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

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.

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

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)*

City

State

Zip Code

Report Below Numbers as Gross Income (Income BEFORE Taxes)

Regular Monthly Employment Income* $
Monthly Child Support/Maintenance $
Monthly Social Security/Disability $
Other $
MONTHLY TOTAL* $
Previous Year’s Income* (Annual) $

HOUSEHOLD MEMBER 2 EMPLOYMENT & INCOME

Are you self-employed?* YesNo

Employer(s)

City

State

Zip Code

Report Below Numbers as Gross Income (Income BEFORE Taxes)

Regular Monthly Employment Income $
Monthly Child Support/Maintenance $
Monthly Social Security/Disability $
Other $
MONTHLY TOTAL $
Previous Year’s Income (Annual) $

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

OTHER FUNDS AND SUPPORTS

Do you have a housing choice voucher or do you receive a rental subsidy? YesNo
If yes, please indicate who issued your voucher (e.g., Lake County Housing Authority, Cook County Housing Authority, etc.) or who provides your subsidy (e.g., Catholic Charities, WINGS, etc.)

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.*

GENERAL

HOUSEHOLD MEMBER 1 EMPLOYMENT & INCOME

HOUSEHOLD MEMBER 2 EMPLOYMENT & INCOME

OTHER FUNDS AND SUPPORTS