Fillable Duke Barrington Rental Application (Page 5 of 5) in pdf

Yes

COMPLETE EACH ITEM:

I have income/assets from sources other than those listed above. (Describe) _________________

A member of my household is under the age of 18 and has assets (see Question #63 for list of assets).

(Describe) ______________________________________

Yes

COMPLETE EACH ITEM:

ALLOWANCES / DEDUCTIONS

(Complete the items below for Section 8, Section 236, and Moderate Projects Only)

I am Elderly (age 62 or older), Handicapped or Disabled and pay Medicare premiums.

I am Elderly (age 62 or older), Handicapped or Disabled and pay medical insurance premiums, other than

Medicare.

I am Elderly (age 62 or older), Handicapped or Disabled and pay medical or prescription or chore provider

expenses which are not reimbursed by insurance.

I am Elderly (age 62 or older), Handicapped or Disabled and pay long term care insurance premiums.

I pay child care expenses for a child age 12 or under in order to be gainfully employed or to further my

education.

Family Independence Agency (FIA) pays child care expenses for a child/children age 12 or under in order

for me to be gainfully employed or further my education. If yes, FIA pays (circle one)

full

partial.

I pay handicap care expenses for a handicapped/disabled family member in order to be gainfully

employed.

I pay handicap equipment expenses for handicapped/disabled family members which are not covered by

insurance.

Other Items

I have provided proof of Social Security number (or certification) for all household members.

DISPOSAL / DIVESTITURE OF ASSETS

(all tenants and prospective residents in all types of projects must complete the section below)

I have sold, given away or otherwise transferred ownership of assets within the last two (2)

years. Initial the “Yes” column or the “No” column at left. If yes, list item(s) and date(s):

_______________________________________________________________________

_____________________________________________________________________________

Assets

include cash (totaling in excess of $999), cash held in savings and/or checking accounts, trust funds,

equity in real estate and other capital investments, stocks, bonds, Treasury bills, certificates of deposit,

money market funds, IRA accounts, retirement and pension funds, lump sum receipts (i.e., lottery

winnings, insurance settlements, etc.), and personal property held as an investment (i.e., gem or coin

collections, paintings, antique cars, etc.). Do not include necessary personal property such as furniture,

automobiles, and clothing.

Under penalties of perjury, I certify that the information presented in this certification is true and accurate to the

best of my (our) knowledge. The undersigned further understands that providing false representation herein

constitutes an act of fraud.

I will notify the Resident Manager when circumstances change, for possible

recertification. False, misleading or incomplete information may result in the termination of the lease agreement

and/or benefits.

______________________________________________

_______________________

Applicant / Tenant Signature

Date

REV6/24/2014

Duke Barrington Rental Application Page 5

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