CPAH Rental Pre-Application Please complete all sections as fully as possible. All fields with an asterisk (*) are required. GENERAL Applicant Name* Address* City* State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code* Telephone Cell Phone Email* D.O.B.* Judgements YesNoN/A Co-Applicant Name Address City State IllinoisAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Telephone Cell Phone Email D.O.B. Judgements YesNoN/A Number of people who will occupy the residence? Are you seeking a certain # of bedrooms or style of housing (house, apartment)? If so, please indicate here. 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?* APPLICANT 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) $ CO-APPLICANT APPLICANT 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 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.* Applicant Signature* Co-Applicant Signature
