Application for Housing - Tulsa Day Center



Applicant Information Applicant Name (First, MI, Last): Have you ever used another name? No___ Yes __ if yes, please list all names you have used: __________________________________________________________________________________________________________________________________________________________________________________________________Social Security Number ____-____-_____ Date of Birth ___/____/_____ Driver’s License & State___________________Current Address ___________________________________________________________________________________City: _______________________________ State: __________________________ Zip: __________________________Phone: __________________________________ Message Phone: _____________________________________Email:______________________________________________ Hours when you can be reached: __ ______________Co-applicant Information Applicant Name (First, MI, Last):Have you ever used another name? No___ Yes___ if yes, please list all names you have used: ____________________________________________________________________________________________________________________________________________________________________________________________________Social Security Number ____-____-_____ Date of Birth ___/____/____ Driver’s License & State____________________Current Address ___________________________________________________________________________________City ______________________________ State: __________________________ Zip: ____________________________Phone: ___________________________________ Message Phone: _____________________________________-46495161031Office Use Only: Date Received: _________________ Time: __________________ By: _______________________________________Date Reviewed: _________________ Time: __________________ By: _______________________________________Unit Type: _________ Unit #: _______ Deposit: _______________ Rent: _____________ App Fee: ____________Lease Date: ___________________________ Move-in Date: ______________________________ Prospect contacted: _________________________________________________________________________________________________________________________________________________________________________ 00Office Use Only: Date Received: _________________ Time: __________________ By: _______________________________________Date Reviewed: _________________ Time: __________________ By: _______________________________________Unit Type: _________ Unit #: _______ Deposit: _______________ Rent: _____________ App Fee: ____________Lease Date: ___________________________ Move-in Date: ______________________________ Prospect contacted: _________________________________________________________________________________________________________________________________________________________________________ Type of Current Residence ___ Shelter (name): ___________________________________________________________________________________ Hotel/Motel ___ With Family or Friends ___ Living in Car ___Living on streets___ Currently Hospitalized (name): _____________________________________________________________________ Location: _____________________________________________________________________ Currently incarcerated (name of facility) ______________________________________________________________Location/Address: _______________________________________________________________Reason for Incarceration: _________________________________________________________Length of Stay: _______________________ Release Date: ______________________________ ___Other (please describe): __________________________________________________________________________Rental HistoryHave you ever been evicted, declared bankruptcy, or had judgment filed against you? No__ Yes__ - Describe and date each occasion: ____________________________________________________________________________________________________________________________________________________________________________________________________Name of previous Landlord ___________________________________________________________________________Address__________________________________________________________________________________________Phone: ____________________ Rent Amount: $_____________ Relationship of Landlord to applicant____________ Do you have a Section 8 Voucher? No__ Yes__ Time remaining on voucher ________ Issuer ____________________Income/Employment History xDo you currently have income? No___ Yes___ If no, please explain any steps you are taking to begin receiving income: ____________________________________________________________________________________________________________________________________________________________________________________________________Are you currently employed? No___ Yes___, Where______________________________________________________ Manager: ________________________________________________ Phone: ___________________________________Hourly rate ______________ Hours per week _____________ Length of current employment_ ___________________Employment Status: __Permanent __ Temporary __ Seasonal __ Other: ___________________________________Other Sources of Income (per month): Source _______________________________________________________ Amount $___________________________ Applicant Criminal Justice History: Have you ever been convicted, plead guilty or “no contest” to a felony? No__ Yes __ If yes please describe below (include dates): recently have a deferred charges (please discuss) _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever been convicted, plead guilty or “no contest” to a misdemeanor? No__ Yes __ If yes please describe below (include dates): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you required to register with any government agency (federal, state, or local) as a sex offender? No___ Yes __ Are there any legal and/or personal matters which could interfere with you or your co applicant taking possession and/or maintaining occupancy in this housing community? ___ No ___Yes If yes please Explain:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Co-Applicant Criminal Justice History- Have you ever been convicted, plead guilty or “no contest” to a felony? No__ Yes __ If yes please describe below (include dates): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Have you ever been convicted, plead guilty or “no contest” to a misdemeanor? No__ Yes __ If yes please describe below (include dates): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Are you required to register with any government agency (federal, state, or local) as a sex offender? No__ Yes __ Determination of Disability (Hudson Villas abides by Fair Housing Rules and will not discriminate against any person or persons on any basis prohibited by law, including, but not limited to race, color, religion, national origin, sex, disability, sexual orientation, age, or familial status). Do you consider yourself as having a disability? No___ Yes___ If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you require special accommodations for housing? No___ Yes ___ please explain: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Emergency Contact: Person over 18, who will not be living with you.Name: __________________________________________________ Relationship:_____________________________Address: _________________________________ City: ____________________ State:_______________ Zip:_______Phone: ____________________________________________ Email: _________________________________________Personal References:Name________________________________________ Relationship_____________________ Phone_______________Name________________________________________ Relationship_____________________ Phone_______________Name________________________________________ Relationship_____________________ Phone_______________Referral Information (if applicable):Referring Agency: ___________________________________________________________________________________Contact Name: _____________________________________________________________________________________Phone: ____________________ Fax: _____________________Email: _________________________________________I agree to the following statements: (please read and initial on the line provided)______ I certify the information in this application is true, complete, and accurate to the best of my knowledge. I understand that any misrepresentation or omission of information is grounds for my application to be rejected and/or eviction.______ I authorize Hudson Villas to verify all the information given in this application, including past rental information, personal references, and employment information provided. I authorize Hudson Villas to obtain a current credit and criminal background check. I understand that any information gained by Hudson will be used solely to determine the approval or denial of this application. ______ I authorize Hudson Villas for the Homeless to contact the sources listed in this application for the purposes of verifying the accuracy of the information provided. I release the individuals/companies listed from liability for any approval/denial of this rental application.______ I understand that this application is not a rental agreement and that this application does not create any obligation to Hudson Villas.By signing below, I certify that the information provided above is true, complete, and accurate to the best of my knowledge. Applicant Signature:___________________________________________________________________________ Print: _________________________________________ Date: ___________________________Co-Applicant Signature:________________________________________________________________________ Print: _________________________________________ Date: ___________________________-159826667500Equal Housing Opportunity Statement: We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the Nation. Hudson Villas will not discriminate against any person or persons on any basis prohibited by law, including, but not limited to race, color, religion, national origin, sex, disability, sexual orientation, age or familial status. Revised: 08/14/2020-159402349500Hudson VillasBackground Check Release AuthorizationIn connection with my wish to obtain housing with Hudson Villas, a supportive housing program of the Tulsa Day Center, I grant approval for Hudson Villas/Tulsa Day Center to run a background check on me. I understand that this is for the purpose of meeting HUD requirements.NOTICE OF DISCLOSURE TO TENANTSThe application information provided by you may be used to obtain a tenant screening report.Every tenant or prospective tenant is entitled to one free consumer report from each National Consumer Reporting Agency on an annual basis. This report can be obtained through .Every tenant or prospective tenant may dispute inaccurate or incorrect information contained in a tenant screening report directly with the Consumer Reporting Agency that provided such report.As an Oklahoma resident, you have the right to receive a free copy of the background report that was requested. If you wish to receive a copy of this report, please indicate by checking the box below.Oklahoma Applicants Only: I request a copy of any credit report requested on me.I HEREBY AUTHORIZE THE TULSA DAY CENTEROPERATING AS HUDSON VILLAS TO OBTAIN CONSUMER REPORTS AND ANY OTHER INFORMATION IT DEEMS NECESSARY, FOR THE PURPOSE OF EVALUATING MY APPLICATION. I UNDERSTAND THAT SUCH INFORMATION MAY INCLUDE, BUT IS NOT LIMITED TO CREDIT HISTORY, RENTAL HISTORY, CIVIL AND CRIMINAL INFORMATION, EMPLOYMENT/INCOME VERIFICATION AND/OR ANY OTHER NECESSARY INFORMATION. I UNDERSTAND THAT SUBSEQUENT CONSUMER REPORTS MAY BE OBTAINED AND UTILIZED UNDER THIS AUTHORIZATION IN CONNECTION WITH AN UPDATE, RENEWAL, EXTENSION OR COLLECTED WITH RESPECT TO OR IN CONNECTION WITH, THE RENTAL OR LEASE OF A RESIDENCE FOR WHICH APPLICATION WAS MADE. I AGREE TO HOLD THE ABOVE NAMED COMPANY AND PROCURER OR FURNISHER OF INFORMATION, FROM ANY LIABILITY WHAT-SO-EVER IN THE USE, PROCUREMENT, OR FURNISHING OF SUCH INFORMATION. I UNDERSTAND THAT ANY FALSE STATEMENTS/REPRESENTATIONS MADE IN THIS APPLICATION MAY BE USED AS TERMINATION OF APPLICATION/LEASE.The following must be filled out completely for your application to be considered.Name:_____________________________________________________________________________________________ Last First Middle (full name)Maiden: _______________________________________ Nickname: __________________________________________Current Address: ___________________________________________________________________________________City: _________________________________ State: ______________________________ Zip: _____________________Social Security Number: ________________________________ Date of Birth: __________________________________Signature of Applicant: ________________________________________________ Date: __________________________1501417335500Hudson VillasRental History VerificationRequest for Verification of Previous History:Privacy Notice: This information is to be used by Hudson villas and/or the Tulsa Day Center in determining whether you qualify as a prospective resident. It will not be disclosed outside the above agencies, except to your previous Landlord(s)/Property Manager(s) for verification of your previous rental history as permitted by law. You are not required to provide this information, but if you choose not to provide this information, your application for approval may be delayed or rejected. Hudson Villas and the Tulsa Day Center abides by the Fair Housing Laws and does not discriminate against any person or persons on any basis prohibited by law, including, but not limited to race, color, religion, national origin, sex, disability, sexual orientation, age or familial status.Previous Landlord Information:Name: ________________________________________ Property Name: ______________________________Address: _________________________________ City: __________________State: ___________ Zip: ______Phone: _______________________ Email: _______________________________________________________Applicant Information:Name: ____________________________________________________Current Address: _________________________________________City: _________________________________ State: _____________________________ Zip: ______________Phone: ___________________________ Email: ___________________________________________________center38735Landlord/Agent use only:Verification of Present or Previous Rental:Rental Dates: From: _________________________ To: _______________________________Was rent always paid in accordance with the lease terms? No ___ Yes ___; if no, how many times was it late _______Were any checks returned for non-sufficient funds? No ___ Yes ___ if yes, how many times? ________Was the property maintained to your expectations? No ___ Yes ___; if no, please explain _____________________________________________________________________________________________________________________Would you rent to this person again? No___ Yes ___ if no, please explain _______________________________________________________________________________________________________________________________________________________________________________________________ ______________________Signature and TitleDate00Landlord/Agent use only:Verification of Present or Previous Rental:Rental Dates: From: _________________________ To: _______________________________Was rent always paid in accordance with the lease terms? No ___ Yes ___; if no, how many times was it late _______Were any checks returned for non-sufficient funds? No ___ Yes ___ if yes, how many times? ________Was the property maintained to your expectations? No ___ Yes ___; if no, please explain _____________________________________________________________________________________________________________________Would you rent to this person again? No___ Yes ___ if no, please explain _______________________________________________________________________________________________________________________________________________________________________________________________ ______________________Signature and TitleDate ................
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