1. home and garden

DATE & TIME STAMP
Cook Inlet
a
Y. .I.OUSingAuthon
Promoting Independence Through Housing
RENTAL HOUSING APPLICATION
APPLICANT NAME:
DATE:
BDRM SIZE:
PROPERTY APPLIED FOR:
RENT AMOUNT:
Items needed for ALL applications (for all members of household 18 and over)
O Completed Rental Application
o Application includes Student Certification Form, Asset Questionnaire, Release of Authorization and
Tenant Responsibility Acknowledgement all of which needs to be completed by all household adults 18
and years of age and over.
o Information of application should include information for ALL household members. Including ALL
income sources, amounts received and asset accounts and current values.
• Income includes all gross income, monetary or not, the household currently receives AND
anticipates receiving from all sources for ALL household members. Sources include, but are
not limited to, full-time, part-time, and seasonal employment, Public Assistance, Social
Security, unemployment, pensions and retirements, child support and alimony, monetary gifts,
stipends, dividends. Self-employment will need additional information to determine income
received.
▪ Assets include, but are not limited to, checking and savings accounts, certificate of deposits,
cash on hand, safety deposit box, stocks, bonds, IRA accounts, 401K accounts, trust funds,
real estate and land contracts, lump sum receipts, capital investments, whole life insurance
policies (exclude term), retirement and pension funds, personal property held as an
investment.
El $20 Non-refundable Application Fee per adult (check or money order only). Fee is valid for 180 days.
El Copies of Government Issued photo ID and Proof of Enrollment Status if applicable (Tribal, Regional, Village)
El Verification of Social Security Number, date of birth, and birth certificate and/or guardianship papers (for all minor
children on application)
O Previous Year's Tax Return
O Most Recent Paystub for Employment
O Copy of Voucher for Rental Assistance (if applicable)
O Homeless Verification (if applicable)
O Landlord References and Contact Information for Current and Previous Landlords.(MUST be returned by landlord
via fax, email or mail).
STAFF
Seen By (Staff Member)
Date:
USE
Seen By (Staff Member)
Date:
ONLY
Seen By (Staff Member)
Date:
Previously Applied? Y or N
Application Fee Date:
Income Calculation
D Estimated Included
First Month's Rent and Security Deposit Due at Time of Move In
3510 Spenard Road, Suite 100+ Anchorage, AK 99503 • Tel 907-793-3000 • Fax 907 793-3073
Page 1 of 6 (Rev 02/2015)
ea
Coqk Inlet
RENTAL HOUSING APPLICATION
Promoting independence Through HausIng
Date & Time received:
Revd Method:
Revd By:
NO white-out can be used on this housing application. Applications with white-out will be considered
"Incomplete".
PHONE #
APPLICANT NAME
ZIP
MAILING ADDRESS
E-MAIL
IF APPLYING TO BE ADDED TO EXISTING LEASE, CURRENT RESIDENT NAME
I. HOUSEHOLD COMPOSITION — List all persons who will reside in the unit in the next twelve (12) months.
NAME
(Last, First, Middle Initial)
Marital
Status
Birth Date
Social Security
Number
Age
Student
Status
FT/ PT/
N/a
Race
(Optional)
Head of
Household
Co-head
3
4
5
6
7
8
II. INCOME — ALL amounts, monetary or not, that go to or are received on behalf of the family head, spouse or cohead (even if the family member is temporarily absent), or any other family member; and/or ALL amounts
anticipated to be received from a source outside the family during the 12-month period following admission or
annual recertification effective date. This includes, but is not limited to: Full and/or part-time employment, seasonal
employment, welfare assistance, social security, pensions, SSI, disability, military pay/benefits, unemployment,
child support, alimony, student grants/loans, self-employment, PFD, Native Dividends, income from the sale of
property, income from trusts and any other income received from people not residing with you.
Additional Sources
of Income
Must mark yes or
no on all sources
listed
Native Corp
Dividends
ATAP
Applicant Name:
Yes
No
Applicant Name:
Monthly Amount
Yes
No
Monthly Amount
APAJOAA
SSI/SSA
Veteran's Pension
Senior Assistance
Pensions/Retirement
Unemployment
Child Support
Alimony
Monetary Gifts *
Other:
Other:
*includes rent and utility payments paid on behalf of family, and other cash or noncash contributions provided on a regular basis
Yes LI No ID
Do all members in the household receive a PFD?
If no, please explain who doesn't and why:
Page 2 of 6
(Rev 02/2015)
_TCook Inlet
RENTAL HOUSING APPLICATION
Promoting Independence Through Housing
III. EMPLOYMENT INFORMATION- Please complete for all employed household members.
Applicant Name:
Applicant Name:
Applicant Name:
Employer Name
Mailing Address
Phone Number
Fax Number
Occupation
Supervisor's Name
Wage & # Hrs. Weekly
From/To
From/To
From/To
Dates of Employment
Does anyone in the household anticipate gaining part or full-time employment status within the next 12 months?
Yes LI No 0 If yes, please explain:
Does anyone in the household anticipate obtaining any other source of income, i.e., Social Security benefits, Public
Assistance, Unemployment Insurance, Child Support, etc. within the next 12 months?
Yes Lii No LI If yes, please explain:
Has anyone in the household applied to receive income such as; Social Security benefits, Public Assistance,
Unemployment Insurance, Child Support,etc.?
Yes LI No 0 If yes, please explain:
Yes 0 No 0
Is anyone in the household divorced within the past three (3) years?
If yes, please provide a copy of the divorce court documents, as well as child support orders in place for all minor
children.
Do you receive rental assistance? Yes LI No E Agency:
If yes, voucher subsidy level is LI Level 1
LI Level 2
0 Level 3 E Level 4
Have you, or any household member, ever been evicted from any housing?
If yes, explain when and why:
Yes LI No LI
Have you, or any household member, ever been convicted of a violent crime, i.e., assault?
If yes, explain when and why:
Yes LI No LI
Have you, or any household member, ever been convicted of a drug-related crime?
If yes, explain when and why:
Yes 0 No LI
Have you, or any household member, ever been convicted of a felony?
If yes, explain when and why:
Yes Lii No n
Have you given legal notice where you currently reside?
Yesn Non
What is the earliest date you can occupy a CIHA residence?
/
/
How did you hear about us?
Are you an employee or Board Commissioner of CIHA, or a family member or business partner of a CIHA
Yesn Non
employee or Board Commissioner?
If yes, name of employee/Commissioner:
Did anyone in the household serve in the active military and receive a DD-214 at discharge?
If yes, was the discharge other than "dishonorable?"
Page 3 of 6
(Rev 02/2015)
E
Yes LI No
Yes 0 No LI
Cook Inlet
ousing,„„
RENTAL HOUSING APPLICATION
IV. RESIDENTIAL HISTORY- Please list last five 5 ears of residential history.
CURRENT RESIDENCE
Current Landlord Name:
Current Landlord Phone Number:
Dates of Residency:
Current Monthly Rental Amount:
Reason for Moving:
0 Other
o Own
o Rent
o In current Lease Agreement
O
Month to Month
If at current residence for less than 5 years 60 months lease complete the below section
Applicant Name
Previous Residence Address
Previous Landlord Name
Previous Landlord Number
Dates of Residency
Monthly Rental Amount
Reason for Moving
El Other
0 Own
El Rent
0
In current Lease Agreement
0
Month to Month
0
In current Lease Agreement
0
Month to Month
Applicant Name
Previous Residence Address
Previous Landlord Name
Previous Landlord Number
Dates of Residency
Monthly Rental Amount
Reason for Moving
D Own
o Other
DI Rent
Applicant Name
Previous Residence Address
Previous Landlord Name
Previous Landlord Number
Dates of Residency
Monthly Rental Amount
Reason for Moving
0 Other
0 Own
o Rent
o In current Lease Agreement
o Month to Month
Are you currently homeless? (Please see the attached "homeless" definition.)
If yes, please attach necessary documentation.
Yes El No n
Are you currently residing in a home that is leased or owned by family and/or friends?
If yes, how many total persons are residing in the household?
Yes D No 0
If you are residing with family and/or friends, how many sleeping areas, including all bedrooms and living/family
rooms, are in the home?
Please note that if you responded affirmatively above, you will be requested to provide documentation from the
homeowner/lease holder verifying this information.
Page 4 of 6
(Rev 02/2015)
Cook Inlet
°using.,
Promoting Independence Through Hawing
RENTAL HOUSING APPLICATION
V. VOLUNTARY SELF-IDENTIFICATION
The questions in this section are voluntary.
Please check below the following that apply to you or any member of the household:
Does anyone in the household meet the definition of disabled? (Please see the attached "Person with Disabilities"
definition.)
Yes 0 No El
Yes El No El
Does anyone in the household require the features of an accessible unit?
If Yes please list:
Does anyone in the household request any reasonable accommodations/modifications?
Yes 0 No El
If Yes please list:
Please select one
o Hispanic or Latino
o Non-Hispanic or Latino
Please select one
o Asian
o Black or African American
o Native Hawaiian or Other Pacific Islander
o White
o Other
Please select all that apply
o Alaskan Native / American Indian
Regional Corporation:
Shareholder 0 Descendent 0
Village Corporation:
Shareholder 0 Descendent 0
Tribal Affiliation:
Shareholder
El Descendent 0
VI. STATEMENT OF TRUTH
I understand that all the information given on this form is subject to verification. Any information determined to be
false or untrue will result in permanent cancellation of the application. I authorize release of information regarding
my credit, references (personal/landlord, etc.), criminal history, and financial information to a representative of CIHA
for a period of one (1) year and one (1) month from the date signed.
Applicant's Signature
Date
Other Signature
Date
Co-Applicant's Signature
Date
Other Signature
Date
Page 5 of 6
(Rev 02/2015)
Cook Inlet
ousIngm.,
PrarnOtIngIndepxndenre Through Housing
RENTAL HOUSING APPLICATION
FOR THE PURPOSE OF THIS APPLICATION, PLEASE NOTE THE FOLLOWING DEFINITIONS:
PERSON WITH DISABILITIES:
A person with a disability is any person who:
1.Has a physical or mental impairment that substantially limits one
or more major life activities;
2. Has a record of such an impairment; or
3. Is regarded as having such an impairment.
HOMELESSNESS:
"Homelessness" includes a family residing in one of the following places and does not include any individual
imprisoned or otherwise detained pursuant to an Act of the Congress or State law:
(1) A place not meant for human habitation, i.e., car, park/camp, sidewalk, or abandoned building.
(2) An emergency shelter, which might include a church.
(3) Transitional or supportive housing for persons who qualify because of homelessness.
(4) In any of the above places, but is being treated in a hospital or other medical facility for 30 days or less.
(5) A family with children that is doubled-up with family or friends AND who receives services from an Alaska
School District under the McKinney-Vento Homeless Assistance Act.
Documentation Required:
1. A letter from the shelter, transitional, or supportive housing agency on letterhead stating the
applicant's current residency in their shelter, or;
2. A letter from a social worker, social service agency, health care official, family intervention
advocate, or school official on letterhead having firsthand knowledge that the family resides in one
of the places listed above, or;
3. A letter from an Alaska School District staff Homeless liaison, or designee, verifying services via
the McKinney-Vento Homeless Assistance Act on letterhead.
Page 6 of 6
(Rev 02/2015)
Cook Inlet
AUTHORIZATION FOR RELEASE OF INFORMATION
Promoting Independence Through Housing
Your signature on this form authorizes Cook Inlet Housing Authority (CIHA) to obtain information on your
income, financial position and personal history to determine your eligibility for CIHA rental housing. This
authorization and the information obtained may be given to any Federal, State, or local program that is
enforcing applicable housing rules and regulations.
Persons and/or organizations that may be contacted include, but are not limited to: employers, financial
institutions, landlords, local governments, Native corporations, the State of Alaska's Permanent Fund Dividend
(PFD) Division, child support enforcement agencies, private individuals, public assistance agencies, school
authorities, the Social Security Administration, law enforcement agencies, and unearned income sources.
Therefore, this consent form authorizes the release of income, financial, and personal information from all of
the persons and organizations described above, including directly from financial institutions, regarding any
period(s) within the last 5 years.
I understand that this authorization cannot be used to obtain any information about me that is not pertinent to
my eligibility for CIHA rental housing.
COMPUTER MATCHING NOTICE AND CONSENT
I understand and agree that CIHA may conduct computer matching programs to verify the information supplied
for my application. If a computer match is done, I understand that I have a right to disprove any information
that may be incorrect.
CONDITIONS
I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this
authorization is on file with CIHA and will stay in effect for one (1) year and one (1) month from the date
signed. I understand that I have a right to review my file and correct any information that may be incorrect.
Applicant/Resident Name (Please print)
Date
Applicant/Resident Signature
Date
STATEMENT OF TRUTH:
I understand that all the information given on this form is subject to verification. Any information determined to
be false or untrue will result in permanent cancellation of the application. I authorize release of information
regarding my credit, references (personal/landlord, etc.), criminal history, and financial information to a
representative of CIHA for a period of one (1) year and one (1) month from the date signed.
(Rev 04/2013)
--TCoqk Inlet
iousing,„,
AUTHORIZATION FOR RELEASE OF INFORMATION
Promoting Independence Through Housing
Your signature on this form authorizes Cook Inlet Housing Authority (CIHA) to obtain information on your
income, financial position and personal history to determine your eligibility for CIHA rental housing. This
authorization and the information obtained may be given to any Federal, State, or local program that is
enforcing applicable housing rules and regulations.
Persons and/or organizations that may be contacted include, but are not limited to: employers, financial
institutions, landlords, local governments, Native corporations, the State of Alaska's Permanent Fund Dividend
(PFD) Division, child support enforcement agencies, private individuals, public assistance agencies, school
authorities, the Social Security Administration, law enforcement agencies, and unearned income sources.
Therefore, this consent form authorizes the release of income, financial, and personal information from all of
the persons and organizations described above, including directly from financial institutions, regarding any
period(s) within the last 5 years.
I understand that this authorization cannot be used to obtain any information about me that is not pertinent to
my eligibility for CIHA rental housing.
COMPUTER MATCHING NOTICE AND CONSENT
I understand and agree that CIHA may conduct computer matching programs to verify the information supplied
for my application. If a computer match is done, I understand that I have a right to disprove any information
that may be incorrect.
CONDITIONS
I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this
authorization is on file with CIHA and will stay in effect for one (1) year and one (1) month from the date
signed. I understand that I have a right to review my file and correct any information that may be incorrect.
Applicant/Resident Name (Please print)
Date
Applicant/Resident Signature
Date
STATEMENT OF TRUTH:
I understand that all the information given on this form is subject to verification. AnyInformation determined to
be false or untrue will result in permanent cancellation of the application. I authorize release of information
regarding my credit, references (personal/landlord, etc.), criminal history, and financial information to a
representative of CIHA for a period of one (1) year and one (1) month from the date signed.
YAI
(Rev 04/2013)
Coo* Inlet
ousing
CIHA Tenant Responsibility Acknowledgement
Cook Inlet Housing Authority (CIHA) provides high quality, affordable homes to its resident
households. In doing so, we entrust our residents with the responsibility to appropriately
treat and care for the home, and to make timely monthly rental payments to CIHA. These
expectations are outlined in the CIHA Lease Agreement, which defines the responsibilities
of each tenant.
It is our desire to support housing success amongst our tenant body. As such, CIHA will
proactively address issues of non-compliance with tenant responsibilities stated in the Lease
Agreement, including, but not limited to:
• Late or Non-Payment of Rent & Tenant Charges
• Unit Damage
• Non-Approved Unit Alterations (Including Paint & Lock Changes)
• Non-Approved Animals/Pets
• Inappropriate and/or Abusive Treatment of Staff
• Unapproved occupants not on Lease Agreement
In all such cases, CIHA will take corrective actions to address these issues in accordance
with the State of Alaska Landlord Tenant Law, including actively pursuing tenant eviction if
applicable. Should a household vacate a unit and leave CIHA with an outstanding financial
balance due, CIHA will vigorously pursue collection of these debt amounts through all
available means, including third party collection methods, notice to credit bureau agencies
and notification to the Tenant Watch® screening system.
In addition, in the event a rental unit is intentionally and maliciously damaged by a tenant,
CIHA will actively pursue criminal prosecution and financial restitution through the Alaska
Court System.
In summary, CIHA takes its responsibility to provide a quality, affordable home to our clients
seriously, and to act in all legal means necessary to ensure the continued affordability of our
homes to future clients. In return, we ask, and entrust our residents to be responsible and
respecfful by paying the required rent charge on a timely basis and to keep their new homes
safe, clean and in good physical condition, which includes the timely report of all
maintenance concerns to property management staff so that these issues can be addressed
before resultant damage can occur.
CIHA Tenant Responsibility Acknowledgement
Page 2
Acknowledgement Statement
By signing below, I acknowledge both receipt and understanding of the information stated
within this document, including the various means with which CIHA will address noncompliance with the Lease Agreement. I understand that should I be determined eligible
and approved for a CIHA unit and choose to sign a CIHA lease, this acknowledgement
form will become a part of my permanent resident file.
Applicant Signature
Date
Applicant Signature
Date
Applicant Signature
Date
Applicant Signature
Date
Cook Inlet
ousingA...„
COOK INLET HOUSING AUTHORITY
Landlord Reference Checklist
l
Promoting Independence Through Housing
Please release the following information to COOK INLET HOUSING AUTHORITY, where I have
applied for an apartment.
Applicant:
Print Name
Signature:
Date:
Property Applying for:
Current Residence:
El Apartment
El Mgmt Co. El R. Estate Co. El Private Owner
Landlords Name:
Phone#:(
)
Date of Residency:
Home El Other
Fax#:(
)
From:
To:
Amount of Monthly Rent:
# of Occupants:
# of Late Payments:
# of Returned Checks:
Is this a LIHTC project? LI yes El no If yes, what is last annual tenant income calculation? $
Were there any disturbances(s)/ Complaints? If yes, please explain:
Yes
No
1.
Did the resident or his family/guests damage the apartment or the property?
0
0
2.
Did the resident pay for the damages?
0
0
3.
Did the resident violate the lease agreement in any way?
0
0
4.
Did the resident violate any of your house rules in anyway?
0
0
5.
Did the resident give the proper notice for vacating the unit?
0
0
6.
Did the resident receive their deposit back?
0
0
7.
Did the resident have any pets?
0
0
8.
Would you rent to this individual again?
0
0
Additional Comments:
Name and title of person providing reference:
Reference Signature:
Date:
*CIHA requests that whenever possible references are returned via fax or email to:
[email protected] or 907-793-3073
Reference Obtained via:
El Telephone
CIHA Employee Obtaining Reference:
LI Person-to-Person 111 In writing/email
Date:
El fax
3510 Spenard Road, Suite 100 • Anchorage, AK 99503 • Tel 907-793-3000 • Fax 907-793-3073
gia
I I
Cook Inlet
ousing
COOK INLET HOUSING AUTHORITY
Landlord Reference Checklist
Authority
Promoting Independence Through Housing
Please release the following information to COOK INLET HOUSING AUTHORITY, where I have
applied for an apartment.
Applicant:
Print Name
Date:
Signature:
Property Applying for:
0 Apartment 111 Home 0 Other
Current Residence:
111 Mgmt Co. ID R. Estate Co. LIII Private Owner
Landlords Name:
Fax#:(
Phone#:(
Date of Residency:
)
To:
From:
# of Occupants:
Amount of Monthly Rent:
# of Late Payments:
# of Returned Checks:
Is this a LIHTC project? Li yes Cl no If yes, what is last annual tenant income calculation? $
Were there any disturbances(s)/ Complaints? If yes, please explain:
Yes
No
1.
Did the resident or his family/guests damage the apartment or the property?
0
0
2.
Did the resident pay for the damages?
0
0
3.
Did the resident violate the lease agreement in any way?
0
0
4.
Did the resident violate any of your house rules in anyway?
0
0
5.
Did the resident give the proper notice for vacating the unit?
0
0
6.
Did the resident receive their deposit back?
0
0
7.
Did the resident have any pets?
0
0
8.
Would you rent to this individual again?
0
0
Additional Comments:
Name and title of person providing reference:
Date:
Reference Signature:
*CIHA requests that whenever possible references are returned via fax or email to:
complianceaccesscookinlethousing.orq or 907-793-3073
Li Telephone ID Person-to-Person El In writing/email
Reference Obtained via:
Date:
CIHA Employee Obtaining Reference:
Li fax
3510 Spenard Road, Suite 100 • Anchorage, AK 99503 • Tel 907-793-3000 • Fax 907-793-3073
Ea
Cook Inlet
ASSET QUESTIONNAIRE
One form per adult, include assets of minor children
Promoting independence Through Housing
NAME:
Section #1
My assets include (answer yes or no to all questions): PLEASE NOTE: Certain funds (e.g., Retirement, Pension, Trust) may or may not
be (fully) accessible to you. Include only those amounts which are.
Yes No
El Checking
Accounts
Acct #
Financial Institution
Current Balance/
Value
Is this asset held jointly?
YES or NO! Name?
Yes No
Acct #
Financial Institution
Current Balance/
Value
Is this asset held jointly?
YES or NO / Name?
o
Savings
Accounts
Financial Institution & Account Number
Yes
0
0
0
0
0
0
0
El
0
0
0
0
0
0
0
0
No
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Certificates of Deposit
Cash on Hand
Safety Deposit Box
Stocks
Bonds
IRA Accounts
401K Accounts
Keogh Accounts
Trust Funds
Equity in real estate
Land Contracts
Lump Sum Receipts
Capital investments
Life Insurance Policies (Excluding Term)
Other Retirement/Pension Funds
Personal Property held as investment*
Type:
Amount $
Contents:
* Personal property held as an investment may include, but Is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary
personal property such as, but not necessarily limited to, household furniture, daily-use autos, clothing, assets of an active business, or special
equipment for use by the disabled.
If you answered NO to all of the above items including bank accounts please check below
0
I/we do not have any assets at this time
Section #2
Within the past two (2) years, I/we have sold or given away assets (including cash, real-estate, etc.) for more than
$1000.00 below their fair market value (FMV).
El Yes El No
(*the difference between FMV
If yes, those amounts* are included above and are equal to a total of: $
and the amount received, for each asset on which this occurred).
Under penalty of perjury, I certify that the information presented in this Certification is true and accurate to the best of my knowledge. The undersigned
further understand(s) that providing false representation herein constitutes an act of fraud and may lead to criminalpenalties. False, misleading, or
Incomplete information may result in the termination of the lease agreement.
Date
— Applicant/Tenant
(Rev 04/2013)
ASSET QUESTIONNAIRE
Cook. Inlet
ousingmhomy
One form per adult, include assets of minor children
PiQtrjaing IfideP&I.donce Thrugli h'ousing
NAME:
Section #1
My assets include (answer yes or no to all questions): PLEASE NOTE: Certain funds (e.g., Retirement, Pension, Trust) may or may not
be (fully) accessible to you. Include only those amounts which are.
Yes No
0 0 Checking
Accounts
Acct #
Financial Institution
Current Balance/
Value
Is this asset held jointly?
YES or NO! Name?
Yes No
O El Savings
Acct #
Financial Institution
Current Balance/
Value
Is this asset held jointly?
YES or NO! Name?
Accounts
Financial Institution & Account Number
Yes
O
O
0
O
El
O
O
O
O
0
El
O
O
O
O
O
LI
LI
LI
LI
o
LI
LI
0
LI
0
LI
LI
LI
LI
LI
LI
Certificates of Deposit
Cash on Hand
Safety Deposit Box
Stocks
.
Bonds
IRA Accounts
401K Accounts
Keogh Accounts
Trust Funds
Equity in real estate
Land Contracts
Lump Sum Receipts
Capital investments
Life Insurance Policies (Excluding Term)
Other Retirement/Pension Funds
Personal Property held as investment *
Type:
Amount $
Contents:
* Personal property held as an investment may include, but is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary
personal property such as, but not necessarily limited to, household furniture, daily-use autos, clothing, assets of an active business, or special
equipment for use by the disabled.
If you answered NO to all of the above items including bank accounts please check below
LI
I/we do not have any assets at this time
Section #2
Within the past two (2) years, I/we have sold or given away assets (including cash, real-estate, etc.) for more than
$1000.00 below their fair market value (FMV).
El Yes El No
If yes, those amounts* are included above and are equal to a total of: $
and the amount received, for each asset on which this occurred).
(*the difference between FMV
Under penalty of perjury, I certify that the information presented in this Certification is true and accurate to the best of my knowledge. The undersigned
further understand(s) that providing false representation herein constitutes an act of fraud and may lead to criminal penalties. False, misleading, or
incomplete information may result in the termination of the lease agreement.
Applicant/Tenant
Date
(Rev 04/2013)
-
Effective Date:
aOr
Cook Inlet
ANNUAL STUDENT CERTIFICATION
ouSina,
umon•
q
Move-in Date:
mm/dd/yyyy
Promming twinprneletio Womb Musky;
This property is governed by rules and regulations of the Low Income Housing Tax Credit (LIHTC) program.
These rules and regulations include specific restrictions on full-time student status of all household members.
The household may NOT be comprised, at initial occupancy or any future date during tenancy, entirely of fulltime students.
This Annual Student Certification is being delivered in connection with the undersigned's application/occupancy in the
following unit:
Unit/Property:
Head of Household Name:
Check A, B or C as applicable (NOTE that students include those attending public or private elementary schools,
middle or junior high schools, high schools, colleges/universities, technical, trade or mechanical schools, however, does .
NOT include those attending on-the-job training courses):
A.
At least one occupant in the household is not a student and has not been or will not be a student for
five (5) months or more out of the current and/or upcoming calendar year (months do not have to be
consecutive). If this item is checked, no further information is needed. Sign and date below.
B,
Household contains all students, but is qualified because the following occupant(s)
is/are PART TIME student(s), Verification of part student status is required for a least one occupant.
C.
Household contains all FULL TIME students for five (5) months or more out of the current and/or
upcoming calendar year (months do not have to be consecutive). If 'C' is checked, questions 1 — 5
below must be completed:
1. Are the students married and entitled to file a joint tax return? (marriage certificate or
tax return must be attached)
Yes 0 No
2. Is at least on student a single-parent with child(ren) and this parent is not a dependent
of someone else, and the child(ren) is/are not dependent(s) of someone other than a
parent? (attach student's and if applicable, divorce/custody decree or other parent's most
recent tax return).
D
3. Is at least one student receiving Temporary Assistance to Needy Families (TANF)
0 Yes 0 No
4. Does at least one student participate in a program receiving assistance under the Job
Training Partnership Act, Workforce Investment Act, or under other similar, federal,
state or local laws? (attach verification of participation)
MI Yes M No
5. Does the household consist of at least one student who was in foster care?
0 Yes 0 No
Yes
0
No
Full-time student households that are income eligible and satisfy one or more of the above conditions are
considered eligible. If questions 1-5 are marked NO, or if verification does not support the exception indicated,
the household is considered an ineligible student household. Under penalties of perjury, I/we certify that the
information presented in this Annual Student Certification is true and accurate to the best of my/our knowledge
and belief. Uwe agree to notify management IMMEDIATELY of any changes in this household's student status.
The undersigned further understands that providing false representation herein constitutes an act of fraud.
False, misleading or incomplete information may result in termination of the lease agreement.
All household members age 18 or older must sign and date.
Head of Household Signature
Date
Signature
Date
Signature
Date
Signature
Date
(Rev 04/2013)