HRA OF LUVERNE / BLUE MOUND TOWER216 N MCKENZIE LUVERNE MN 56156507-283-4922 FAX 507-449-3664

Name________________________________________________________________________________First Full Middle Name Last

DOB:_____________________________ SS#: ____________________________________ Sex: _____

Current Address: ______________________________________________________________________Street City State, Zip Code

Mailing Address: ______________________________________________________________________(If different) Street City State, Zip Code

Phone#: ___________________________________ Email Address______________________________

Current Landlord: ______________________________________________________________________

Mailing Address: ______________________________________________________________________Street/PO Box City State/Zip Code

Monthly Rent: _______ Number of Bedrooms: ______ Number of persons living in household: _____

How long have you lived at the above address? Years ________ Months____ _____

Do you owe any money to above landlord? Yes ____ No ____ If yes, amount owed $__________

List city, state, and year of locations where you have lived for the past five years.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

LIST ALL PERSONS WHO WILL LIVE IN THE UNIT other than yourself: Give their name, relationship to you, their DOB, SS#, and if they are a US Citizen.

1) __________________________________________________________________________________

2) __________________________________________________________________________________

Do you anticipate any changes in your family size? Yes ___ No ___ If yes, explain

______________________________________________________________________________

Is any member of the household now serving in the military? Yes ___ No ___ If yes, explain

____________________________________________________________________________________

INCOME INFORMATION

List all income for everyone who will live in the unit.

Name Source of Income Amount

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Income includes but is not limited to: Employment, welfare, social security, social security disability, pensions, unemployment, child care, alimony, child support, annuities, dividends, rental income, cash contributions, scholarships, grants, etc.)

BANK INFORMATION: List any checking, savings, credit union, certificate of deposit, etc.

Type of Account Bank Name Amount/Value

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you have any stocks/bonds/savings bonds. Yes __ No __ If yes, value $____________

Do you own real estate? Yes __ No __ If yes, current value $ ____________

Have you ever owned real estate? Yes __ No __ If yes, when? ____________

Do you have life insurance or a retirement account? Yes __ No __ If yes, current amount/value $ ______

CHILDCARE EXPENSE:

Do you pay for childcare to allow you to work? Yes __ No __ If yes, how much $__________

MEDICAL EXPENSES (If elderly, disabled, or handicapped)

Are you on Medicare? If yes, monthly cost $____________________

Do you receive benefits through the welfare office? If yes, monthly amount $_________________

Do you pay for medical and/or prescription insurance? If yes, monthly cost $____________________

Do you pay for prescription drugs? If yes, monthly cost $____________________

SPECIAL NEEDS

For the purpose of determining allowable income deductions, does any member of the household have a disability? Yes __ No __

Does anyone who will live in the unit require any special accommodations? Yes __ No __

If yes, what? ___________________________________________________________________

Do you pay for a care attendant or equipment for anyone with a disability to allow that member or anyone else in the family to work? If yes, describe. ______________________________________________________________________________

______________________________________________________________________________

BACKGROUND

Has anyone who will live in the unit ever been arrested? Yes __ No __

Has anyone who will live in the unit ever had a warrant issued for an arrest? Yes __ No __

Is anyone who will live in the unit a registered sex offender? Yes __ No __

Has anyone who will live in the unit ever engaged in the felonious use of drugs? Yes __ No__

Has anyone who will live in the unit used any other name or social security number? Yes __ No __

If you answered yes to any of these questions, explain.

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you plan to bring a pet onto our property? Yes __ No__

If yes, list breed, age, weight.

____________________________________________________________________________________

Has anyone who will live in the unit ever applied for or lived in Public Housing? Yes __ No __

If yes, where and when.

_____________________________________________________________________________________

Do you or anyone who will live in the unit owe any money to a Public Housing Authority or past landlord?

Yes __ No __ If yes, where and how much? _____________________________________________________________________________________

I understand it is my responsibility to notify the Luverne HRA, in writing, of any change of address/contact information. If we cannot reach you, your name will be removed from the waiting list and you will have to re-apply.

By signing below, I / We certify that all information given to the Luverne HRA in this application is correct. I/We understand that if these facts are not true, housing assistance will NOT be provided and I/We will be declared ineligible. I understand that after the information in this application is verified the information will be submitted to HUD on Form HUD-50058 (The Federal Privacy Act Statement contains additional information concerning the authorized use of this information.) I also understand that staff of the Luverne HRA will verify this information and I authorize the Luverne HRA to submit inquiries necessary for the purpose of verifying the facts herein stated.

______________________________________________________ __________________________Head of Household Date

______________________________________________________ ______________________Spouse or Other Adult Date

How did you hear about this housing? Please check all that apply.

Newspaper Ad Friend /Relative Other ________________________

NOTICE TO ALL APPLICANTS:

REASONABLE ACCOMMODATIONS FOR APPLICANTS WITH DISABILITIES OR HANDICAPS

The Housing and Redevelopment Authority of Luverne is a public agency that provides low rent housing to eligible families, elderly families and single people. The Housing Authority is not permitted to discriminate against applicants on the basis of their race, religion, sex, national origin, disability or handicap. In addition, the Housing Authority has a legal obligation to provide “reasonable accommodations” to applicants if they or any family member has a disability or handicap.

A reasonable accommodation is some modification or change the Housing Authority can make to its apartments or procedures that will assist an otherwise eligible applicant with a disability to take advantage of the Housing Authority’s programs. Examples of reasonable accommodations would include:

Making alterations to a unit so it could be used by a family member with a wheelchair. Installing strobe light smoke detectors in an apartment for a family with a haring impaired

member. Permitting a family to have a support animal necessary to assist a family member with a

disability in a Housing Authority development where animals are not usually permitted. Making large type documents or a reader available to a vision impaired applicant during the

application process. Making a sign language interpreter available to a hearing impaired applicant during the

interview. Permitting an outside agency to assist an applicant with a disability to meet the Housing

Authority’s applicant screening criteria.

An applicant family that has a family member with a disability must still be able to meet essential obligations of tenancy – they must be able to pay rent, to care for their apartment, to report required information to the Housing Authority, to avoid disturbing their neighbors, etc., but there is not a requirement that they must be able to do these things without assistance.

If you or a member of your family has a disability, you may request a reasonable accommodation at the application process or after admission. This is up to you. If you would prefer not to discuss your situation with the Housing Authority, that is your right.

SMOKE_FREE POLICY

A Smoke-Free Policy is effective October 1, 2015, that eliminates smoking anywhere on the property except for a designated smoking area located at the Southeast corner of our property.

All tenants will be required to sign a lease including the policy that will be in force, along with the consequences of any violations by tenants and/or their guests. Failure to abide by this policy may result in termination of a resident’s lease.

DECLARATION OF 214 STATUS

Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read the declaration statement carefully and sign and return to the Housing Authority’s admissions office. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.

I, ___________________________________________________ certify, under penalty of perjury, that, to the best of my knowledge, I am lawfully within the United States because (please check the appropriate box):

___ I am a citizen by birth, a naturalized citizen or a national of the United States; or

___ I have eligible immigration status and I am 62 years of age or older. Attach evidence of proof of age 2/; or

___ I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing eligible immigration status and signed verification consent form.

___ Immigrant status under 101 (a)(15) or 101 (a)(20) of the Immigration and Nationality Act (INA) 3/; or

___ Permanent residence under 249 of INA 4/; or

___ Refugee, asylum, or conditional entry status under 207, 208, or 203 of the INA 5/; or

___ Parole status under 212(d)(5) of the INA 6/; or

___ Threat to life or freedom under 243(h) of the INA 7/; or

___ Amnesty under 245A of the INA U8/.

_________________________________________________________________________________Applicant Signature Date

____ Check here if signature is of adult residing in the unit who is responsible for child named on statement above.

(One copy of this form is needed for each adult in household)

HOUSING & REDEVELOPMENT AUTHORITY OF LUVERNE

216 N McKenzie, Luverne MN 5156(507) 283-4922

FINGERPRINT / CRIMINAL CONVICTION HISTORY REPORT RELEASE FORM

I authorize The HRA of Luverne – Blue Mound Tower to utilize the information below for the sole purpose of obtaining a criminal arrest and conviction history report via FBI Live Scan, which I understand is linked to a national database. As an applicant, I understand the Housing Authority is required to secure a criminal background report as part of the eligibility screening process.

NAME (print clearly):_________________________________________________________________First Middle Last

MAIDEN/FORMER NAMES PREVIOUSLY USED:

_____________________________________________________________________________________

BIRTH DATE: _____/_____/_______ PLACE OF BIRTH: __________________________________

SSN: __________ - __________ - __________ SEX: M□ F□ RACE: _________________________

ADDRESS: _________________________________________________________________________________

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. The HRA of Luverne – Blue Mound Tower DOES NOT DISCRIMINATE ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, ANCESTRY, SEXUAL ORIENTATION, AGE, FAMILIAL STATUS, OR PHYSICAL OR MENTAL DISABILITY IN

THE ACCESS TO ITS PROGRAMS OR IN ITS ACTIVITIES, FUNCTIONS, OR SERVICES. I UNDERSTAND THAT THE PERSONAL INFORMATION ABOVE WILL BE USED SOLELY FOR THE PURPOSES OF

ACCESSING MY CRIMINAL/ARREST RECORDS FOR ELIGIBILITY SCREENING AND VERIFYING THAT THE DATA COLLECTED IS THAT OF MY OWN.

Signature: ______________________________________________________________ Date: __________________________

(One copy of this form is needed for each adult in household)

STAFF ONLY

MY SIGNATURE BELOW INDICATES THAT I HAVE REVIEWED THE CRIMINAL/ARREST RECORDS SHOWN ABOVE, IF ANY.

Signature: ___________________________________________ Date: __________________________Faciltiy Director/Owner or Office Manager (circle one)

Date Printed: _________________________________________ Check One: Eligible □ Ineligible □

ROCK COUNTY SHERIFF’S OFFICE

Notification for Release of Information

You are hereby informed that the following agencies will be contacted for information in connection with the evaluation of your application.

___ Bureau of Criminal Apprehension

___ Local County Sheriff’s Office

___ NCIC

NATURE OF INFORMATION TO BE DISCLOSED

The Housing & Redevelopment Authority of Luverne is required to obtain background information regarding the individual named below. The information may include criminal conviction data, arrest information, reports about abuse and neglect of children, or adults, homicides, crimes against the person, coercion, criminal sexual conduct, incest, theft/burglary, arson, obscene phone calls, illicit drug/alcohol use and investigation results available from local, state and national criminal record repositories. The information will be disclosed to the HRA of Luverne.

Name of Business Requesting Information: HRA of Luverne – Blue Mound TowerAddress of Business: 216 N. McKenzie, Luverne MN 56156Phone Number of Business: 507-283-4922

I hereby acknowledge that I have been notified of and understand the right to disclosure of information.

__________________________________________________________________ _________Applicant Signature Date

_________________________________________________________________ _____________HRA Signature Date

(One copy of this form is needed for each adult in household)

ATHORIZATION ROCK COUNTY SHERIFF’S OFFICE

Release of Information

Last Name First Name Full Middle Name Maiden NameSex

Street Address City State Zip Code

Date of Birth Driver’s License # & State of Issue Social Security #

Have you resided in any other state or county? ___ Yes ___ No

If yes, list all addresses including state and county (use back of page if necessary).

_____________________________________________________________________________________

_____________________________________________________________________________________

DO NOT WRITE IN THIS SECTION. This section is to be completed by law enforcement agency,

local social service agency, or Bureau of Criminal Apprehension.

___ Bureau of Criminal Apprehension ___ Local County Sheriff’s Office

___ NCIC

INFORMATION DISCLOSED IS AS FOLLOWS:

_____________________________________________________________________________________

_____________________________________________________________________________________

Signature ___________________________________________________Title _____________________

Agency ___________________________________ Date ________________________________

(One copy of this form is needed for each adult in household)