Rental Application

Application Date*
MM slash DD slash YYYY
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
SS#*

Please enter using dashes (000-00-0000)
County of Legal Settlement*
Disability Type*
Guardian
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Protective Payee / Conservator
Check if Same as Guardian*
- Same as Guardian
- Different than Guardian
Are they*
- Protective Payee
- Conservator
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Site Preference
Site Preference*
- Independence
- Fairbank
- Jesup
- Winthrop
Monthly Income
Select type and fill in amount. Fill in all that apply.
- Employment Wages
Applicant Amount (Employment Wages)*
Others in Household Amount (Employment Wages)*
- Public Assistance
Applicant Amount (Public Assistance)
Others in Household Amount (Public Assistance)
- Social Security
Applicant Amount (Social Security)
Others in Household Amount (Social Security)
- SSDI
Applicant Amount (SSDI)
Others in Household Amount (SSDI)
- SSI
Applicant Amount (SSI)
Others in Household Amount (SSI)
- Veterans Benefits
Applicant Amount (Veterans Benefits)
Others in Household Amount (Veterans Benefits)
- Railroad Pension
Applicant Amount (Railroad Pension)
Others in Household Amount (Railroad Pension)
- Child Support
Applicant Amount (Child Support)
Others in Household Amount (Child Support)
- Dividends, Interest, Etc.
Applicant Amount (Dividends, Interest, Etc.)
Others in Household Amount (Dividends, Interest, Etc.)
- Other
Other Income Type
Applicant Amount (Other)
Others in Household Amount (Other)
Record Information
Are you a convicted sex offender?*
- Yes
- No
Have you ever been convicted of a felony or violent crime of any nature?*
- Yes
- No
If yes, please explain:*
Have you ever been evicted from a previous residence?*
- Yes
- No
If yes, please explain:*
Name of Case Manager/County Social Worker*
First Last
Case Manager/Social Worker Phone Number*
Case Manager/Social Worker Email
Current and Previous Landlords
Do not include providers such as Residential Care Facility (RCF), Mental Health Institute (MHI) etc.
Current Landlord (if applicable)
First Last
Dates at this Residence
Landlord's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Landlord's Phone
Previous Landlord (if applicable)
First Last
Dates at this Residence
Landlord's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Landlord's Phone
Previous Landlord (if applicable)
First Last
Dates at this Residence
Landlord's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Landlord's Phone
Previous Landlord (if applicable)
First Last
Dates at this Residence
Landlord's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Landlord's Phone
The previously listed services have been discussed with me and are requested with my knowledge and consent. As a signatory of this document, I certify that the above information is true and complete to the best of my knowledge, and I authorize the County CPC staff to check for verification of the information provided. I understand that the information gathered in this document is for the use of the Buchanan Housing, Inc. to determine my eligibility for housing through their program. I understand that information in this document will remain confidential.
Applicant's (or guardian's) Signature*

Please type your name
Date*
MM slash DD slash YYYY

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Guardian

Protective Payee / Conservator

Site Preference

Monthly Income

Record Information

Current and Previous Landlords