement to Coastal Properties of VA, Inc.,

Agent for the owner of the property, to accept this application, I warrant that all statements contained herein are true. I have been advised and

understand that residency at this community entails certain income restrictions and that residency is subject to qualification. I hereby authorize Landlord

to procure a consumer report as defined in the Fair Credit Reporting Act, 15 U.S.C. 1881 a (d) seeking information on the credit worthiness, credit

standing, credit capacity, character, general reputation, personal characteristics or mode of living. I tender in addition to any security deposit, the amount

of $

which I acknowledge is the cost of procuring a consumer credit report, employment verification, character references and other

administrative set-up costs. This fee is non-refundable. I agree that in addition to execution of a Lease Agreement that I will execute a tenant certification

attesting to the information contained herein which certification will be made under the penalty of perjury.

A deposit of $

is made herein. If the application is approved, said deposit will be held as (partial/full) security for the performance of the

covenants of the lease and as damage deposit. The full security deposit will be $

. If the applicant(s) notifies the Landlord within

three (3) days after the execution of this application that applicant(s) no longer wishes to rent said apartment, Landlord agrees to return said deposit in

full. Landlord reserves the right to retain the security deposit if, for any reason, prospective resident withdraws the application for tenancy, if said

application is withdrawn after the time limit set out in the previous sentence.

By execution of this application, I hereby authorize Coastal Properties of VA, Inc. to make such investigations into my credit history as they may deem

appropriate. I understand that such investigations typically include (but are not limited to) verification of employment and salary, rental history and

consumer credit reports. By signing below, the applicant gives permission to procure a criminal background check and understands the results of such

background check could affect the approval of this application. The undersigned do hereby acknowledge disclosure that the licensee Coastal Properties

of VA, Inc. represents the Landlord in a real estate transaction.

WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any matter within the jurisdiction of a federal agency.

Applicant:

Date:

Coastal Properties of VA April 2010 Revised

Tax Credit Form #10