Courtyards at Arcata Online - Home | The Danco Group

APPLICATION FOR ADMISSION

9/27/07 (TC all)

Cottages Dt Cypress

330 Cypress Street

Fort Bragg, CA 95437

ph. (707) 962-9080

fax (707) 962-9077

OFFICE USE ONLY

Date:

Time:

Apt. Size:

OFFICE USE ONLY

Gross Income:

Income Limit:

GENERAL INFORMATION:

Head of Household:

Name

1)

2)

3)

4)

5)

6)

7)

¡õ

Will anyone live with you who is not listed above?

No

¡õ

No

¡õ

Are you requesting an accommodation in housing due to a disability?

If yes, what is the accommodation requested?

¡õ

Yes

No

¡õ

Yes

¡õ

No

Are you or any member of your household, 18 or older, attending school?

Do you own a pet?

¡õ

No

¡õ

Yes

Do you have a washing machine?

Did you file taxes?

¡õ

No

Do you have a waterbed?

¡õ

¡õ

No

¡õ

Yes

¡õ

M OR F

M OR F

M OR F

M OR F

M OR F

¡õ

Yes

If yes, who?

Documentation required.

Yes

Yes

No

M OR F

If yes, please be advised that we accept service animals only.

¡õ

Drivers Lic.# / State

/

/

/

/

/

/

/

M OR F

Yes

¡õ

Has any member of the household been convicted of a felony?

GENDER

CIRCLE

ONE

Birthdate/Age

/

/

/

/

/

/

/

Social Security #

Email:

APARTMENT SIZE REQUESTED

2¡õ

Bedroom

1 Bedroom

3 bedroom¡õ

4 bedroom

RENTAL HISTORY- Management's policy is to have 5 years of continuous housing history. If additional space is needed, please use the back of this application or

attach an additional sheet.

(Head of Household) Current Address:

Street

Apt.#

Phone Number:

City

State

Dates you lived here:

Zip

to

Mailing Address (if different from above)

Street

CURRENT LANDLORD:

apt.#

city

state

zip

Address:

Phone Number:

if apt., name of complex:

Reason you want to move:

Amount of rent you are paying:

Are you being or have you been evicted?

No

Yes

If yes, please explain:

PREVIOUS ADDRESS:

Street

Apt.#

If apt., name of complex:

Previous Landlord:

City

State

Dates you lived there:

Phone Number:

Reason for moving:

Address:

Page 1 of 6

Zip

to

ALL OTHER APPLICANTS NOT RESIDING WITH THE HEAD OF HOUSEHOLD APPLICANT MUST PROVIDE 5 YEARS OF CONTINUOUS HOUSING

HISTORY.

(Applicant #2) Current Address:

Street

Apt.#

Phone Number:

City

State

Dates you lived here:

Zip

to

Mailing Address (if different from above)

Street

CURRENT LANDLORD:

apt.#

city

state

zip

Address:

Phone Number:

if apt., name of complex:

Reason you want to move:

Amount of rent you are paying:

Are you being or have you been evicted?

No

Yes

If yes, please explain:

PREVIOUS ADDRESS:

Street

Apt.#

If apt., name of complex:

City

State

Dates you lived there:

Previous Landlord:

Phone Number:

Zip

to

Reason for moving:

Address:

(Applicant #3) Current Address:

Street

Apt.#

Phone Number:

City

State

Dates you lived here:

Zip

to

Mailing Address (if different from above)

Street

CURRENT LANDLORD:

apt.#

city

state

zip

Address:

Phone Number:

if apt., name of complex:

Reason you want to move:

Amount of rent you are paying:

Are you being or have you been evicted?

No

Yes

If yes, please explain:

PREVIOUS ADDRESS:

Street

Apt.#

If apt., name of complex:

City

State

Dates you lived there:

Previous Landlord:

Phone Number:

Zip

to

Reason for moving:

Address:

PERSONAL REFERENCES (do not list relatives-preferably business/professional acquantances):

(Applicant #1)

Name

Address

Phone #

Relationship

(Applicant #2)

Name

Address

Phone #

Relationship

(Applicant #2)

Name

Address

Phone #

Relationship

Page 2 of 6

EMERGENCY CONTACT PERSON:

Name

Address

Phone Number

Relationship

AUTOMOBILES:

Make:

Color:

Year:

License Plate #:

Make:

Color:

Year:

License Plate #:

Include ALL medical expenses, car payments,

child support, loans, etc.

MONTHLY PAYMENT

HOUSEHOLD FINANCIAL OBLIGATIONS

PAYABLE TO:

(Company Name)

/

/

/

/

INCOME: Do you or any member of your household anticipate receiving income from any of the following sources during the next

12 months? Please mark EVERY question YES or NO. If you answer any questions with a YES, please complete the

information on the right.

Received By Which

Household Member

Amount Received

(per time period)

Yes No

Employment

(Earned income)

¡õ

¡õ ¡õ

$

Employment

(Earned income)

¡õ

¡õ ¡õ

$

Alimony

¡õ

¡õ ¡õ

$

Child Support

¡õ

¡õ ¡õ

$

Disability Benefits

(worker's compensation

disability income)

¡õ

¡õ

¡õ

week

¡õ

month

¡õ

week

¡õ

month

¡õ

week

¡õ

month

¡õ

week

¡õ

month

per

hour

per

hour

per

hour

per

hour

Monetary Gifts

¡õ

¡õ ¡õ

$

Pension or Retirement

Benefits

¡õ

¡õ ¡õ

$

Public Assistance

¡õ

¡õ ¡õ

$

Schoold Grants or

Scholarships

¡õ

¡õ ¡õ

Social Security / SSI

¡õ

¡õ ¡õ

$

Unemployment

Compensation

¡õ

¡õ ¡õ

$

Veterans Administration

¡õ

¡õ ¡õ

$

Other:____________

¡õ

¡õ ¡õ

$

¡õ

week

¡õ

month

¡õ

week

¡õ

month

¡õ

week

¡õ

month

¡õ

week

¡õ

month

per

hour

per

hour

per

hour

$

hour

hour

hour

hour

hour

(name,

per

hour

$

¡õ

Source of Income

address & phone)

per

¡õ

¡õ

week

semester

per

¡õ

week

¡õ

month

¡õ

week

¡õ

month

¡õ

week

¡õ

month

¡õ

week

¡õ

month

per

per

per

Do you anticipate any change in this income in the next 12 months?

¡õ

Yes

¡õ

No

Does an outside party pay your utilities, phone service or other household expenses?

If yes, please explain:

¡õ

Yes

¡õ

No If yes, amount paid per month $

Name and address of outside party:

Name

Address

City

FEDERAL INCOME TAX RETURNS: Are you or any member of your household exempt from filing a Federal Tax Return?

,

If yes, which members:

Name

,

Name

Name

Page 3 of 6

State

¡õ

Yes

Zip

¡õ

No

ASSETS:

In the last TWO years have you sold, given away, or disposed of assets for less than "fair market value" (example: real

estate and other items held for investment purposes such as gems, jewelry, coins, or collections)?

No

Yes

If yes, list type of asset:

Amount given:

Name of party who received asset:

Address:

Was this due to divorce, separation or bankruptcy?

ASSETS II:

No

Yes

Please mark every question either YES or NO. If you answer YES, complete the blanks on the right.

DO YOU HAVE...?

YES

NO

Checking Account(s)

¡õ

¡õ

Checking Account(s)

¡õ

¡õ

Savings Account(s)

¡õ

¡õ

Savings Account(s)

¡õ

¡õ

Money Market Account(s)

¡õ

¡õ

Certificate/Time Deposits

¡õ

¡õ

Safety Deposit Box

¡õ

¡õ

Trust Account(s)

¡õ

¡õ

IRA/Keough/Life Insurance

or other retirement account

¡õ

¡õ

Stocks or Bonds

¡õ

¡õ

Rental Property

¡õ

¡õ

Other Real Estate

¡õ

¡õ

Other:_______________

¡õ

¡õ

NAME ON ACCOUNT

ACCOUNT #

Page 4 of 6

BALANCE/VALUE . Bank (name & address)

CHILDCARE: (Complete only if your child/children is/are 12 years of age or younger and living in your household)

Do you pay for childcare expenses?

Name:

¡õ

Yes

¡õ

No

If yes,

If yes,

howhow

much

much

$ $

To whom is this expense paid?

Address:

Do you employ childcare in order for a household member to work or continue education?

¡õ

Yes

¡õ

No

ELDERLY HOUSEHOLDS: (Applicable only if the head of household or co-tenant is 62 years of age or older; or disabled,

regardless of age).

Do you anticipate having ANY medical expenses within the next twelvle (12) months that are not paid for by Medicare or an

insurance policy?

¡õ Yes

¡õ No

(examples: medical or dental expenses, including cost of insurance, prescriptions, eyeglasses, hearing aids or nursing care)

DO NOT INCLUDE expenses that are reimbursed or paid by others outside your household.

DISABILITY ASSISTANCE EXPENSE: (Applicable only if a household member has a disability).

Does your household have disability assistance expenses?

¡õ Yes ¡õ No (examples: care attendant, special apparatus,

such as, wheelchairs, ramps, and adaptations to vehicles or workplace equipment) DO NOT INCLUDE expenses that are

reimbursed or paid by others outside your household.

DRUG FREE HOUSING:

In order to comply with Federal and State laws, all attempts must be made by the Owner of this apartment community to assure

DRUG and VIOLANCE-FREE Housing. The following questions MUST be answered by ALL applicants for this housing:

Yes

¡õ

¡õ

No

¡õ

Is any household member a current illegal user of a controlled substance?

¡õ

Has any household member been convicted of the illegal use, possession, sale, distribution or manufacturing

of a controlled substance?

If either of the above questions were answered "Yes", which member(s):

¡õ

¡õ

If any of the questions above were answered "Yes", has the household member successfully completed a

controlled substance abuse recovery program?

¡õ

¡õ

¡õ

¡õ

¡õ

¡õ

Has any household member been convicted of a violent crime?

Is any household member currently on probation for a violent or drug-related offense?

Is any household member currently on probation for a violent or drug-related offense?

Page 5 of 6

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