Application For Residency - Covenant Manor Page 5
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12COVENANT MANOR
Office Use Only
600 E. FOURTH STREET
Date Received:
LONG BEACH, CA 90802
Time Received:
PHONE (562) 435-1804
Wait List No.:
FAX (562) 495-2223
TDD/TTY/RELAY SERVICE - 711
APPLICATION FOR RESIDENCY
PLEASE PRINT CLEARLY AND COMPLETE ALL INFORMATION
List the Head of Household and all other members who will be living in the unit and, provide social security
numbers for all household members.
Member
Relationship
Birth
No.
Last Name
First Name
M/I
to Head
Date
Age
Sex
Soc. Sec. No.
Head
Self
2
3
All members of household, regardless of age, must declare their citizenship or immigration status. Please complete the
attached Citizenship Declaration documents and return with this application.
Are you or any members of your household disabled?
Yes [ ]
No [ ]
Are you or any members of your household a person with a disability that requires the amenities of an accessible unit?
Yes [ ]
No [ ]
Are you or any members of your household a part-time or full-time student enrolled in an institute of higher education?
Yes [ ]
No [ ]
Check which apartment size you are interested in:
1 Bedroom [ ]
2 Bedroom [ ]
Any [ ]
Current Address:
Street
City
State
Zip Code
Area Code & Phone #
Landlord’s Name
Area Code and Phone #
Rent Amount
Length of Stay
If you have lived at your current address less than five years, please provide the name, address and phone number of all
former landlords for the past five years:
Name of Landlord
Address
Phone
Dates you lived there
From
To
1.
Has any member of the household ever been evicted from another federally assisted
site for drug related criminal activity within the past three years?
Yes [ ]
No [ ]
2. Does any member of the household use illegal drugs or abuse alcohol?
Yes [ ]
No [ ]
3. Have any members of the household been convicted and or adjudicated of a
misdemeanor or felony?
Yes [ ]
No [ ]
4. Are you or any members of your household registered as a Life-time Sex Offender?
Yes [ ]
No [ ]
5. List every State you have ever resided in:________________________________________________________________
INCOME
Income Source
Monthly Income
Monthly Income
Monthly Income
Head of Household
Member #2
Member #3
Social Security
SSI/Disability
Pension/Annuity
Employment/Salary
General Relief
Interest/Dividends
Family Assistance
Other __________
TOTAL:
Please complete other side
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