HUD Affordable Pre-Application -Lexington Park

Pre-Application
VHDA Financed Property

INSTRUCTIONS TO APPLICANT…PLEASE READ CAREFULLY!

Each household member 18 and older must complete and sign the application.
All lines must be filled in! You may write “NONE” or “NO” in a line, but do not leave a line blank.
All information should be complete and correct. False, incomplete or misleading information will cause your application to be declined.
If you need to make a correction, insert a line through the incorrect information, write the correct information above, and initial the change.
As long as your application is on file with us, it is your responsibility to contact us whenever your address, telephone number or income situation changes, or whenever you need to add or remove a household member from your application.
After we receive your complete application, we will make a preliminary determination of eligibility. If your household appears to be eligible for housing, your application will be placed on a waiting list if there is one. This does not mean that your household will be offered an apartment. If later processing establishes that your household is not actually eligible, or does not meet our Resident Selection Criteria, your application will be denied.
We will process your application according to our procedures which are summarized in the Resident Selection Criteria, posted in the Rental Office.
An office representative will review your application with you upon completion.

Government Program Selection

Today's Date*

I am applying for ( Select all that apply ):

Number of Bedrooms

3 4

Floor

Upstairs Downstairs

OCCUPANT INFORMATION

List all occupants of the unit, their relationship to each other, ages, whether they are students (for this purpose a student is anyone who has been or will be a full-time student at an educational institution with regular facilities and students during 5 months of the year this Application is submitted, other than correspondence school).

Please Note: If an occupant does not have a middle name, please enter "None".

How many occupants will be in the unit?*

Occupant 1

Occupant Name 1*

First Name

Middle Name

Last Name

Relationship (Occupant 1)*

Social Security Number (Occupant 1)*

Sex (Occupant 1)*

Male Female I choose not to respond

Birth Date (Occupant 1)*

Place of Birth (Occupant 1)*

Race (Occupant 1)*

Student (Occupant 1)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 2

Occupant Name 2*

First Name

Middle Name

Last Name

Relationship (Occupant 2)*

Social Security Number (Occupant 2)*

Sex (Occupant 2)*

Male Female I choose not to respond

Birth Date (Occupant 2)*

Place of Birth (Occupant 2)*

Race (Occupant 2)*

Student (Occupant 2)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 3

Occupant Name 3*

First Name

Middle Name

Last Name

Relationship (Occupant 3)*

Social Security Number (Occupant 3)*

Sex (Occupant 3)*

Male Female I choose not to respond

Birth Date (Occupant 3)*

Place of Birth (Occupant 3)*

Race (Occupant 3)*

Student (Occupant 3)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 4

Occupant Name 4*

First Name

Middle Name

Last Name

Relationship (Occupant 4)*

Social Security Number (Occupant 4)*

Sex (Occupant 4)*

Male Female I choose not to respond

Birth Date (Occupant 4)*

Place of Birth (Occupant 4)*

Race (Occupant 4)*

Student (Occupant 4)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 5

Occupant Name 5*

First Name

Middle Name

Last Name

Relationship (Occupant 5)*

Social Security Number (Occupant 5)*

Sex (Occupant 5)*

Male Female I choose not to respond

Birth Date (Occupant 5)*

Place of Birth (Occupant 5)*

Race (Occupant 5)*

Student (Occupant 5)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 6

Occupant Name 6*

First Name

Middle Name

Last Name

Relationship (Occupant 6)*

Social Security Number (Occupant 6)*

Sex (Occupant 6 (Optional))*

Male Female I choose not to respond

Birth Date (Occupant 6)*

Place of Birth (Occupant 6)*

Race (Occupant 6)*

Student (Occupant 6)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 7

Occupant Name 7*

First Name

Middle Name

Last Name

Relationship (Occupant 7)*

Social Security Number (Occupant 7)*

Sex (Occupant 7)*

Male Female I choose not to respond

Birth Date (Occupant 7)*

Place of Birth (Occupant 7)*

Race (Occupant 7)*

Student (Occupant 7)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Occupant 8

Occupant Name 8*

First Name

Middle Name

Last Name

Relationship (Occupant 8)*

Social Security Number (Occupant 8)*

Sex (Occupant 8)*

Male Female I choose not to respond

Birth Date (Occupant 8)*

Place of Birth (Occupant 8)*

Race (Occupant 8)*

Student (Occupant 8)*

Yes No

Current Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Are ALL household members listed above full-time students?*

Yes No

Do you expect any change in the above-listed household composition in the next 12 months?*

Yes No

Describe the change:

LIST ALL INCOMES THAT YOU RECEIVE IN THE APPROPRIATE AREA BELOW!

Do you have more than one job/employer? If yes, please list all below.*

Yes No

How many total employers do you have?*

Present Employer 1

Name of Employee*

First Name

Last Name

Company Name*

Annual Income*

Present Employer 2

Name of Employee*

First Name

Last Name

Company Name*

Annual Income*

Present Employer 3

Name of Employee*

First Name

Last Name

Company Name*

Annual Income*

Present Employer 4

Name of Employee*

First Name

Last Name

Company Name*

Annual Income*

Present Employer 5

Name of Employee*

First Name

Last Name

Company Name*

Annual Income*

Present Employer 6

Name of Employee*

First Name

Last Name

Company Name*

Annual Income*

Any Additional Income (This includes but is not limited to child support, alimony, social service aid, cash contributions from anyone outside your household who gives you money or pays your bills, social security, SSI disability, unemployment compensation, workers compensation, retirement benefits, veterans benefits, or any “other” income (other than employment) for any member of the family and the source):

Does Family Member 1 have any additional income sources?*

Yes No

Does Family Member 2 have any additional income sources?*

Yes No

Does Family Member 3 have any additional income sources?*

Yes No

Does Family Member 4 have any additional income sources?*

Yes No

Family Member 1*

First Name

Last Name

Source/Type of Income*

Annual Amount* $

Family Member 2*

First Name

Last Name

Source/Type of Income*

Annual Amount* $

Family Member 3*

First Name

Last Name

Source/Type of Income*

Annual Amount* $

Family Member 4*

First Name

Last Name

Source/Type of Income*

Annual Amount* $

Do you expect any changes to the above-listed income In the next 12 months?*

Yes No

Describe the change.

Emergency Contact 1

Emergency Contact 1 (Name)*

First Name

Last Name

Emergency Contact 1 (Relationship)*

Emergency Contact 1 (Phone)*

Emergency Contact 2

Emergency Contact 2 (Name)

First Name

Last Name

Emergency Contact 2 (Relationship)

Emergency Contact 2 (Phone)

Emergency Contact 3

Emergency Contact 3 (Name)

First Name

Last Name

Emergency Contact 3 (Relationship)

Emergency Contact 3 (Phone)

Emergency Contact 4

Emergency Contact 4 (Name)

First Name

Last Name

Emergency Contact 4 (Relationship)

Emergency Contact 4 (Phone)

Owner/agent 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.

Do you have an animal(s)?*

Yes No

If yes, is this an assistance animal?

Yes No

If yes, you will need to complete a Request for a Reasonable Accommodation.

How many animals?

Description of Animal 1

Breed 1*

Height 1*

Weight (At Full Growth) 1*

Description of Animal 2

Breed 2*

Height 2*

Weight (At Full Growth) 2*

Description of Animal 3

Breed 3*

Height 3*

Weight (At Full Growth) 3*

Description of Animal 4

Breed 4*

Height 4*

Weight (At Full Growth) 4*

If you or any members of your household are hearing impaired, do you require a visual detector?*

Yes No

Do you or any member of your household have a condition that requires special features in your housing unit?*

Yes No

The unit applied for will be my/our household’s permanent residence and I/we will not maintain a separate subsidized rental unit in a different location.*

Yes No

Owners of section 221(d)(4), 221(d)(3), 221(d)(3) BMIR and Section 236 properties must give preference to applicants who have been displaced by government action or a presidentially declared disaster. If this property is identified as a Section 236 property at the top of page 1 of the application please indicate if you have been displaced by government action or a presidentially declared disaster.*

Yes No Not Applicable

Criminal Activity

This property’s eligibility requirements exclude housing to individuals and households with specific types of criminal activity in their history. Please see the Resident Selection Plan Addendum for specific categories of criminal activity for which your application could be rejected. Please answer the following questions. If any of the answers are false, misleading or incomplete your application may be rejected or, if move in has occurred, you may be evicted.

Have you or any members of your household ever been evicted from federally assisted housing for drug-related criminal activity?*

Yes No

Please explain the circumstances.

Are you or any members of your household currently abusing alcohol?*

Yes No

Please explain the circumstances.*

Are you or any members of your household ever been convicted of violent criminal activity?*

Yes No

Please explain the circumstances.*

Are you or any members of your household subject to a lifetime registration requirement under a Sex Offender registration program?*

Yes No

Please explain the circumstances.*

Have you or any members of your household ever committed fraud in a federally assisted housing program or been requested to repay money for knowingly misrepresenting information for such housing programs?*

Yes No

Please explain the circumstances.*

Have you or any members of your household ever used any names or social security numbers other than the one you are currently using?*

Yes No

Please explain the circumstances.*

Do you or any members of your household have a felony conviction?*

Yes No

Please explain the circumstances.*

Are you or any members of your household currently illegal users of controlled drugs/substances?*

Yes No

Please explain the circumstances.*

Have you or any members of your household currently or in the past used illegal drugs?*

Yes No

Please explain the circumstances.*

SIGNAGE INFORMATION

It is the policy of Lawson Realty Corporation to provide housing on an Equal Opportunity basis in accordance with all Federal and State Fair Housing laws. We do not discriminate on the basis of race, color, religion, national origin, sex or gender, elderliness, familial status, disability, source of income, Veteran status, sexual orientation, gender identity or any other protected status. We are committed to compliance with all laws governing access by persons with disabilities and wish to make our facilities and services as accessible and usable as possible, including appropriate and reasonable accommodations and modifications. If, because of a disability, you require such a modification or accommodation, please request a copy of our policy.

RESIDENTS STATEMENT: I understand that the above information is being collected to determine my eligibility for residency. I authorize the owner/manager to verify all information provided on this Application/Certification and my signature is consent to obtain such verification. I further certify that I have revealed all income received and all assets currently held or previously disposed of and that I have no other assets than those listed on this form (other than personal property). I further certify that the statements made on this Application/Certification are true and complete to the best of my knowledge and belief and are aware that false statements may cause termination of my lease and may be punishable under Federal law. In addition, I understand that all information provided on this form will be checked with the credit bureau, police records, former landlords and individual creditors, as necessary. By signing this application, you are giving us permission to obtain this information in order to entice this project to enter into a rental agreement with you. Should your application be disapproved, you will be provided the reason for such disapproval and if it should be based on information from another source, you will be referred to that source. This information is supplied in conformance with the “Fair Reporting Practices Act” and “Freedom of Information and Privacy Act”.

OWNERS STATEMENT: Based on the representations herein and upon the proof and documentation obtained, the household named on this application/Certification is eligible under provisions of Section 42 of the Internal Revenue Code to live in a unit in the community. Based on the representation herein and upon the proofs and documentation obtained, the household constitutes a low-income resident whose anticipated annual income for the next twelve months does not exceed the Tax Credit Low Income Limits, which are posted.

PRIVACY ACT NOTICE: (For properties with HUD Section 236 and/or Section 8) The information requested under authority of Title 12, United States Code, Section 1701 et seq. (Sec 101 & 236, National Housing Act) will be used to determine eligibility based on family income and composition for reduced monthly rentals under Section 236 and rent supplement programs. The information may not be disclosed outside of HUD except as required or permitted by law. It is voluntary on your part to supply the requested information; however, failure to provide this information could result in a delay or rejection of your application for assistance.

GOVERNMENT DATA COLLECTION AND DISSEMINATION PRACTICES ACT LETTER (Market Rate): As provided by the Government Data Collection and Dissemination Practices Act, anyone who is requested to provide personal information about himself must be informed whether he is legally required to provide such information, or whether he may refuse to supply the information requested. As an applicant for housing financed by the Virginia Housing Development Authority, you are requested to provide certain information that will enable Forest Cove to complete a “Tenant Income Certification”.

The information requested will be used to determine an adjusted annual income which you and your family receive from all income sources. This is necessary because the Rules and Regulations adopted pursuant to the Authority conferred on the Virginia Housing Development Authority limit eligibility for initial occupancy to families whose adjusted income does not exceed certain established limits. In addition, it is necessary to know the composition of your family (number of dependents) so that the proper size of dwelling unit may be authorized for you and your family.

Although you are not legally required to provide the information requested, your failure to do so will result in our inability to determine your eligibility for housing in this development.

The completed “Tenant Income Certification” is electronically transmitted by this management agent/owner to the Virginia Housing Development Authority, 601 South Belvidere Street, Richmond, VA 23220. It is possible that information provided by you will be revealed to others for the purpose of confirmation or for other purposes in accordance with the Virginia Freedom of Information Act, but any information so supplied is subject to the safeguards of the Government Data Collection and Dissemination Practices Act.

I consent to the terms above

DISCLOSURE OF BROKERAGE RELATIONSHIP

THE UNDERSIGNED DO HEREBY ACKNOWLEDGE DISCLOSURE THAT: THE LICENSEE LAWSON REALTY CORPORATION REPRESENTS THE LANDLORD IN A REAL ESTATE TRANSACTION.

Signature*

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Date/Time

Co Head Signature*

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Date/Time

SIGNATURES

Head of House Signature*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Phone*

Email Address*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Co-Head*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Occupant 3*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Occupant 4*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Occupant 5*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Occupant 6*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Occupant 7*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Occupant 8*

[clear]

Use your mouse or finger to draw your signature above

Print Name*

First Name

Last Name

Email Address*

Phone*

ID Type*

Govt-Issued ID Drivers License Number/ State ID

State where ID was issued*

ID Number*

Date

Signature of Leasing Consultant/Manager

State where ID was issued*

ID Number*

Date

Income Limits

Occupants	Income
1	$23,100 - $34,680
2	$26,400 - $39,600
3	$29,700 - $44,580
4	$33,000 - $49,500
5	$35,650 - $53,460
6	$38,300 - $57,420

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 42 U.S.C. 208 (f)(g) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 f, g and h.