MOHAWK INDIAN HOUSING CORPORATION•

• MIHC.

Dear Applicant:

Attached you will fmd the application you requested for rental of an apartment atMohawk River Apartments, Iroquois Village Apartments, Sweetflag Estate orMcGee Road. A separate application must be completed for each property you areapplying for.

Please make sure ALL requested information is complete before you submit theapplication with copies of:

• Social Security Card for all family members• Birth Certificate for all family members• Photo ill all members 18 and over (e.g. Drivers license/Tribal card)

The application must be completed in your own handwriting. If another person isassisting you with completing this application, they must sign middle portion ofsignature page. You must use the correct legal name for each member of yourhousehold as it appears on their social security card.

Expect to receive notification by mail that your application is complete and youare put on the waiting list or application is missing information that must be sub-mitted. Respond to theses requests quickly so there is no delay. Please provideaccurate contact information for both mailing address & phone numbers.

Thank you for your interest in becoming a resident in one our Complexes. If youhave any questions regarding your application, please call our office between 8:00am and 4:00 pm Monday through Friday. Our telephone number is (518) 358-4860

SincerelyMohawk Indian Housing Corporation

•PO Box 402, Rooseveltown, NY 13683 ~ 188 McGee Road, Akwesasne NY 13655Phone: 518-358-4860 Fax: 518-358-4870 TDDmy 1-800-421-1220

www.MohawkHousing.org

•RESIDENTIAL RENTAL APPLICATION

Mohawk Indian Housing CorporationHogansburg Housing Development Fund Company Inc.

Sweetflag Estate Iroquois Village Mohawk River Village McGee RoadAdministration Office: 188 McGee Road, Akwesasne NY 13655

Mailing Address: P.O. Box 402, Rooseveltown, NY 13683PHONE: (518) 358-4860 FAX: (518) 358-4870 TDD: (800) 421-1220

APPLICANT: This form must be completed in your own handwriting or must be signed by the person assist-ing you with this form. You must use the correct legal name for each member of your household as it appearson their social security card. All blanks must be filled in and information is confidential. This applicationCAN NOT BE PROCESSED without the following documentation: Social Security Cards for all familymembers, Birth Certificates for all Family members and Photo ill for all Family Members over the age of 18.

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Which property are you applying to:

o Sweetflag Estate 0 Iroquois Village ApartmentsoMohawk River Village 0 McGee Road Apartments

HEAD OF HOUSEHOLD

Office Use Only. Date & Time Received:

Name: Phone: Cell: _

Social Security No. Date of Birth: _

Mailing Address City, state, Zip: _

Drivers License No. State Email: _

CO-APPLICANT

Name: Phone: Cell: _

Social Security No. Date of Birth: _

Mailing Address City, state, Zip: _

Drivers License No. State Email:

IN CASE YOU CANNOT BE REACHED, or in case of emergency who should be contacted:

Name: Relationship: _

Home Phone: Cell Phone: Work Phone: _

Address City, state, Zip: _

Please check any box that pertains to your present dwelling:

o Standard 0 Sub-standard 0 Living with parents 0 Without or soon to be without housing

o Overcrowded 0 My present rent is 50% or more of my current montWy income

Are you currently under eviction or have you ever been evicted? 0 Yes 0 No If yes, explain: _

. .HOUSEHOLD COl\IPOSITION AND CHARACTERISTICS

Do you or anyone in your household currently engage in use of controUed substances DYes D No

If yes, please specify household member _

Are you or anyone in your household subject to state lifetime registration requirement for sex offenders?

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DYes DNo If yes, please identify household member _

DNo

DNo

List Head of Household and ALL other members who will be living in the unit.complete all sections for all family members.

NAME DATE OF BIRTH AGE SOCIAL SECURITY NO. SEX RELATIONSHIPTo Head of Household

Does anyone live with you now who is not listed above? DYes

Please Explain: _

Do you expect a change in your household composition? DYes

Please Explain: _

Does Head of Household/Spouse meet the dermition ofa person with a disability? DYes D No [orprogram eligibility purposes

Please identify any special housing needs you would require: _

Are you currently living in subsidized housing unit? DYes D No (if no skip to Landlord References)

Complex: Address: _

Name of Manager: Telephone Number: _

, < ,.' ~ - • " • - •

LANDLORD REFERENCES .

This section MUST be completed.

Current Landlord: Phone: _

Address:

Previous Landlord:

Address:

Phone:

Previous Landlord: Phone: _

Address:

INCOME AND ASSET INFORMATION

1. Do you work full time, part time or seasonally?2. Work for someone who pays cash? DYes D No

4. Expect a leave of absence from work due to lay-off, medical, maternity, or military leave? DYes D No

5. Now receive or expect to receive unemployment benefits? DYes D No

6. Now receive or expect to receive child support? 0 Yes 0 No

7. Not receiving child support that he/she is entitled to? 0 Yes D No

8. Now receive or expect to receive alimony? DYes 0 No

9. Have entitlement to receive alimony that is not currently being received? DYes D No

10.Now receive or expect to receive public assistance? DYes D No

11.Now receive or expect to receive Social Security or disability benefits? DYes D No

12.Now receive or expect to receive an income from a pension or annuity? DYes 0 No

13.Now receive or expect to receive contributions from organizations/individual not living in the unit 0 Yes 0 No

MEDICAL COSTSComplete this part ONLY if head of household or Co-Head is disabled/handicapped or 62 or older

Name of eligible person: _Expense (Medical Insurance, Prescriptions, Hearing Aid, Dr's Apt) _

Address Phone: _Monthly Cost: Annual Cost: _

Expense (Medical Insurance, Prescriptions, Hearing Aid, Dr's Apt) _

Address Phone: _Monthly Cost: Annual Cost: _

Expense (Medical Insurance, Prescriptions, Hearing Aid, Dr's Apt) _

Address Phone: _Monthly Cost: Annual Cost: _

INCOMEList ALL household members receiving an income. Indicate if the sources of income is Wages, Social Services, SocialSecurity, SSI, Pension, Disability, Unemployment, Alimony, Child Support, etc.

NAME SOURCE OF ADDRESS PHONEAMOUNT

INCOME WeeklylBi weeklylMoothly

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Childcare CostS: Only for children 12 & youngerChild's Name Age Child Care Cost Per Week:

Child's Name Age Child Care Cost Per Week:

Child's Name Age Child Care Cost Per Week:

Child's Name Age Child Care Cost Per Week:

BANKING AND FINANCIAL ASSETSList all types of bank or credit union accounts (types of accounts include Checking, Savings, certificates of deposits)

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TYPE OF ACCOUNT BANK/CREDIT UNION ACCOUNT NO BALANCE RATE

If Yes, Type of property _

Do you own any stocks, bonds, mutual funds, certificate of deposit, etc.? 0 Yes 0 No

Do you own real estate? 0 Yes 0 No

Address Appraised Value $ _

Type of property _

Address Appraised Value $ _

Does anyone in the household receive recurring gifts or contributions from non-household members 0 Yes 0 No

If yes, explain Value $ _

Have you disposed of any assets in the last 2 years (property/money) 0 Yes 0 No

If yes, Describe asset Date Market Value$ _

Name Phone _

Address _

Name Phone _

Address _

Name Phone _

Address". ' <. }

PERSONAL' REFERENCES (no relatives)Name Phone _

Address _

Name Phone--------------------- -------------Address _

Name Phone _

Address

Do you own any pets? 0 Yes 0 No

OTHER INFORMATIONIf Yes describe

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Are you a drug dealer or have you ever been a drug dealer? 0 Yes 0 No

Have you ever been convicted of a felony? 0 Yes 0 No

VEHICLES: List year, make, color and license plate # for all vehicles in your household:

YEAR MAKE/MODEL COLOR STATE LICENCE PLATE NO.

EthnicitylRace of Head of Household: Check one (Optional for statistical purposes only)

o American Indian/Alaskan Native 0 Asian/Pacific Islander 0 Black or African American

o Native Hawaiian/Other Pacific Islander 0 White

The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assurethat Federal Government, acting thorough the Rural Housing Service that the Federal laws prohibiting discriminationagainst tenant applications on the basis of race, color, national origin, religion, sex, familial status, age and disability arecomplied with. You are not required to furnish this information, but are encouraged to do so. This information will notbe used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnishit, the owner is required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation orsurname.

Optional For Statistical Purposes only. ETHNICITY: 0 Hispanic or Latino o Not Hispanic or Latino

Everyone over 18 years of age must INITIAL each of the following statements:

____ I (we) certify that I (we) do/will not maintain a separate rental unit in a different location.

____ I (we) certify that this will be my (our) permanent resident.

____ Acceptance of this application does not guarantee rental of an apartment. All Applicants must meet screen-

ing criteria and reference checks.

____ Changes in family income, size, address, phone number must be reported promptly to management in order

to process your application.

____ A security deposit, first months rent an a one-year lease will be required before occupancy of an apartment.

How did you hear about the vacancy/property?

o Newspaper 0 Poster/Bulletin

o Current Tenant o Word of Mouth

o Agency Referral

o FamilylFriend

o Website

o Other

What Agency referred you? _

What Newspaper did you see our ad in? _

Where was the Poster/Bulletin?

I/we certify that all information in this application is true to the best of my/our knowledge and that I/we un-derstand that false statements or information are punishable by law and will lead to cancellation of this appli-cation or termination of tendency after occupancy.

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Applicant Signature:

Date

Co-Applicant Signature:

Date

I have completed this application for the applicant(s). I have read each question or statement to him/her andused the information provided. He/she understands what he/she is signing.

Signature Print Name

AUTHORIZATION

Date

I/we understand the purpose of this consent and I/we do hereby authorize Mohawk Indian Housing Corporation and itsstaff or authorized representatives to contact any agencies, office, groups or organizations to obtain and verify any infor-mation or materials, which are deemed necessary to complete my/our application for housing in this property managed byMohawk Indian Housing Corporation. (The authorization MUST be signed by all family members over the age of 18)

Applicant Signature:

Print Name

Date

Co-Applicant Signature:

Print Name

Date

Co-Applicant Signature:

Print Name

Date

Co-Applicant Signature:

Print Name

Date

"This institution is an equal opportunity provider and employer. If you wish to file a Civil Rights program complaint of discrimination, complete the USDAProgram Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complainUiling_cust.html, or at any USDA office, or call (866) 632-9992to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us bymail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov."

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any de-partment of the United States Government HUD, the PHA and any owner (or any employee ofHUD the PHA or the owner) may be subject to penalties forunauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification formis restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concern-ing an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosureof information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the ownerresponsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Actat 208(a) (6), (7) and (8). Violation oftllese provisions are cited as violations of 42 U.S.c. 408 (a) (6), (7) and (8).