HARTINGTON, NE

SUBSIDIZED HOUSING: PORTE VILLA APARTMENTS

PLEASE READ BEFORE YOU FILL OUT THE APPLICATION

Filling out the application:

Please complete the attached application VERY thoroughly. All incomplete applications will be returned back to you to be completed.
List places where you have lived in the rental history section (use complete addresses and names). This could be a landlord, family or friends.
Provide complete names, address, and phone numbers for all employers, banks, child care providers, schools/colleges, etc.
If you have children, you must provide us with child support information if applicable.
All questions and lines must be completed. (Example: employer name – not employed at this time.) If the question does not apply write none or NA.
Signatures are required for all applicants 18 and over. Electronic signatures appearing on this application are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

To apply, we need the following:

The completed application. Every person 18 years of age or over must provide income information and sign where signature is required.
A copy of each household member’s social security card and birth certificate.
A copy of each non-US Citizen’s INS document(s).

If you have any questions about the information requested, feel free to call the Skogen Company office. We do maintain an active waiting list. The average time needed to process your application is 10 to 14 business days.

Thank you!

Skogen Company

P.O. Box 216

112 W Main

Irene, SD 57037

(605) 263-3941

www.skogencompany.com

BERESFORD, SD

SUBSIDIZED HOUSING: EVERGREEN SQUARE

RENT BASED ON INCOME

SMOKE FREE COMPLEX

NO PETS

Application Date: * +

Unit Size Needed: *

Each party agrees that this application may be electronically signed, and that any electronic signatures appearing on this application are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Please complete the application thoroughly. Any incomplete applications will be returned.

When your application is received and there is an apartment available, your application will be reviewed and you will be contacted. If there are no apartments available your application will be placed on an Active Waiting List. When a vacancy occurs and your name comes up on the waiting list your application will be reviewed and you will be contacted at that time.

HOUSEHOLD COMPOSITION AND RESIDENCE HISTORY

HEAD OF HOUSEHOLD

Full Legal Name *

SPOUSE OR CO-APPLICANT

Full Legal Name

Address *

Address

City: *

State: *

Zip: *

City:

State:

Zip:

Social Security #: *

Social Security #:

Birthdate: * +

Birthdate: +

Home Telephone: *

Home Telephone:

Cell Phone Number: *

Cell Phone Number:

E-Mail Address

Work Telephone:

RESIDENCE OR RENTAL HISTORY

Please enter the information requested for your current address and the most recent prior address. Be sure to write complete addresses. Include places where you were not listed on the lease and places where you lived under a different name.

PRIMARY APPLICANT

Present Address: *

SPOUSE or CO-APPLICANT

Present Address:

Dates living there: *

Dates living there:

Landlord's Name:

Landlord's Address:

Landlord's Phone Number

Amount of rent
at your present address? *

First & Last Name:

Relationship:

Sex:

Birthdate: * +

Occupation (If student, name of school):

Social Security Number: *

Will any of the above household members live anywhere except the apartment? (if answer yes, please explain) *

Are there any other persons who will live in the apartment on a less than full-time basis? (if answer yes, please explain) *

EMPLOYMENT INCOME

HEAD OF HOUSEHOLD:

Employer Name *

Address

Phone Number:

Rate per Hour

Hours per Week

Annual Income

How long have you been employed at this job?

Date you started the job: +

CO-APPLICANT:

Employer Name

Address

Phone Number:

Rate per Hour

Hours per Week

Annual Income

How long have you been employed at this job?

Date you started the job: +

OTHER INCOME

	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Social Security	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Supplemental Social Security	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Welfare	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Child Support/Alimony	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Unemployment Benefits	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Disability Benefits	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Workman's Compensation	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Pensions	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Net Income from Business	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Bank Interest	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Income from Assets	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Contributions from friends of family	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)
Other	Yes	No	Annual Amount (Applicant)	Annual Amount (Co-Applicant)

ASSETS

List Assets for all Household Members:

	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Cash on Hand	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Checking Accounts	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Saving Accounts	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Money Market Certificates/CD's	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
IRA's	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Pensions or 401-K's	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Revocable Trusts	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Stocks	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Bonds (any type)	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Life Insurance (cash value)	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Other	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)
Other	Head of Household $ Amount	Co-Applicant $ Amount	Financial Institution (Name & Address)

List Real Estate Owned by any member of the household

Description of Real Estate

Value

Debt

Description of Real Estate

Value

Debt

Have you sold or disposed of any asset(s) valued over $1,000 in the last two years? *

Yes

No

If yes, type of asset (e.g., money/land/house)

Market value when sold/disposed $

Amount sold/disposed for $

Date of transaction +

DEDUCTIONS

Dependent Deduction: Enter the names of all household members other than head or spouse who are:

Under the age of 18:

18 or older and full time students:

18 or older and disabled or handicapped

Childcare Expenses: For children 12 and younger that are gainfully employed or full-time students

$ per week

List names of children for whom care is provided:

Name and address of childcare provider:

Handicapped Care/Expenses:

List amounts you pay for care or apparatus on behalf of a handicapped/disabled family member to permit an adult family member to work:

$

If such amounts are claimed, list the names of the handicapped/disabled family member on whose behalf they are claimed:

If an adult member can work because of care or apparatus list amount of income earned:

$

For Elderly or Disabled Household Only:

Complete only if Head of Household or spouse is 62 or older, disabled or handicapped. Out of pocket medical expenses this household pays that are not reimbursed by medical insurance or other sources can be deducted from Gross Income. Deducations could be for clinic, hospital, prescriptions, insurance and Medicare premiums.

Estimated Annual Medical expenses $: (These expenses will be verified)

QUESTIONS FOR ALL APPLICANTS

Does any member of your household receive regular cash contributions from agencies or from individuals not living with you? *

Yes

No

Does any member of your household receive income from assets, including interest, dividends, stocks or bonds? *

Yes

No

Does any member of your household receive money from school-aid, scholarship, or educational grant? *

Yes

No

Have you sold or given away any real property or other assets in the past two years? *

Yes

No

Has any place where you, your spouse, or co-applicant were living been destroyed or damaged by fire or other causes? If yes, explain: *

Have you, your spouse, or your co-applicant ever applied for a government-subsidized apartment before this? If yes, when and where? *

Have you or any member of your household been involved in criminal activity that poses a threat to the health, safety or welfare of others? If yes, explain: *

Have you, spouse or co-applicant ever been evicted or otherwise removed from rental housing? If yes, explain: *

Has any household member been arrested or convicted of a crime? If yes, explain: *

Are you or any member of your household listed as a registered sex offender in any state? If yes, what state? *

Have you, your spouse, or co-applicant ever been evicted from a federally assisted property for drug-related criminal activity? If yes, explain? *

List all the states in which you have lived: *

Is any member of the household a Military Veteran? If yes, who: *

NOTE: Answering the following questions is optional, however, without this information we may not be able to determine your eligibility for a particular apartment or calculate your rent with correct deductions:

Do you or any member of your family/household require a handicapped accessible apartment?

Yes

No

To determine eligibility we need to know if you are elderly (62 or older), disabled or handicapped.

Yes

No

HUD requires us to report the race and ethnicity of the Head of Household for all applicants. We request your cooperation in completing the following questions. The response is optional and your entry will have no bearing on your eligibility for housing.

Race of Head of Household. Check one:

Ethnicity of Head of Household:

Hispanic or Latino

Not Hispanic or Latino

STATEMENTS BY ALL ADULT HOUSEHOLD MEMBERS

We certify that all information given in this application and any addenda thereto is true, complete and accurate. We understand that if any of this information is false, misleading or incomplete, management may decline our application or, if move-in has occurred, terminate our Rental Agreement. WARNING: Willful false statements or misrepresentation are a criminal offense under section 1001 of Title 18 of the U.S. Code.

We agree to notify management in writing regarding any changes in household address, telephone numbers, income, and household composition.

We understand if we do not hear from Skogen Company immediately, our application will be placed on an Active Waiting list and we will be contacted if a vacancy occurs and our name comes up on the waiting list. We also understand that if after six (6) months, we have not heard from Skogen Company and we want to remain on the Active Waiting List, we will contact Skogen Company to confirm our continued interest in remaining on the Active Waiting List for an apartment. If we do not contact Skogen Company six (6) months after the application was made, we understand that our application will be removed from the Active Waiting List.

If this application is for a household of more than one, we consider ourselves a stable household, and all of our income is available for its needs.

I (We) authorize Skogen Company to:

Obtain one or more “consumer reports” as defined in the Fair Credit Reporting Act, 15 US C. Section 1681a(d), seeking information on our creditworthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I (We) also authorize Skogen Company to obtain present and previous landlord references. Any information given shall be held in strict confidence.

Obtain Criminal Background information on the adult household members. This information will be used to determine eligibility of the household for admission to the complex and this information shall be held strictly confidential.

Date * +

Signature of Head of Household *

clear

Date +

Signature of Spouse or Co-Applicant

clear

Date +

Signature of Co-Applicant

clear

IMPORTANT NOTICE: In accordance with the Fair Housing Act, Skogen Company will not discriminate against any person in the provision of housing because of race, color, religion, sex, handicap, familial status or national origin.

_____________________________________________________________________________________

The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), by Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the social security number of each household member who is 6 years old or older.

Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities.

Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate federal, state, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.

Penalty: You must provide all of the information requested by the owner, including all social security numbers you, and all other household members age 6 years and older, have and use. Giving the social security numbers of all household members 6 years of age and older is mandatory, and not providing the social security numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

“This institution is an equal opportunity provider and employer.” Revised 5/2017

Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

This form is to be provided to each applicant for federally assisted housing

Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing; the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing and special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.

Applicant Name:

Mailing Address:

Telephone No:

Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No:

Cell Phone No:

E-Mail Address (if applicable):

Relationship to Applicant:

Reason for Contact: (Check all that apply)

Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant's application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.

Check this box if you choose not to provide the contact information.

No I do not want to provide the contact information

Signature of Applicant *

clear

Date * +

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers participating in HUD's assisted housing programs to provide any information or family applying for occupancy in HUD-assisted housing with this option to include in this application for occupancy the name, address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with resolving and tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information. Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud, waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all of the information (except the Social Security Number (SSN) which will be used by HUD to protect disbursement data from fraudulent actions.

Form HUD-92006 (5/09)