CPAH Inclusionary Rental Pre-Application – Community Partners for Affordable Housing

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All fields with an asterisk (*) are required.

GENERAL

Household Member 1 First Name*

Household Member 1 Last Name*

Address*

City*

State

Zip Code*

Primary phone

Email*

D.O.B.*

Household Member 2 First Name

Household Member 2 Last Name

Address

City

State

Zip Code

Primary Phone

D.O.B.

Number of people who will occupy the residence?

Does anyone in your household reside with you less than full-time?
YesNo
If yes, please explain:

Do you currently:*
RentOwnOther
Payment:

How were you referred to CPAH?*

Please indicate which communities are of interest to you:
Highland ParkEvanstonEvanston (55+)NorthbrookDeerfieldSkokie

Do you work in one of these communities?
Highland ParkEvanstonNorthbrookDeerfield
If so, where?

HOUSEHOLD MEMBER 1 EMPLOYMENT & INCOME

Are you self-employed?* YesNo

Employer(s)*

Address(es)

City

State

Zip Code

Title*

Years @ current employer*

Report Below Numbers as Gross Income (Income BEFORE Taxes)

Regular Monthly Employment Income* $
Monthly Overtime $
Monthly Bonuses/Commissions $
Monthly Child Support, SSI/SSDI $
Monthly Unemployment, etc. $
Other $
MONTHLY TOTAL* $
Previous Year’s Income* (Annual) $

HOUSEHOLD MEMBER 2 EMPLOYMENT & INCOME

Are you self-employed?* YesNo

Employer(s)

Address(es)

City

State

Zip Code

Title

Years @ current employer

Report Below Numbers as Gross Income (Income BEFORE Taxes)

Regular Monthly Employment Income $
Monthly Overtime $
Monthly Bonuses/Commissions $
Monthly Child Support, SSI/SSDI $
Monthly Unemployment, etc. $
Other $
MONTHLY TOTAL $
Previous Year’s Income (Annual) $

Are there additional household members who have income?
YesNo
If yes, please indicate their name and current gross monthly income.

Additional Household Member 1 Name:
Gross Monthly Income:

Additional Household Member 2 Name:
Gross Monthly Income:

HOUSEHOLD ASSETS (Please add together and note the assets of all household members)

Checking* $
Savings* $
401(k), IRA, Pension $
Stocks/Mutual Funds $
Other $
Please Describe:

OTHER FUNDS AND SUPPORTS

Do you have a housing voucher? YesNo
If yes, please provide who the voucher is with (Lake County Housing, Cook County Housing, Chicago Housing Authority, etc.)
If you are the owner/beneficiary of an ABLE account, what is the current balance? $ How much is deposited in this account each month? $
Are you the beneficiary of a Special Needs Trust? yesno
If yes, what is the current balance? $
Do you anticipate receiving any one-time or recurring gifts? yesno
If yes, please describe.

Additional Comments:

I/We certify that all information contained in this application is true and correct, to the best of my knowledge. I understand that the submission of this information is one of the requirements for tenancy and does not constitute an approval of my application, or my acceptance as a tenant.*

I/We agree to contact CPAH to update my contact information if it changes. I/We understand that failure to do so may result in my not receiving information about available apartments and waitlist updates, and may result in my removal from the waiting list.*

Household Member 1 Signature*

Household Member 2 Signature