CONTACT US

Pleasant Terrace Apartments 1027 East Pleasant Street Milwaukee, Wisconsin 53202 414-271-1403

Application for federally subsidized Housing
TELL ABOUT YOURSELF
Applicant Name:*
First Last
Phone*
Email*
SSN:*
Date of Birth*
MM slash DD slash YYYY
A Federal Preference will be given to applications submitted by the Elderly (62 or older). Applications submitted by the Near Elderly Disabled ( older than 50 but not 62)and Non Elderly Disabled Adults will also be considered with priority given to the Near Elderly.
What size unit
- One Bedroom
Disability*
- Yes
- No
Do you require an assistive animal:*
- Yes
- No
Do you require mobility accessible or special features/accommodations:*
- Yes
- No
List special features/accommodations:*
We will assist an applicant or family member with a disability/handicap to provide reasonable accommodations. A reasonable accommodation is some modification or change we can make to the rules/procedures or to the structure of the property that will assist an otherwise eligible applicant with a disability to take advantage of the program.
How soon can you relocate*
MM slash DD slash YYYY
Have you or your family previously received HUD assistance:*
- Yes
- No
Do you own a pet you intend on keeping:*
- Yes
- No
Will you require parking*
- Yes
- No
Have you ever committed fraud in a federally assisted housing program or been requested to repay money knowingly misrepresenting information for such programs:*
- Yes
- No
CRIMINAL HISTORY
Please list any and all criminal background:
Are you or any member of your household subject to a lifetime sex offender registration requirement in any state?*
- Yes
- No
WHO WILL OCCUPY THE UNIT
Name
Birthdate
SSN:
Name
Birthdate
SSN:
Name
Birthdate
SSN:
INCOME
Type of Income:
- Employment
- Social Security
- SSI
- Pension
- Other
Total Monthly Income*
Present Employer
Previous Employer
PRESENT ADDRESS
Address*
Street Address City State ZIP Code
How long have you lived here:*
Landlord's Name*
Landlord's Phone #*
Landlord's Address
Street Address City State ZIP Code
PERSONAL REFERENCES (no relatives)
1. Reference Name*
Phone Number*
2. Reference Name*
Phone Number*
EMERGENCY CONTACT INFORMATION
Emergency Contact Name*
Phone Number*
Are you currently a student enrolled in an academic institution?*
- Yes
- No
Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

OMB Control # 2502-0581 Exp. (11/30/2015)
Supplemental Contact Information
- YES - I wish to provide Supplemental Contact Information
Instructions: Optional Contact Person or Organization : You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.
Supplemental Contact
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code
Telephone No.
Cell Phone No.
Email
Relationship to Applicant:
Reason for Contact: (Check all that apply)
- Emergency
- Unable to contact you
- Termination of rental assistance
- Eviction from unit
- Late payment of rent
- Assist with Recertification Process
- Change in lease terms
- Change in house rules
- Other
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the issues or in providing any services or special care to you.

Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the applicant or applicable law.

Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992) requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on age discrimination under the Age Discrimination Act of 1975.
NOTE
All questions on this application must be completed, if not, the application will be returned to applicant. All of the information provided in this application is preliminary and in no way insures occupancy and is held in the strictest confidence. Additional information may be requested. This is an Equal Housing Opportunity in which there are no barriers to obtaining housing on the basis of race, color, religion, sex or national origin.

WARNING
Section 1001 of Title 18 of the US Code makes it a criminal offense to make willful false statements or misrepresentations to any agency or department of the United States as to any matter within its jurisdiction. Any false or erroneous information herein shall constitute grounds to void, invalidate or cancel the lease if applicant(s) should qualify and a lease is subsequently executed. By signing below you/we swear that all the information provided herein is true to the best of my/our knowledge.
Applicants Signature
Date*
MM slash DD slash YYYY
Spouse and/or co-adult signature*
Date*
MM slash DD slash YYYY
In addition to any false information provided; your application will be rejected if applicant and other household members; in the last 15 years have had a felony conviction for any type of crime, including but not limited to being engaged in any type of drug related behavior, in the last 10 years had a conviction of a crime (other than traffic violations) which would raise concerns about the health and safety of others, during the past 5 years have been through a court ordered eviction, or had a judgment against you for financial delinquency, are subject to a state lifetime sex offender registration program, or abuse or have a pattern of abuse with alcohol, previous or current landlords would be disinclined to rent to you again for any other reason pertaining to the behavior of yourself or others allowed on the property during your tenancy, previous or current landlords report significant complaints of noncompliance with leases, rental agreements, and rules and regulations.
Comments
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