Accessible Space, Inc. HOUSING FOR PERSONS WITH DISABILITIES NATIONWIDE HOUSING SITE LOCATIONS

5/9/2014

This application can be filled out electronically or by hand. Print the completed application and mail it to Accessible Space, Inc. 2550 University Ave. West Ste. 330N St. Paul, MN 55114. Call 800-466-7722 with questions

APARTMENT LIVING Each resident rents his/her own accessible apartment. ASI supportive services are available in some locations, and some locations offer services from other providers. Housing locations in bold print indicate housing with ASI Services available. Please contact ASI’s Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722, extension 224. TTY/TDD (800) 627-3529. Please note: ASI services are available only to qualified applicants and residents, and rent payments do not include the cost or provision of ASI supportive living services that may be available. Alabama □ Florence – Dogwood Terrace □ Hoover – Patton Ridge Apts. □ Mobile – Anderson Fischer Apts. Arizona □ Chandler – Arroyo Terrace □ Mesa – R.J. Piltz Vista Bonita California □ Capitola – The Dakota □ Davis – Becerra Plaza □ Fullerton – Harbor View Terrace □ South Lake Tahoe – Sky Forest Acres Colorado □ Fort Collins – Harmony Road Apts. □ Greeley – Fox Run □ Longmont – Casa Libertad □ Greeley – Twin Rivers Illinois □ Carbondale – Heartland Apts. Kansas □ Kansas City – Mid America Commons (1 BR only) □ Topeka – Melissa Anne Hanger Apts. □ Kansas City – Blackbird Apts. Missouri □ Springfield – Tim O’Brien Apts.

Montana □ Billings – Grandview Apts. □ Bozeman – Spring Run Apts. □ Great Falls – Meadow Lark Apts. □ Great Falls – Southwinds Estates □ Helena – Queen City Estates □ Missoula – Bruce Blattner Apts. □ Missoula – Eagle Watch Estates North Dakota □ Fargo – Northland Apts. □ Grand Forks – Linden Place (1 BR only) □ Jamestown – Dewey Apts. □ Minot – Accessible Space Apts. Nevada □ Carson City (89701) – Frost Yasmer Estates □ Henderson (89009) – Major Avenue Apts. □ Henderson (89015) – George & Lois Brown Estates □ Las Vegas (89110) – Sandy Robinson Apts. □ Las Vegas (89115) – John Chambers Apts. □ Las Vegas (89119) – Bob Hogan Apts. □ Las Vegas (89122) – Carol Haynes Apts. □ Las Vegas (89122) – Dina Titus Estates □ Las Vegas (89123) – Shelbourne Avenue Apts. □ Las Vegas (89146) – Ray Rawson Villa □ Las Vegas (89156) – Bledsoe Lane Apts. □ Las Vegas (89156) – Park Apts. □ Las Vegas (89104) – Mojave Cedar Apts. □ Reno (89502) – John Butterworth Estates □ Reno (89502) – William J. Raggio Apts.

Accessible Space, Inc. HOUSING FOR PERSONS WITH DISABILITIES NATIONWIDE HOUSING SITE LOCATIONS (PAGE TWO)

5/9/2014

APARTMENT LIVING (CONTINUED) New Mexico □ Santa Fe – Homeward Bound Apts. Oklahoma □ Rock Ridge Apartments- McAlester South Dakota □ Rapid City – Galaxy Apts. □ Sioux Falls – Crocus Meadow Apts. □ Watertown – Eastwood Apts. Tennessee □ Memphis – McCullough Place □ Memphis – Welsh Manor □ Nashville – Hagy Commons Texas □ Austin – Pecan Hills □ Baytown – Rollingbrook Apts. □ Clear Lake – Paul Chase Commons □ Corpus Christi – Henry Harbour □ Pasadena – Vista Villa (1 BR only) □ San Antonio – Oak Forest Heights □ The Woodlands – Windvale Pines Apts. □ Universal City – Wagon Crossing Apts. Virginia □ Chesapeake – The Sanderling □ Exmore – AP’s Freedom Apts. (1 BR only) □ Norfolk – The Anchorage Washington □ Spokane – Eagle Crest Estates Wisconsin □ Hudson – Tribute Commons **Please note that the LIHTC & HOME income can increase to 140% AMI which is appropriate for LIHTC, however for HOME units the income can only increase to 80% AMI before rent must be adjusted to be 30% of the tenants income See Minnesota Properties on Next Page

Accessible Space, Inc. HOUSING FOR PERSONS WITH DISABILITIES NATIONWIDE HOUSING SITE LOCATIONS

5/7/2013

***PLEASE LIMIT YOUR SELECTIONS TO A TOTAL OF FIVE (5) HOUSING LOCATIONS***

APARTMENT LIVING Each resident rents his/her own accessible apartment. ASI supportive services are available in some locations, and some locations offer services from other providers. Housing locations in bold print indicate housing with ASI Services available. Please contact ASI’s Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722, extension 224. TTY/TDD (800) 627-3529. Please note: ASI services are available only to qualified applicants and residents, and rent payments do not include the cost or provision of ASI supportive living services that may be available. Alabama □ Florence – Dogwood Terrace □ Hoover – Patton Ridge Apts. □ Mobile – Anderson Fischer Apts. Arizona □ Chandler – Arroyo Terrace □ Mesa – R.J. Piltz Vista Bonita California □ Capitola – The Dakota □ Davis – Becerra Plaza □ Fullerton – Harbor View Terrace □ South Lake Tahoe – Sky Forest Acres Colorado □ Fort Collins – Harmony Road Apts. □ Greeley – Fox Run □ Longmont – Casa Libertad □ Greeley – Twin Rivers Illinois □ Carbondale – Heartland Apts. Kansas □ Kansas City – Mid America Commons (1 BR only) □ Topeka – Melissa Anne Hanger Apts. □ Kansas City – Blackbird Apts. See Minnesota Properties on Next Page Missouri □ Springfield – Tim O’Brien Apts.

Montana □ Billings – Grandview Apts. □ Bozeman – Spring Run Apts. □ Great Falls – Meadow Lark Apts. □ Great Falls – Southwinds Estates □ Helena – Queen City Estates □ Missoula – Bruce Blattner Apts. □ Missoula – Eagle Watch Estates North Dakota □ Fargo – Northland Apts. □ Grand Forks – Linden Place (1 BR only) □ Jamestown – Dewey Apts. □ Minot – Accessible Space Apts. Nevada □ Carson City (89701) – Frost Yasmer Estates □ Henderson (89009) – Major Avenue Apts. □ Henderson (89015) – George & Lois Brown Estates □ Las Vegas (89110) – Sandy Robinson Apts. □ Las Vegas (89115) – John Chambers Apts. □ Las Vegas (89119) – Bob Hogan Apts. □ Las Vegas (89122) – Carol Haynes Apts. □ Las Vegas (89122) – Dina Titus Estates □ Las Vegas (89123) – Shelbourne Avenue Apts. □ Las Vegas (89146) – Ray Rawson Villa □ Las Vegas (89156) – Bledsoe Lane Apts. □ Las Vegas (89156) – Park Apts. □ Las Vegas (89104) – Mojave Cedar Apts. □ Reno (89502) – John Butterworth Estates □ Reno (89502) – William J. Raggio Apts.

Accessible Space, Inc. HOUSING FOR PERSONS WITH DISABILITIES

NATIONWIDE HOUSING SITE LOCATIONS (PAGE TWO)

5/7/2013

APARTMENT LIVING (CONTINUED) New Mexico □ Santa Fe – Homeward Bound Apts. Oklahoma □ Rock Ridge Apartments- McAlester South Dakota □ Rapid City – Galaxy Apts. □ Sioux Falls – Crocus Meadow Apts. □ Watertown – Eastwood Apts. Tennessee □ Memphis – McCullough Place □ Memphis – Welsh Manor □ Nashville – Hagy Commons Texas □ Austin – Pecan Hills □ Baytown – Rollingbrook Apts. □ Clear Lake – Paul Chase Commons □ Corpus Christi – Henry Harbour □ Pasadena – Vista Villa (1 BR only) □ San Antonio – Oak Forest Heights □ The Woodlands – Windvale Pines Apts. □ Universal City – Wagon Crossing Apts. Virginia □ Chesapeake – The Sanderling □ Exmore – AP’s Freedom Apts. (1 BR only) □ Norfolk – The Anchorage Washington □ Spokane – Eagle Crest Estates Wisconsin □ Hudson – Tribute Commons **Please note that the LIHTC & HOME income can increase to 140% AMI which is appropriate for LIHTC, however for HOME units the income can only increase to 80% AMI before rent must be adjusted to be 30% of the tenants income can only increase to 80% AMI before rent must be adjusted to be 30% of the tenants income

Accessible Space, Inc. HOUSING FOR PERSONS WITH DISABILITIES

MINNESOTA HOUSING SITE LOCATIONS

***PLEASE LIMIT YOUR SELECTIONS TO A TOTAL OF FIVE (5) HOUSING LOCATIONS***

Housing locations in bold print indicate housing with ASI Services available. Please contact ASI’s Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722, extension 224. TTY/TDD (800) 627-3529. Please note: ASI services are available only to qualified applicants/residents, and resident rent payments do not include the cost or provision of ASI supportive living services that may be available.

APARTMENT LIVING Each resident rents his/her own accessible apartment. ASI Assisted Living Services are available in some locations, and some locations offer services from other providers. □ Alexandria – Nordic Meadow Apts. □ Austin – Prairie Sky Apts. □ Bloomington – Henry Courts I (1 BR only) □ Brainerd – Northern Lights Apts. □ Burnsville – Leah’s Apts. □ Burnsville – West Apts. □ Duluth – Burke Apts. □ Duluth – Pine Grove Apts. □ Duluth – Redruth Valley Apts. (1 BR only) □ Duluth – Superior View Apts. □ Hibbing – Winston Court Apts. □ Marshall – River Winds Apts. □ Owatonna – Kay Knutson Apts. □ Rochester – Bostrom Terrace (1 BR only) □ Rogers – Meadow Trail Apts. □ Roseville – Roselawn Village □ Sartell – Hope Village Apts. □ Shakopee – River Bluff Apts. □ St. Cloud – Quarry Heights □ St. Paul – Henry Courts II (1 BR only) □ Stillwater – Hillcrest Apts. □ Willmar – Becker Avenue Apts.

HOMES WITH ASSISTED LIVING SERVICES Each resident has a private bedroom and shares common areas with other residents in an accessible home. ASI offers/provides 24/7, on-site Assisted Living services to Medicaid eligible residents. □ Grand Rapids – Moses □ Minneapolis – 28th Street □ Minneapolis – Camden □ Minneapolis – Chicago

ADULT LICENSED FOSTER CARE HOMES Each resident has a private bedroom and shares common areas with other residents in an accessible home. ASI offers/provides 24/7, on-site Adult Licensed Foster Care services to Medicaid eligible residents. □ Blaine – Van Buren Home □ Coon Rapids – Flintwood Home □ Coon Rapids – Magnolia Home □ Falcon Heights – Snelling Home □ St. Anthony – Silver Lake Home □ White Bear Lake – Cedar Home HOMES WITHOUT ASI SERVICES Each resident has a private bedroom and shares common areas with other residents in an accessible home. Residents who need supportive services can arrange with the provider of their choice. □ Golden Valley – Pesch Place □ St. Paul – Iglehart Home □ St. Paul – Selby Home

Accessible Space, Inc. HOUSING FOR SENIORS AGE 62 & BETTER NATION WIDE HOUSING SITE LOCATIONS

5/7/2013

***PLEASE LIMIT YOUR SELECTIONS TO A TOTAL OF FIVE (5) HOUSING LOCATIONS***

APARTMENT LIVING (1 BR) Each resident rents his/her own apartment. Accessible apartments are available. ASI supportive services are available in some locations, and some locations offer services from other providers. Housing locations in bold print indicate housing with ASI Services available. Please contact ASI’s Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722, extension 224. TTY/TDD (800) 627-3529. Please note: ASI services are available only to qualified applicants and residents, and rent payments do not include the cost or provision of ASI supportive living services that may be available. Some locations offer information and referral services at no charge to residents. Meal programs are available at some locations from other providers for a suggested donation.

Minnesota □ Albert Lea – Washington Avenue Apts. □ Owatonna – Maple Trail Apts. □ Rochester – Kenosha Drive Apts. □ Rogers – Autumn Trails □ Sartell – David F. Day □ St. Paul – Arlington Gardens □ Worthington – Buffalo Ridge Apts. Montana □ Bozeman – Summer Wood Apts. □ Great Falls – The Portage □ Helena – Aspen Village □ Kalispell – Van Ee Apts. Nevada □ Las Vegas – Tonopah Lamb Apartments. North Dakota □ Dickinson – Frontier Apts. South Dakota □ Brookings – Pheasant Run Apts. □ Sioux Falls – Pasque Meadow Apts. Texas □ The Woodlands – Tangle Brush Villa Wisconsin □ Hudson –Heirloom Court Apts. **Please note that the LIHTC & HOME income can increase to 140% AMI which is appropriate for LIHTC, however for HOME units the income can only increase to 80% AMI before rent must be adjusted to be 30% of the tenants income

Wyoming □ Cheyenne – Heritage Court Apts.

1

**FOR OFFICE USE ONLY DO NOT WRITE IN THIS BOX**

1 BR _____ 2 BR _____ Date Rcv’d_____________________

Location #1_____________ Location#2_______________

Location #3________________ Location#4__________________

Location #5 ________________

Interest List(s) __________________________________________

APPLICATION FOR HOUSING ADMISSION AND RENTAL ASSISTANCE

APPLICANT NAME _____________________________________________________________________________________________

CO-APPLICANT NAME __________________________________________________________________________________________

CURRENT MAILING ADDRESS___________________________________________________________________________________

CITY, STATE, ZIP CODE_________________________________________________________________________________________

HOME PHONE (________) ______________________________ WORK PHONE (_________) _______________________________

E-MAIL ADDRESS:___________________________________________CELL PHONE(______)_______________________________

If I cannot be reached at above number(s), please contact: PERSON TO CONTACT_________________________________________

PHONE (_________) ________________________________ RELATIONSHIP_____________________________________________

In case of an EMERGENCY please contact: PERSON TO CONTACT ____________________________________________________

PHONE ( ) RELATIONSHIP___________________________________________

**ALL CO-APPLICANTS AGE 18 OR OLDER, OTHER THAN SPOUSE ARE REQUIRED TO COMPLETE A SEPARATE

APPLICATION

Any applicant, who purposefully falsifies, misrepresents or withholds any information related to program eligibility or submits

inaccurate and/or incomplete information on this application will not be considered for housing nor placed on the waiting list.

HOUSEHOLD COMPOSITION AND CHARACTERISTICS

1. List the Head of Household and all other members who will be living in the unit. Give the relations of each family member to the head.

Member #

Member’s Full Name

Relationship

Birth Date

Age

Sex

Social Security Number

1

Head

2. Is Head of Household or spouse/Co-Head handicapped or disabled? ______ Yes ______ No

(For program and unit eligibility purposes only)

01/11 FORM # HUD-1

2550 University Ave West, Suite 330N 651-645-7271 (800-466-7722) Fax: 651-209-6623 Equal Opportunity Employer

Saint Paul, Minnesota 55114 TTD/Voice: 800-627-3529 Equal Housing Opportunity

2

The Department of Housing and Urban Development requires that, for statistical purposes only, we report the race and ethnicity of the Head

of Household for applicants. You are not required to answer, nor does your answer affect your position on our waiting list or your eligibility

for housing

3. Race of Head of Household: (Select all that apply)

______ White _______ Black or African American ______ American Indian or Alaskan Native

______Asian _______ Native Hawaiian or Other Pacific Islander ________ Other

4. Ethnicity of Head of Household: (Select One)

______ Hispanic ______ Non-Hispanic

5. Will you be the only person to occupy the unit? ______ Yes ______ No

6. Do you expect a change in your household composition? ______ Yes ______ No If yes, please explain: __________________

____________________________________________________________________________________________________________

7. Please identify any special housing needs your household has: ___________________________________________________________

____________________________________________________________________________________________________________

RENTAL HISTORY

CURRENT HOUSING

____ Own Home _____ Apartment _____ Rehab Center

____ Parent’s Home _____ Nursing Home Other:

Name and Address of Your Current Landlord:

____________________________________________________ Landlord Phone___________________________________________

____________________________________________________ How Long Have You Lived There? __________________________

____________________________________________________ Reason for Leaving? ______________________________________

Is this a subsidized unit? _____ Yes _____ No

Has your housing assistance ever been terminated for fraud, non-payment of rent or utilities, failure to cooperate with recertification

procedures or for any other reason? _____ Yes _____ No If yes, please explain ____________________________________________

Name and Address of your Former Landlord:

____________________________________________________ Landlord Phone___________________________________________

____________________________________________________ How Long Did You Live There?_____________________________

Reason for Leaving?______________________________________

3

HOUSEHOLD INCOME INFORMATION (All information will be verified by a third party)

Please answer each of the following questions. List current and anticipated income for the next twelve months, (including full time, part time

or seasonal income). If a household member has more than one source of income, use a separate line for each source.

MONTHLY

DOES ANY MEMBER OF YOUR HOUSEHOLD: YES NO AMOUNT

1. Work full-time, part-time or seasonally? ______ ______ ____________

2. Work for someone who pays them cash? ______ ______ ____________

3. Expect to work for any period during the next year? ______ ______ ____________

4. Expect a leave of absence from work due to lay-off, medical, maternity ______ ______ ____________

or military leave?

5. Now receive or expect to receive unemployment benefits or severance pay? ______ ______ ____________

6. Now receive or expect to receive child support? ______ ______ ____________

7. Entitled to child support that he/she is not now receiving? ______ ______ ____________

8. Now receive or expect to receive alimony? ______ ______ ____________

9. Have an entitlement to receive alimony that is not currently being received? ______ ______ ____________

10. Now receive or expect to receive public assistance or welfare? ______ ______ ____________

11. Now receive or expect to receive Social Security or disability benefits? ______ ______ ____________

12. Now receive or expect to receive income from a pension or annuity? ______ ______ ____________

13. Now receive or expect to receive regular contributions from organizations ______ ______ ____________

or from individuals not living in the unit?

14. Other (list) : ________________________________________________ ______ ______ ____________

HOUSEHOLD ASSETS (All information will be verified by a third party)

CURRENT

DO YOU HAVE MONEY HELD IN: YES NO BALANCE

1. Checking Accounts? ______ ______ __________

2. Savings Accounts? ______ ______ __________

3. Stocks? ______ ______ __________

4. Capital Investments? ______ ______ __________

5. Bonds? ______ ______ __________

6. Trust? ______ ______ __________

7. Securities? ______ ______ __________

8. IRA/KEOGH Accounts? ______ ______ __________

9. Certificates of Deposit? ______ ______ __________

10. Pension/Retirement Funds? ______ ______ __________

4

HOUSEHOLD ASSETS (All information will be verified by a third party) continued

11. Money Market Funds? ______ ______ __________

12. Treasury Bills? ______ ______ __________

13. Other (list)? __________________________________________ ______ ______ __________

YES NO BALANCE

Do you currently hold a contract for deed? ______ ______ __________

Do you currently own real estate? ______ ______ __________

If yes, please list the location(s), number of acres owned, any expenses incurred (i.e., taxes, insurance) and any income received:

________________________________________________________________________________________________________________

Do you have any coin collections, antique cars, gems/jewelry, stamps or any other items held for investment purposes (do not consider

wedding rings and personal jewelry)? ______ ______ __________

Are any assets held jointly with another person? ______ ______ __________

If yes, list person’s name and the asset(s) held jointly: __________________________________________________________

I/We hereby certify that I/We Have _____ have not _____ sold or disposed of any assets for less than fair market value during the two year

(24 month) period preceding the date of this application. Any assets sold or disposed of for less than fair market value is subject to

identification and verification.

HOUSEHOLD ALLOWANCE INFORMATION (All information will be verified by a third party)

All or part of your household’s expenses may be allowable as a deduction from your annual income. Eligible expenses include child care

costs, payments on outstanding medical insurance premiums, cost of assistive devices, cost of attendant care, and any other medical and dental

costs NOT covered by an outside source: e.g. insurance, Medicare, state agency, or charitable organizations.

MONTHLY

DO YOU EXPECT TO INCUR ANY OF THE FOLLOWING EXPENSES: YES NO AMOUNT

1. Child care which enables you or another household member to work, go to

school or seek employment? ______ ______ ____________

2. Attendant care for a handicapped or disabled household member, so that an adult

household member can work, seek employment or go to school? ______ ______ ____________

3. Medicare premiums? ______ ______ ____________

4. Other medical insurance premiums? ______ ______ ____________ Name of Company _________________________________________

5. Outstanding medical bills on which you are currently paying? ______ ______ ____________

6. Cost of assistive devices for a handicapped or disabled household member? ______ ______ ____________

7. Do you receive medical assistance through the County or State? ______ ______ ____________

8. Do expect to have any additional medical expenses during the next twelve months? ______ ______ ____________

If yes, please explain: __________________________________________________________________________________________

5

MISCELLANEOUS

1. Are you attending college? _____ Yes _____ No _____ Full Time _____ Part Time

2. Have you or any members of your household ever been convicted of a felony or misdemeanor other than a traffic violation?

_____ Yes _____ No

3. Drug related criminal activity _____ Yes _____ No

4. Are you or any household member a registered sex offender? ______ Yes ______ No

If answered yes for questions 2, 3 and/or 4 please explain and list the states of conviction and/or registration:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Please list all of the states you and all household members have resided in:

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

SIGNATURES

I/We understand the information in this application will be used to determine eligibility for housing assistance and that this information will be

verified. I/We understand that any false information may make me/us ineligible for a unit.

I/We certify that all information given in this application is true, complete and accurate. I/We understand that if any of this information is

false, misleading or incomplete, management may decline our application or, if move-in has occurred, terminate our lease agreement.

I/We authorize management to make any and all inquiries to verify this information, directly or through information exchanged now or later

with rental and credit screening services, and to contact previous and current landlords or other sources for credit and verification information

which may be released to appropriate federal, state or local agencies.

If my/our application is approved and move-in occurs, I/we certify that only those persons listed in this application will occupy the unit, that it

will be my/our only residence, and that there are no other persons for whom I/we have, or expect to have, responsibility to provide housing.

I/We agree to notify management in writing regarding any changes in household address, telephone numbers, income and household

composition.

Applicant’s Signature _________________________________________________ Date__________________________

Co Applicant Signature ____________________________________________________ Date _________________________

INCOMPLETE APPLICATIONS WILL BE RETURNED AND NOT PROCESSED

DO YOU HAVE A LEGAL GUARDIAN, CONSERVATOR OR POWER OF ATTORNEY?

_____ Yes _____ No IF YES, ATTACH A COPY OF LEGAL DOCUMENTATION.