Clinton

Apply

Please complete the rental application to be considered for residency at The Governor Clinton, or click here to download the form.
  • FAMILY COMPOSITION:
  • D. O. B.
    *
  • *
    • AGE
      *
    • SEX
      *
  • ARE YOU A U.S. CITIZEN?
  • ETHNICITY: (SELECT ONE)
  • APARTMENT DESIRED: (SELECT ONE)
  • RACE: (SELECT ONE)
  • PRESENT HOUSING INFORMATION:
  • FORMER PLACE OF RESIDENCE : (prior to current address)
  • ARE YOU A VETERAN?
  • INCOME INFORMATION
  • ADDITIONAL PERSONAL INFORMATION:
  • IMPORTANT! All income must be reported; Including Social Security, SSI, Employment, Unemployment, Bank Interest, Mortgage Income, Pensions, Dividends, Annuities, Etc. Application will be returned if this section is blank.
  • DO ANY OF THE APPLICANTS HAVE A CAR?
  • PERSONAL REFERENCES:
  • INCOME GROSS AMOUNT:
  • LIST ONE (1) CREDIT REFERENCE: Such as: Credit Card, Utility Co., Bank, etc.
     
  • FILL IN IF YOU OWN YOUR HOME:

  • CURRENT ASSETS (MUST BE FILLED OUT BY EVERYONE APPLYING):

  • ANNUITIES / DIVIDENDS:
  • ASSETS CONTINUED:

  • CHECKING ACCOUNTS:
  • SAVINGS ACCOUNTS:
  • CERTIFICATES OF DEPOSIT:
  • OTHER CURRENT ASSETS:
  • ASSETS RECENTLY DISPOSED OF:

  • HAVE YOU OR ANY FAMILY MEMBER IN YOUR HOUSEHOLD DISPOSED OF ANY ASSETS FOR LESS THAN FAIR MARKET VALUE DURING THE PAST TWO YEARS?
  • IF “YES”, PROVIDE THE FOLLOWING INFORMATION:
  • HAVE YOU EVER BEEN CONVICTED OF A FELONY CRIME?
    MUST BE FILLED OUT IN ORDER TO PROCESS YOUR APPLICATION
  • PERSON TO NOTIFY IN AN EMERGENCY: (MUST BE FILLED OUT)

  • PLEASE BE SURE TO INCLUDE PHONE #
DECLARATION: I understand this is not a contract and does not bind either party. I certify that the information contained herein is complete, true and accurate to the best of my knowledge.

WARNING:

FALSE STATEMENTS OR MISREPRESENTATION ARE A CRIMINAL OFFENSE UNDER SECTION 1001 OF TITLE 18 OF THE U.S. CODE.

I have no objections to inquiries being made to verify statements contained herein. I authorize Governor Clinton Apts. to verify the above information, and I consent to the release of the necessary information to determine my eligibility in compliance with the Tenant Selection Plan. I further agree to furnish documents and affidavits verifying income and other information contained herein as requested by owner / agent.
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing.
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.
    • Applicant Name:

    • Mailing Address:

    • Telephone No:

      Cell Phone No:

    • Name of Additional Contact Person or Organization:

    • Address:

    • Telephone No:

      Cell Phone No:

    • E-Mail Address (if applicable):

    • Relationship to Applicant:

  • Reason for Contact: (Check all that apply)

  • Emergency
    Assist with Recertification Process
  • Unable to contact you
    Change in lease terms
  • Termination of rental assistance
    Change in house rules
  • Eviction from unit
    Other:
  • Late payment of rent
  • Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.
  • Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.
  • Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.
Check this box if you choose not to provide the contact information.
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number. Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be used by HUD to protect disbursement data from fraudulent actions.