This institution is an equal opportunity provider.
IMPACT SEVEN, INC.
147 LAKE ALMENA DRIVE
EQUAL
HOUSING
ALMENA, WI 54805
APPLICATION FOR OCCUPANCY
Roland Kannenberg Villa - 693
Project Name
Where did you hear of the housing program? _____ Newspaper _____ Radio _____ Poster _____ Word of Mouth
_____ Personnel Office (Abbyland ___ Other ___________________)
Mr.
Mrs.
Ms.
Preferred Moving Date:
Applicants Full Name ________________________________________________ Age
Present Address
(Mailing Address)
(City)
(Zip Code)
Social Security Number ____________________ Sex __________ Date of Birth
Telephone Number ______________________________
Mr.
Mrs.
Ms.
Spouse/Co-Tenant __________________________________________________ Age
Present Address
(Mailing Address)
(City)
(Zip Code)
Social Security Number ____________________ Sex __________ Date of Birth
Telephone Number ______________________________
Other Members of Household that will live in the unit:
Name
Date of Birth
Sex
Age
SS#
Person to be notified in case of emergency:
Name _____________________________________
Phone
Address ___________________________________
Relationship
___________________________________
(City)
(State)
(Zip-code)
Is someone legally empowered to act in your behalf?
Yes
No
Relationship
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Name _____________________________________
Home Phone
Address ___________________________________
Business Phone
___________________________________
(City)
(State)
(Zip-code)
Do you have any specific housing requirements, such as a special handicapped accessible unit?
Do you certify that this unit will be your permanent residence and that you do not/will not maintain a
separate subsidized unit in a different location? _____________
Your signature on the back of this application authorizes the owner/manager of the project in which
you are applying for occupancy to contact your prior landlords for information regarding your prior
tenancies, to check personal and credit references, and to obtain credit, employment and court
records.
Complete all applicable information for Applicant, Spouse or Co-Applicant on this page and the next
page. Attach an additional sheet if more space is needed. (Include names and addresses.)
INCOME INFORMATION
1. Salary/Wages - List gross amount (before deductions) of wages and salaries, overtime pay,
commissions, fees, tips and bonuses. Indicate source.
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
2. Net Income from Business or Profession or Rental or Real or Personal Property.
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
3. Social Security/SSI Payments.
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
4. Pensions, Annuities, Retirement Funds, IRA Accounts.
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
5. All other income: Include income from all other sources, such as Unemployment, Disability
Compensation, Workmans Compensation, Severance Pay, Alimony, Child Support, Regular
recurring contributions or gifts of money, Educational Grants, Scholarships, VA Benefits, Regular
Pay, Special Pay and Allowances for Head of Household in Armed Services; Public Assistance,
AFDC, Welfare or any other source.
$____________ Annually from ______________________________________
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$____________ Annually from ______________________________________
$____________ Annually from ______________________________________
Please list below any former rental addresses, landlord names & addresses within the past 10 years,
starting with the present, if now renting:
Rental Address
Landlords Name, Address & Phone #
Dates Rented From
______________________
____________________________________
_____________
______________________
____________________________________
_____________
____________________________________
_____________
______________________
____________________________________
_____________
______________________
____________________________________
_____________
____________________________________
_____________
______________________
____________________________________
_____________
______________________
____________________________________
_____________
____________________________________
_____________
References: List personal and credit references; names, addresses and telephone numbers:
_______________________________________________________
Applicants Signature
________________________________
Date
_______________________________________________________
Spouse/Co-Tenants Signature
Date
________________________________
_______________________________________________________________________________
The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting
through the Rural Housing Service that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin,
religion, sex, familial status, age, and disability are complied with. You are not required to furnish this information, but are encouraged to do so. This
information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is
required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.
Applicant
Race
White
Black or African American
Asian
American Native/Alaskan Native
Native Hawaiian or Other Pacific Islander
Other (Specify) _________________
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Sex
Male
Female
Co-Tenant/Spouse
Race
White
Black or African American
Asian
American Native/Alaskan Native
Native Hawaiian or Other Pacific Islander
Other (Specify)
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Sex
Male
Female
STATEMENT REQUIRED BY THE PRIVACY ACT
Rural Development is authorized by the Consolidated Farm and Rural Development Act (7 U.S.C. 1921 et. seq.); and Title V of the Housing Act of 1949, as
amended (42 U.S.C. 1471 et. seq.) or other Acts administered by Rural Development to solicit the information requested on Rural Development application
forms.
Disclosure of information requested is voluntary. However, failure to disclose certain items of information requested, including your Social Security Number or
Federal Identification Number, may result in a delay in the processing of an application or its rejection.
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The principle purposes to collecting the requested information are to determine eligibility for occupancy in the Rural Development financed rental project and to
determine the amount of tenant contribution for rent. The information collected on this form may be released to appropriate Federal, State and Local Agencies
when relevant to civil, criminal or regulatory proceedings.
