CPAH Inclusionary Rental Pre-Application Please complete all sections as fully as possible. All fields with an asterisk (*) are required. GENERAL Household Member 1 First Name* Household Member 1 Last Name* Address* City* State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code* Primary phone Email* D.O.B.* Household Member 2 First Name Household Member 2 Last Name Address City State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Primary Phone Email 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 ParkLake Forest (62+)EvanstonEvanston (55+)NorthbrookDeerfield Do you work in one of these communities? Highland ParkLake ForestEvanstonNorthbrook If so, where? HOUSEHOLD MEMBER 1 EMPLOYMENT & INCOME Are you self-employed?* YesNo Employer(s)* Address(es) City State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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 IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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
