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 and Last Name* Address* City* State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code* Primary phone Email* D.O.B.* Judgements YesNoN/A Household Member 2 First and Last Name Address City State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Primary Phone Email D.O.B. Judgements YesNoN/A Number of people who will occupy the residence? Are you seeking a certain number of bedrooms or style of housing (house, apartment)? Studio1 Bedroom2 Bedroom3 Bedroom Do any dependents in your household reside with you less than full-time? YesNo If yes, please explain: Do you currently:* RentOwn Payment: How were you referred to CPAH?* Please indicate which communities are of interest to you: Highland ParkLake Forest (62+)EvanstonEvanston (55+)Northbrook Do you work in one of these communities? Highland ParkLake ForestEvanstonNorthbrook If so, where? Would you like to apply to be added to our waitlist for other Lake County communities? yesno 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 CPAH accepts housing vouchers (i.e., Section 8, VASH, etc..). 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.) Are you the owner/beneficiary of an ABLE account? yesno If yes, what is the current balance? $ 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. BACKGROUND INFORMATION Have you or any member of your household been convicted of a crime in the last 10 years?* YesNo If yes, please describe: Have you or any member of your household been evicted or otherwise involuntarily removed from rental housing due to fraud, non-payment of rent, failure to cooperate with recertification procedures, or for any other reason, in the past 5 years?* YesNo 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.* Household Member 1 Signature* Household Member 2 Signature
