Application for Occupancy Step 1 of 9 11% A. General InformationApplicant Names Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe PhoneList all persons who will live in the apartment. List head of household first.NameRelationshipBirthdateSSNSex Is anyone in this household a full-time student?YesNoNames B. Reference InformationCurrent LandlordNameAddressTelephone Previous Landlord(s)NameAddressTelephone Non-related Personal ReferencesNameAddressTelephone Credit ReferencesNameAddressTelephone C. Household IncomeList all sources of income for all household membersNameSource of IncomeMonthly GrossWagesEmployer$ Social Security$ SSI Benefits$ Veterans Benefits$ Pension(s)Source of Pension(s)$ Unemployment Comp$ AFDC$ AlimonySource$ Child SupportSource$ Full Time Student IncomeSource$ (Only Full Time Students 18 & Over)Total Gross Monthly Income$ Total Gross Annual Income$ (Base on Monthly amount listed above and multiply x 12Do you anticipate any changes in this income in the next 12 months?YesNoIf Yes, explain D. AssetsChecking Account(s)#BankBalance $ Savings Account(s)#BankBalance $ Money Market Account(s)#BankBalance $ Trust Account(s)#BankBalance $ Certificates of Deposit#BankBalance $ IRA#CompanyBalance $ Savings Bonds#Cash Value Whole Life Insurance Policy#Cash Value Real PropertyDo you own any property?YesNoIf yesProperty TypeLocationCurrent Market ValueOutstanding Mortgage Balance Have you sold/disposed of any business, property or other assets in the last 2 yearsHave you sold/disposed of any business, property or other assets in the last 2 years?YesNoIf yesProperty TypeDate of Sale/DispositionMarket Value When Sold/Disposed ofAmount Sold/Disposed for Do you have any other assets not listed aboveDo you have any other assets not listed above (ie. recreational vehicle or mobile home; do not include personal property)?YesNoIf yes, please list E. Medical / Handicap Assistance ExpensesMedical ExpensesComplete this part ONLY if head of household or spouse is 62 or older, handicapped or disabled.Medicare PremiumsMonthly Amount $Medical Insurance CoverageMonthly Amount $Name of CompanyAddressAnticipated Medical Expenses NOT covered by Insurance NOR reimbursedMonthly Amount $Medical bills or outstanding costs on which you are making monthly paymentsMonthly Amount $Medical related travel costsMonthly Amount $Any other medical expensesTypeAmount List type and amountsHandicap Assistance ExpensesComplete this part ONLY for expenses to the extent needed to enable any family member to be employed.Specialized Medical Attendant CareName of Care GiverCost Auxiliary ApparatusTypeCost F. Child Care ExpensesComplete this part household minors under 13 ONLY.Children Cared forNameAge Agency Caring for ChildrenNameAddressTelephone Weekly cost of child care due to employment$Weekly cost of child care due to education$ G. Program InformationWhat size of unit are you requesting?1 Bedroom2 Bedroom3 BedroomDo you wish to claim a $400 deduction from your household income0 based on an "Elderly Household" status, where the tenant or co-tenant is 62 or older, handicapped or disabled?YesNoDo you wish to have priority for a handicapped accessible unit with special design features?YesNoDo you have a Letter of Priority by USDA-Rural Development due to displacement from another property?YesNoHave you ever been evicted from any type of housing?YesNoHave you ever been convicted of a felony?YesNoAre you currently a user of an illegal controlled substance?YesNoHave you ever been convicted of a drug violation?YesNo(use, attempted use, possession, manufacture, sale or distribution)Have you successfully completed a controlled substance abuse recovery program or presently enrolled in such a program?YesNoAre you now or will you become a part time or full time student prior to move-in?YesNoHow did you hear about this housing? I. CertificationI/We hereby certify that the unit applied for will be the household's permanent residence. I/We further certify that I/we do/will not maintain a separate subsidized rental unit in another location. I/We understand that I/we must pay a security deposit for this unit. I/We understand that my/our eligibility for housing will be based on USDA-Rural Development income limits and tenant selection criteria. I/We certify that all information in this Application is true to the best of my/our knowledge and understand that false statements or information are punishable by law and will lead to cancellation of this Application or termination of tenancy after occupancy.TenantDate Co-TenantDate J. AuthorizationI/We do hereby authorize NETA Property Management and its staff or authorized representative to contact any agencies, law enforcement offices, companies, groups or organizations to verify any information contained in this Application or to obtain and verify any additional information or materials which are deemed necessary to complete my/our Application for housing in programs administered by the United States Departments of Agriculture.TenantDate Co-TenantDate "In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer." Please provide the following information so that Greater Minnesota Property will be in compliance with Title VI of the Civil Rights Act of 1964. The following information is requested by the Federal Government in order to monitor compliance with the Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White Ethnicity Hispanic or Latino Not Hispanic or Latino Gender Male Female "Please be aware that under federal laws, persons with disabilities have the right to request reasonable accommodations to rules and modifications to apartments at no cost to themselves."