ULREDC Rental Application

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This application is in two parts.  The first is the rental application.  The 2nd is an Emergency Contact Form.  Both are required for your application to be complete.  Once you complete the rental application and hit “Submit”, you will be directed to the Emergency Contact Form.  Be sure to complete both!

All applicants over 18 years of age are subject to a $15.00 credit check fee and criminal/background records check.  Fees may be collected at time of applicant interview.  Failure to pay fees may result in denial of housing opportunity.  Applicants will need to provide copies of required documents, social security cards and birth certificates for all household members before occupancy.  REV 6-17
Chair                                                                                                                       EHO

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***Please note*** - Your social security number will be required to complete your application. 

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Please provide a complete list of states where you have lived.  This disclosure is mandatory under HUD rules and criminal screening will be reviewed in each state listed and via national criminal screening/sex offender databases.  Failure to provide a complete and accurate list will result in the rejection of the application.  

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Present Landlord Information

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Previous Landlord(s) - If you have not had a previous landlord, type N/A in required fields.

UTILITY PROVIDERS:  You may not live in the unit unless you can establish utilities in the unit.

Will you be able to establish utilities in your unit?

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Other Members

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Unit Size: 

The owner/agent will take your unit preferences/requirements in to consideration.  The owner/agents occupancy standards indicate a minimum of one person per bedroom and maximum of two people per bedroom.  

If you request a unit size different from these standards, the owner/agent is required to verify the need for a larger or smaller unit in accordance with HUD Handbook 4350.3 Revision 1.  Please indicate unit size preferences below.  

If you require special unit features, the owner/agent may verify the need for those features in accordance with HUD Handbook 4350.3 Revision 1.  Please indicate any necessary special features below.

Pets & Assistance/Companion Animals:   Please review the property pet/assistance animal rules.  The presence of any animal must be approved before the animal is allowed to be kept in the unit.  

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INCOME AND ASSET INFORMATION: In order to determine eligibility and to ensure that your family receives the correct assistance, please provide the following information.
Please provide the name and address of your present employer(s) below.

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Assets

Page 11 - Deductions

This section only needs to be completed if you are applying for HUD 811 or HUD 202 Housing.  If you are seeing this message just skip and go to the next page.
Households in which the head-of-household, co-head of household or spouse are disabled or at least 62 years old qualify for deductions based on out-of-pocket medical expenses.  Please let us know if you or any members of your household have out-of-pocket expenses for the following:

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Please provide the ethnicity and racial data for the Head of Household and any other adult to live in the unit.  Head of Household and Co-Head of Household MUST fill out this form.  
Household Information

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PENALTIES FOR MISUSING THIS  FORM
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.  Use of the information collected based on this verification form is restricted to the purposes cited above.  Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.  Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use.  Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8).  Violation of these provisions are cited as violations of 42 U.S.C.  408 (a) (6), (7) and (8).

APPLICANT CERTIFICATION

By signing this document, I certify that if selected to receive the unit I/we occupy will by my/our only residence.  I/we understand that the above information is being collected to determine my/our eligibility.  I/we authorize the owner/manager/PHA to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies.  I/we certify that the statements made in the application are true and complete.  I/we understand that providing false statements or information is punishable under Federal Law.



ULREDC  does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.

The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing
 Section 504 (24 CFR, part 8 dated June 2, 1988).

                            Name         Abi Phillips
                            Address 312 State St
                            City              Rochester, NY 14608
                            Telephone    585-454-5710 x 2007
                          

See HUD Handbook 4350.3 Revision 1, Paragraph 2-29-c-3 & 4 for information about the requirements to include this information.

This application is in two parts.  The first is the rental application.  The 2nd is an Emergency Contact Form.  Both are required for your application to be complete.  Once you complete the rental application and hit “Submit”, you will be directed to the Emergency Contact Form.  Be sure to complete both!

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