Aster Place 2405 Aster Place Eureka, CA 95501 ph. (707) 496-6894

9/27/07 (TC all)

OFFICE USE ONLY

Date: Gross Income:

Time:

Apt. Size:

Aster Place

2405 Aster Place

Eureka, CA 95501

ph. (707) 496-6894

GENERAL INFORMATION:

Name Social Security # Drivers Lic.# / State

1) / /

2) / /

3) / /

4) / /

5) / /

6) / /

7) / /

□ No □ Yes

Has any member of the household been convicted of a felony? □ No □ Yes

Are you requesting an accommodation in housing due to a disability? □ No □ Yes

If yes, what is the accommodation requested?

Are you or any member of your household, 18 or older, attending school? □ No □ Yes If yes, who?

Do you own a pet? □ No □ Yes If yes, please be advised that we accept service animals only. Documentation required.

Do you have a washing machine? □ No □ Yes

Did you file taxes? □ No □ Yes Email:

Do you have a waterbed? □ No □ Yes

APARTMENT SIZE REQUESTED: □ □ 3 bedroom

(Head of Household) Current Address:

Street Apt.# City State Zip

Phone Number: Dates you lived here: to

Mailing Address (if different from above)

Street apt.# city state zip

CURRENT LANDLORD: Address:

Phone Number: if apt., name of complex:

Reason you want to move:

Amount of rent you are paying: Are you being or have you been evicted? No Yes

If yes, please explain:

PREVIOUS ADDRESS:

Street Apt.# City State Zip

If apt., name of complex: Dates you lived there: to

Previous Landlord: Phone Number: Reason for moving:

Address:

Birthdate/Age

APPLICATION FOR ADMISSION

Income Limit:

M OR F

GENDER

CIRCLE

ONE

M OR F

Head of Household:

OFFICE USE ONLY

M OR F

Will anyone live with you who is not listed above?

RENTAL HISTORY- Management's policy is to have 5 years of continuous housing history. If additional space is needed, please use the back of this application or

attach an additional sheet.2

2 bedroom

Page 1 of 6

(Applicant #2) Current Address:

Street Apt.# City State Zip

Phone Number: Dates you lived here: to

Mailing Address (if different from above)

Street apt.# city state zip

CURRENT LANDLORD: Address:

Phone Number: if apt., name of complex:

Reason you want to move:

Amount of rent you are paying: Are you being or have you been evicted? No Yes

If yes, please explain:

PREVIOUS ADDRESS:

Street Apt.# City State Zip

If apt., name of complex: Dates you lived there: to

Previous Landlord: Phone Number: Reason for moving:

Address:

(Applicant #3) Current Address:

Street Apt.# City State Zip

Phone Number: Dates you lived here: to

Mailing Address (if different from above)

Street apt.# city state zip

CURRENT LANDLORD: Address:

Phone Number: if apt., name of complex:

Reason you want to move:

Amount of rent you are paying: Are you being or have you been evicted? No Yes

If yes, please explain:

PREVIOUS ADDRESS:

Street Apt.# City State Zip

If apt., name of complex: Dates you lived there: to

Previous Landlord: Phone Number: Reason for moving:

Address:

PERSONAL REFERENCES (do not list relatives-preferably business/professional acquantances):

(Applicant #1) Name Address Phone # Relationship

(Applicant #2) Name Address Phone # Relationship

ALL OTHER APPLICANTS NOT RESIDING WITH THE HEAD OF HOUSEHOLD APPLICANT MUST PROVIDE 5 YEARS OF CONTINUOUS HOUSING

HISTORY.

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EMERGENCY CONTACT PERSON:

Name Address Phone Number Relationship

AUTOMOBILES:

Make: Color: Year: License Plate #:

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ hour □ week □ semester

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

$ per

□ □ □

Do you anticipate any change in this income in the next 12 months?

□

Yes

□

No If yes, please explain:

Does an outside party pay your utilities, phone service or other household expenses? □ Yes □ No If yes, amount paid per month $

Name and address of outside party:

Name Address City State Zip

FEDERAL INCOME TAX RETURNS: Are you or any member of your household exempt from filing a Federal Tax Return? □ Yes □ No

If yes, which members: , ,

Name Name Name

hour week month

Employment

(Earned income)

Alimony

hour week month

□

hour week month

week month

Amount Received

(per time period)

Received By Which

Household Member

Source of Income

(name,

address & phone)

Employment

(Earned income)

□□

hour

Yes No

INCOME

: Do you or any member of your household anticipate receiving income from any of the following sources during the next

12 months? Please mark EVERY question YES or NO. If you answer any questions with a YES, please complete the

information on the right.

HOUSEHOLD FINANCIAL OBLIGATIONS Include ALL medical expenses, car payments,

PAYABLE TO: child support, loans, etc.

(Company Name) MONTHLY PAYMENT

hour week month

Child Support

Disability Benefits

(worker's compensation

disability income)

Monetary Gifts

Pension or Retirement

Benefits

Public Assistance

Schoold Grants or

Scholarships

Social Security / SSI

Unemployment

Compensation

Veterans Administration

Other:____________

□□

□

□□

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ASSETS:

In the last TWO years have you sold, given away, or disposed of assets for less than "fair market value" (example: real

estate and other items held for investment purposes such as gems, jewelry, coins, or collections)? No Yes

If yes, list type of asset:

Amount given: Name of party who received asset:

Address:

Was this due to divorce, separation or bankruptcy? No Yes

ASSETS II: Please mark every question either YES or NO. If you answer YES, complete the blanks on the right.

DO YOU HAVE...? YES NO NAME ON ACCOUNT ACCOUNT #

BALANCE/VALUE .

Bank (name & address)

□ □

Checking Account(s)

Savings Account(s)

Money Market Account(s)

Certificate/Time Deposits

IRA/Keough/Life Insurance

or other retirement account

Stocks or Bonds

Rental Property

Other Real Estate

□ □

Other:_______________

□

Safety Deposit Box

Trust Account(s)

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CHILDCARE: (Complete only if your child/children is/are 12 years of age or younger and living in your household)

Do you pay for childcare expenses?

□

Yes

□

If yes, how much $

To whom is this expense paid?

Name: Address:

Do you employ childcare in order for a household member to work or continue education? □ Yes □ No

Do you anticipate having ANY medical expenses within the next twelvle (12) months that are not paid for by Medicare or an

insurance policy? □ Yes □ No

(examples: medical or dental expenses, including cost of insurance, prescriptions, eyeglasses, hearing aids or nursing care)

DO NOT INCLUDE expenses that are reimbursed or paid by others outside your household.

DISABILITY ASSISTANCE EXPENSE: (Applicable only if a household member has a disability).

Does your household have disability assistance expenses?

□

Yes

□

such as, wheelchairs, ramps, and adaptations to vehicles or workplace equipment) DO NOT INCLUDE expenses that are

reimbursed or paid by others outside your household.

DRUG FREE HOUSING:

DRUG and VIOLANCE-FREE Housing. The following questions MUST be answered by ALL applicants for this housing:

Is any household member a current illegal user of a controlled substance?

If either of the above questions were answered "Yes", which member(s):

If any of the questions above were answered "Yes", has the household member successfully completed a

controlled substance abuse recovery program?

Has any household member been convicted of a violent crime?

Is any household member currently on probation for a violent or drug-related offense?

ELDERLY HOUSEHOLDS: (Applicable only if the head of household or co-tenant is 62 years of age or older; or disabled,

regardless of age).

In order to comply with Federal and State laws, all attempts must be made by the Owner of this apartment community to assure

Yes

□

□ □

□

(examples: care attendant, special apparatus,

□

Has any household member been convicted of the illegal use, possession, sale, distribution or manufacturing

of a controlled substance?

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I/We certify the housing I/We will occupy at Apartments will be my/our

permanent residence and I/We will not maintain a separate rental unit in a different location. I/We authorize the owner

to obtain a credit/criminal report and to contact current and previous landlords.

I/We also certify that the information given is accurate and complete and understand any misrepresentation will

disqualify the application.

Signature: Date:

It is your responsibility as the applicant to keep the Management notified of any changes in your application. This

includes a change in household size, current address, income, or assets.

Marital Status of Head of Household (check one): Disability Status (check one):

Married Disabled

Separated Not Disabled

Unmarried single divorced widowed

Race/National Origin of Head of Household (check all that apply): Ethnicity:

White Hispanic/Latino

Black/African American Mexican/Chicano

Asian Puerto Rican

Asian AND White Cuban

American Indian or Alaskan Native Non-Hispanic/Latino

Native Hawaiian or Other Pacific Islander

Black/African American AND White

American Indian or Alaskan Native AND White

American Indian or Alaskan Native AND Black/African American

How did you hear about this complex? Newspaper Ad Tenant Referral Internet Project Sign

Other:

HOUSEHOLD COMPOSITION: "The following information is requested by the owner as required by the United States

Government under conditions of the funding they made available for the property's development. This information is confidential

and is only used for government reporting purposes to monitor compliance with equal opportunity laws. Please note that self-

identification of race/ethnicity is voluntary.

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