BLUE RIDGE MANOR APARTMENTS RENTAL APPLICATION
Your replies will be respected as confidential. PLEASE ANSWER ALL QUESTIONS: Information will be checked to determine eligibility.
Head of Household: Name: (Mr. Mrs. Ms. Miss) Telephone No. Social Security No. Last Name: First Name: Middle Initial: Age: Birthdate:
Spouse/Co-Adult: Social Security No. Last Name: First Name: Middle Initial: Age: Birthdate:
Present Address: Street: City: State: Zip code: How Long?
Landlord's Name: Rent Amount: Telephone No.:
Last Previous Address: How Long?
Landlord's Name: Telephone No.:
Prior Previous Address:
Number in Family: Number of Bedrooms desired: (Check One) One Two Three
NAMES AND AGES OF CHILDREN AND ANY OTHER PERSONS WHO WILL RESIDE IN THIS UNIT RACE/ETHNICITY: White Black American Indian Asian or Pacific Islander Hispanic *Include Last Name if different from yours *Show relationship to you
CURRENT SOURCES OF INCOME: (List all income sources. This includes, but not limited to, full and/or part time employment, all income from welfare agencies, Social Security, Pensions, SSI, Disability Compensation, Armed Forces Reserve, Unemployment Compensation, Babysitting, Care-Taking of Elderly/Disabled, Alimony, Child Support, Educational Loans, Scholarships and Grants, Income from Rental Property, Interest on Assets, Dividends, Annuities, Regular Contributions from people not residing with you.)
ASSETS: (List all assets, which include, but are not limited to, sums in checking accounts, savings accounts, safe deposit boxes and cash on hand; stocks and bonds; certificates of deposit, real estate or other capital investments).
Checking Account: Bank Account # Amount $
Passbook Savings: Bank Account # Amount $
Savings Certificate: Bank Account # Amount $
Credit Union Share: Credit Union Name: Amount $ Address:
Stocks & Bonds (value): $ War Bonds (value): $
Do you own real estate? Yes No
If YES, indicate full address of property:
UNUSUAL EXPENSES: Do you pay for babysitting due to employment? Yes No If YES, list child care provider name, address and telephone number: Cost Per Week $ Cost per Month $
MEDICAL EXPENSES:
Are you receiving Medicare Benefits? Yes No Are you receiving Medical Assistance through the Welfare Dept? Yes No Do you pay any medical insurance/hospitalization, such as Blue Cross, etc? Yes No (Do not include Life Insurance Policies) If YES, give name of Insurance company and Policy number: Name of Insurance Co.: Policy # Is this a payroll deduction? Yes No If YES, How often? How much? If paid directly by you? Yes No If YES, How often? How much? Do you take prescription drugs on a regular basis? Yes No Do you anticipate any health care related expenses for the next 12 months which are not covered by health insurance? Yes No If YES, explain:
AUTOMOBILES:
OTHER VEHICLES:
Have you disposed of any Assets within the Last Two Years? Yes No If YES, describe:
Cash Value of Assets: $ Amount Received: $
In case of any emergency, please notify: Name: Relationship: Phone: Address:
NOTE: (1) This application and the information contained therein must be updated every 90 days to remain valid and retain position on the waiting list. (2) A credit report and final verification investigation will be conducted prior to initial occupancy. (3) Copies of birth certificates will be required on all household members prior to initial occupancy.
I/We (the applicant(s) agree to give the management agent the authority to investigate my credit rating, my current and past rental record, and all other information necessary to determine eligibility. I understand that any misrepresentation of information on this form will disqualify me from consideration for leasing. I hereby affirm that the foregoing information is true and correct to the best of my knowledge.
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to matters within its jurisdiction.