HAVERFORD

HOUSE

APARTMENTS

DEAR APPLICANTS:

THANK YOU FOR APPLYING AT HAVERFORD HOUSE APARTMENTS, ATTACHED YOU WILL FIND AN APPLICATION FOR HOUSING. PLEASE FILL OUT ALL APPROPRIATE AREAS.

THE MOST COMMON ERROR IS THE LANDLORD INFORMATION, PLEASE TAKE NOTE THAT IT IS A THREE YEAR HISTORY. MANY APPLICANTS DO NOT INCLUDE ALL NECESSARY INFORMATION.

PLEASE TAKE YOUR TIME, IF THERE IS ANYTHING THAT YOU DO NOT UNDERSTAND, PLEASE CONTACT THE OFFICE FOR ASSISTANCE AT THE NUMBER LISTED BELOW.

AGAIN, THANK YOU FOR YOUR INTEREST IN OUR DEVELOPMENT.

EQUAL HOUSING OPPORTUNITY…………………………………..

PLEASE RETURN APPLICATION TO:

1603 Cecil B. Moore Avenue, Suite 200, Philadelphia, PA 19121

(215) 232-9900

HAVERFORD HOUSE APARTMENTS

Location: 3416-18 Haverford Ave., Philadelphia, PA 19104

Office: 1603 Cecil B. Moore Ave., Philadelphia, PA 19121

P.O. Box 56260, Philadelphia, PA 19130

Office: (215) 232-9900 * Fax: (215) 236-6072

Applicant Name: __________________________________________________________

Current Address: _________________________________________________________

Apt. Number: ____________________ City, State & Zip: ______________________

Home Phone #: _________________________ Work Phone #: __________________

List names, addresses and phone number of two relatives or friends who generally know how to contact you:

Name: _________________________ 2. Name: _____________________

Address: _______________________ Address: ___________________

City, State & Zip: ________________ City, State & Zip: ____________

Phone#: ________________________ Phone#: ___________________

HOUSEHOLD COMPOSITION AND CHARACTERISITICS:

List the Head of Household and all other members who will be living in the assisted unit. Give the relationship of each member to the head.

FULL NAME RELATIONSHIP BIRTHDATE AGE SEX SOCIAL SECURITY #

What size apartment is desired? ____________________ How did you hear about us?

_____ Friend _____ Newspaper _____ Drive-by _____ Phone Book _____ Resident

_____ Another Apt. Complex ______ Other.

Race of Head of Household: _____White _____African-American _____American Indian (for statistical data) _____ Asian _____Do not wish to answer

Ethnicity of Head of Household: _____ Hispanic______Non-Hispanic (for statistical data) _______Do not wish to answer.

Do you plan to have anyone living with you in the future who are not listed above? _____Yes ______No If yes, please explain: __________________________________

_______________________________________________________________________

Is there a handicap or disability that you as Head of the Household or spouse chose to claim for Section 8 eligibility purpose? _______________________________________

_______________________________________________________________________

Are there any special accommodations that the household will require, for example, unit for mobility impaired, unit for visually impaired, unit for hearing impaired, live-in aide, housekeeping, grab bars, or wheel-in showers? ________________________________

______________________________________________________________________

Identify any special housing needs required as a result of the handicap: _____________

_______________________________________________________________________

CURRENT HOUSING STATUS:

Provide the name, address and phone number of all your landlords and the address of the apartment or house you rented from them for the past THREE YEARS.

PLEASE PUT DATES IN CHRONOLOGICAL ORDER, FOR THE PAST (3) YEARS.

Current Landlord’s Name: _____________________ Your Address: ____________________

Address: ___________________________________ ____________________

City, State & Zip: ____________________________ _____________________

Phone #: ___________________________________ What dates FR: _________ TO: _______

Previous Landlord’s Name: __________________ Your Address: __________________

Address: _________________________________ __________________

City, State & Zip: __________________________ __________________

Phone#:__________________________________ What dates FR: ________TO:______

Previous Landlord’s Name: __________________ Your address: __________________

Address: _________________________________ __________________

City, State & Zip: __________________________ __________________

Phone#:__________________________________ What dates FR: ________TO:_____

SHOULD YOU NEED MORE SPACE, PLEASE FEEL FREE TO ATTACH ANOTHER SHEET OR SEE PAGE #5 FOR ADDITIONAL SPACE.

INCOME INFORMATION:

Please answer each of the following questions. For each yes answer, provide the details in the checklist below.

YES NO

1. Is any member of your household employed (full-time, part-time or

seasonally)? ________ ______

2. Does any member of hour household expect to work for any period

during the next twelve months? ________ ______

3. Does any member of your household work for someone who pays

them cash? ________ ______

4. Is any member of your household on leave of absence from work

due to lay-off, medical, maternity or military leave? ________ ______

5. Does any member of your household now receive or expect to

receive unemployment benefits? ________ ______

6. Does any member of your household now receive or expect to

receive child support? ________ ______

7. Is any member of your household entitled to child support that

he/she is not now receiving? ________ ______

8. Does any member of your household now receive or expect to

receive alimony payments? ________ ______

9. Is any member of your household entitled to alimony payments

that he/she is not now receiving? ________ ______

10. Does any member of your household receive or expect to

receive welfare assistance? ________ _____

11. Does any member of your household receive or expect to receive

Social Security benefits? ________ ______

12. Does any member of your household receive or expect to

receive income from pension or annuity? ________ ______

13. Does any member of your household receive regular cash

contributions from individuals not living in the unit or from

agencies? ________ ______

14. Does any member of your household receive income from assets,

including interest on checking or savings accounts, interest and

dividends from certificates or deposit, stocks or bonds, or income

from the rental of property? ________ ______

For each type of income that your household receives, give the source of income and the amount of income that can be expected from that source during the next 12 months.

FAMILY MEMBER# SOURCE OF INCOME TYPE OF INCOME ANNUAL INCOME

ASSET INFORMATION:

List all checking and savings accounts (including IRA’s, Keogh accounts, and Certificates of deposit) of all household members. (If not applicable write N/A)

FAMILY MEMBER BANK NAME ACCOUNT # TYPE OF ACCOUNT CURRENT BALANCE

List value of stocks, bonds, trusts, pension contributions, or other assets: (If not applicable write N/A)

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Do you own a home or other real estate? ________yes _______no.

Have you sold or given away any real property or other assets, e.g., cash certificates of deposit, etc., in the past two years? ________yes ________no.

If yes, what was the current market value of the assets? ________________________.

EXPENSES:

Do you pay childcare to enable you or another family member to look for work or go to school?

______yes _______no.

If yes, give name and address of child care provider, weekly cost and name of family member enable to work.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

ELDERLY/HANDICAP/DISABLED FAMILIES ONLY:

Do you have Medicare? _______yes ______no.

Do you have any kind of medical insurance? ______yes ______no.

Do you have any outstanding medical bills on which you are paying? ______yes ______no.

Do you expect to have any medical expenses during the next 12 months? ______yes ______no.

If yes, list amount of medical expenses.

____________________________________________________________________________________________________________________________________________________________

Do you pay for any auxiliary apparatus, e.g., adaptations to vans, interpreters, etc., or attendant care to enable someone to work? _______yes _______no.

If yes, please describe:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

APPLICANT CERTIFICATION:

I/We certify that if selected to move into this project, the unit I/We occupy will be my/our only residence. I/We understand that the above information is being collected to determine my/our eligibility for section 8 assistance. I/We authorize the Agent to verify all information provided on this application and to contact previous or current landlords or other sources for credit and verification information, which may be released to appropriate federal, state or local agencies. I/We certify that the statements made in this application are true and complete to best of my/our knowledge and belief. I/we understand the false statements or information are punishable under federal law and may result in my/our family being ineligible for housing assistance.

____________________________________ ______________________________

Signature of Head Date

____________________________________ ______________________________

Signature of Co-Head Date

COMMENTS/ADDITIONAL INFORMATION: