Pre-Application Questionnaire

The following items will be requested during the application process. If at all possible, please have these items ready during submission.

Do you currently have a job?

• Need 6 current consecutive paystubs. If this is a new job, we would need the offer letter and any paystubs received. Self-Certification will be required if you have no offer letter and fewer than 6 paystubs.
• If No, must complete an Affidavit of Unemployment
• If you have not worked in the current year, we will need prior year W-2’s or the tax return. A Self- Certification will also be required.

Do you have minor children that live with you (if both parents are not in household?

• If Yes, must complete the Custody and Child Support Affidavit. One per child
• Will the child live with you 50% or more of the time? We will need either the court order, the first page of your tax return to show you claimed the child, or a public assistance form showing the number of adults & children in the household.
• Do you have court ordered child support? If Yes, you will need to provide a copy of the court order.

Are you divorced?

• If Yes, we will need a copy of the divorce decree, if less than 5 years since divorce.
• If you are separated, you will need to complete the Marital Separation Form
• Do you receive any spousal support, or do you anticipate receiving any? Do you have sporadic or no income?
• If Yes, must complete the zero-income questionnaire
• Is someone is providing money or other items to your household? If Yes, we will need to 3rd party verify that income. The person providing this income will complete a regular contribution form and sign.
• Will also need to fill out cash on hand form.

Assets?

• Do you have a Direct Express or EBT Card that is not linked to a bank account? If Yes, we will need a copy of a receipt showing current balance. You must also complete a Debit Card Affidavit.
• Do you own a home or other real estate? If Yes, we will need a copy of the property tax statement and a copy of the mortgage balance. Do you receive rental income from this property? If Yes, we will need something that shows how much you receive.

All family members 18 or over listed as Full-Time students provide the following information.

Please complete the following fields based on your current address you provided earlier.

Current Address: {currentAddress}.

Indicate the amount of anticipated income for all household members named on this application (for minors, unearned income amounts only), during the 12-month period beginning this date. Do you or anyone in your household have:

CURRENT ASSETS – List all assets currently held by all household member and the cash value of each. The cash value is the market value of the asset minus reasonable costs there were, or would be, incurred in selling or converting theasset to cash.

Please upload a copy of all household members social security cards.

Do you currently have a job?

• Need 6 current consecutive paystubs. If this is a new job, we would need the offer letter and any paystubs received. Self-Certification will be required if you have no offer letter and fewer than 6 paystubs.
• If No, must complete an Affidavit of Unemployment
• If you have not worked in the current year, we will need prior year W-2’s or the tax return. A Self- Certification will also be required.

Do you have minor children that live with you (if both parents are not in household?

• If Yes, must complete the Custody and Child Support Affidavit. One per child
• Will the child live with you 50% or more of the time? We will need either the court order, the first page of your tax return to show you claimed the child, or a public assistance form showing the number of adults & children in the household.
• Do you have court ordered child support? If Yes, you will need to provide a copy of the court order.

Are you divorced?

• If Yes, we will need a copy of the divorce decree, if less than 5 years since divorce.
• If you are separated, you will need to complete the Marital Separation Form
• Do you receive any spousal support, or do you anticipate receiving any? Do you have sporadic or no income?
• If Yes, must complete the zero-income questionnaire
• Is someone is providing money or other items to your household? If Yes, we will need to 3rd party verify that income. The person providing this income will complete a regular contribution form and sign.
• Will also need to fill out cash on hand form.

Assets?

• Do you have a Direct Express or EBT Card that is not linked to a bank account? If Yes, we will need a copy of a receipt showing current balance. You must also complete a Debit Card Affidavit.
• Do you own a home or other real estate? If Yes, we will need a copy of the property tax statement and a copy of the mortgage balance. Do you receive rental income from this property? If Yes, we will need something that shows how much you receive.

I/we understand that the above information is being collected to determine my/our eligibility for residency. I/ we authorize the owner/manager to verify all information provided on this Application/Certification and my/our signature is our consent to obtain such verification. I/we certify that I/we have revealed all assets currently held or previously disposed of and that I/we have no other assets than those listed on this form (other than personal property). I/we further certify that the statements made in this Application/Certification are true and complete to the best of my/our knowledge and belief and are aware that false statements are punishable under Federal law.

Any applicant, who purposefully falsifies, misrepresents or withholds any information related to program eligibility or submits inaccurate and/or incomplete information on this application will not be considered for housing.

I authorize RENTBUREAU and MetroPlains to investigate my criminal history, residential, employment and income hisotry, and bank and credit history for the purpose of housing and/or employment. The source of the information may come from, but is not limited to: Credit Bureaus; banks and other depository institutions; current and former employers; federal or state records including State Employment Security Agency records, county or state criminal records as follows, or other sources required. It is understood that a photocopy or facsimile copy of this form will serve as authorization.

This authorization is for this transaction only and continues in effect for one (1) year unless limited by state law, in which case the authorization continues in effect for the maximum period, not to exceed one (1) year, allowed by law.

As a condition of participating in an affordable housing program, I understand the property owner is required to initially and annually certify each resident’s eligibility for such program. Consequently, I understand it is necessary for me to give authorization for specific income, asset, medical, and childcare expense information to be provided on one or more of the following forms:

This authorization is limited to the forms listed above and expires 365 days after the date of my signature below unless revoked in writing by me earlier. By my signature below, I authorize the representative individuals to disclose my specific income, asset, and medical information as requested on the forms above. No other information may be released without my express written authorization.

By the signature of its authorized management agent below, and in consideration for execution of this Authorization by the applicant/resident, property representative warrants the following:

1. Information requested on the above form is required and necessary to complete certification of the applicant/resident’s eligibility to reside in the above housing property;
2. The information requested above will be used for no purpose other than determining such applicant/resident’s eligibility; will be maintained as confidential personal information subject to disclosure only as required by property administrative or judicial process, and will not be otherwise disclosed by the property owner or management; and
3. The property owner and management have instituted procedures that insure all personally identifiable information provided pursuant to this authorization will be maintained in electronic or magnetic form, sufficient to protect such information form any unauthorized use, access, or disclosure.