Hud Application For Housing Template (Page 6 of 9) in pdf

Part VII. Allowances

Yes

Do you have any out-of-pocket childcare expenses?

If yes, how much do you pay per month? $____________



Are there any household members over the age of 18 that is a student? If yes, please list:



Name ______________________ PT

FT

Name _____________________ PT

FT

Are you covered by any medical insurance? If yes, how much are your monthly premiums? $______________



ο Medi-Cal

ο Medicare ο Blue Cross

ο Kaiser

ο AARP

ο Other _____________

Do you or any household member have any medical expenses including prescription drug, vision and dental expenses



not covered by insurance? If yes, how much do you anticipate paying out-of-pocket per month? $___________

I/We certify the above information to be true and correct to the best of my knowledge.

I/We authorize

verification of age, income, assets, allowances, credit history, rental history, criminal background, register sex

offender, eviction and references.

I/We understand that falsification of information found before or after

acceptance of this property includes penalties that will result in cancellation of your application, also to include

eviction, loss of assistance, if applicable. If this is a HUD subsidized property, the additional fines are imposed:

fines of $10,000.00 and five years imprisonment. WARNING!: Title 18, Section 1001 of the United States Code,

states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to

any department or agency of the United States:

Head of Household Signature

Date

Secondary Applicant Signature

Date

THE FILING OF THIS APPLICATION IN NO WAY GUARANTEES YOU AN APARTMENT. A FINAL DETERMINATION OF

ELIGIBILITY WILL NOT BE MADE UNTIL INFORMATION IS VERIFIED. INCOMPLETE OR UNSIGNED APPLICATIONS

WILL BE RETURNED AND NOT ACCEPTED.

Return Application to the following address:

Shepherd’s Garden

6927 196

St SW

Lynnwood, WA 98036

EQUAL HOUSING OPPORTUNITY

Shepherd’s Garden does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in its federally

assisted programs and activities. Our Fair Housing Coordinator is designated to ensure compliance with the nondiscrimination requirements contained

in Section 504 of the HUD Regulations and can be contacted via e-mail at or at 6120 Stoneridge Mall Road, Third Floor,

Pleasanton, CA 94588, Telephone 925-924-7116 TDD 800-545-1833 Ext 478.

Page 5 of 5

v. 04/2015

Hud Application For Housing Template Page 6

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