Dear Applicant:

Thank you for contacting Joseph Caffey Apartments & Jordan-Caffey Townhomes to inquire about submitting an
application for housing.

Joseph Caffey Apartments & Jordan-Caffey Townhomes are Low Income Housing Tax Credit Communities. Once we receive
a completed application, signed by all household members 18 years of age and older, you then be will be notified
regarding your initial eligibility status.

Completed applications must be returned to the following location only:

Omni Development Corporation
810 Eddy Street
Providence, RI 02905

Enclosed you will find the following information:

• Application for Housing
• HUD-92006 “Optional Contact” form

Incomplete and/or missing forms WILL NOT BE ACCEPTED.

Completed applications will be date and time stamped upon their receipt. An applicant’s place on the waitlist will be
determined solely by date the completed application is received. If there is no waiting list for the type of unit you are
applying for, we will contact you regarding an initial meeting.

At the meeting, we will need to independently verify all of your income and assets prior to determining eligibility. There
are other qualifying criteria described in our Tenant Selection Plan (TSP). All applications are subject to the complete
screening process defined in the TSP prior to any offer for an apartment. Applicants not meeting the requirements of the
tenant selection plan may be rejected.

If you are a person with disabilities and require a reasonable accommodation, please contact us at (401) 461-4442 to
process the request for a reasonable accommodation.

Wingate Management Company, LLC. does not discriminate on the basis of disability status in the admission or access to, or treatment or
employment in, its federally assisted programs and activities. The person listed below has been designated to coordinate compliance
with the nondiscrimination requirements contained in the Dept. of Housing & Urban Development’s regulations implementing Sec. 504
(24 CFR Part 8 dated June 2, 1988). Contact: Site Manager
 FOR OFFICE USE ONLY
HOW DID YOU HEAR ABOUT Joseph Caffey Apartments &
Jordan-Caffey Townhomes? DO NOT COMPLETE THIS BOX
(Please check an option) Application Date: ___________________
____ Drive By / Sign _____ Friends or Family Application Time: ___________________
____ Internet ____ Newspaper/Advertisement Gross Annual Income: _______________
Waiting List: _______________________
____ Other: (Describe) _____________________________________

EMAIL ADDRESS: ____________________________________________

Do you have a SECTION 8 VOUCHER?: YES _____ NO ____

APPLICATION FOR HOUSING

Low-Income Housing Tax Credit

Please Print Clearly

Project(s): Joseph Caffey Apartments; Jordan-Caffey

This Application is for housing at:
Townhomes
Name: OMNI DEVELOPMENT CORP.
Please complete this application and Address: 810 EDDY STREET
return to: PROVIDENCE, RI 02905

Applications are placed in order of date and time received. An applicant may be interviewed only after the
receipt of this tenant application.
A. GENERAL INFORMATION

Applicant Name(s):

Address:
Street Apt.# City State ZIP

Daytime Phone: Evening Phone:

No. of BR’s in
current unit: Do you  RENT or  OWN (check one)

Amount of current monthly RENT or MORTGAGE

payment: $

If owned, do you receive monthly rental income from property?  Yes  No (check one)

Check utilities paid by you:  Heat  Electricity  Gas  Other (specify)

Approximate monthly cost of utilities paid by you (excluding phone and cable TV): $

Building Style preference: No preference  Midrise (4 story bldg. w/ elevator)  Townhome

Bedroom size requested:  One BR  Two BR  Three BR  Four BR  HANDICAP BR
Application
Page 1 of 7
 Name Relationship (Optional) Birth Date Are you a FULL-TIME
(FIRST & LAST NAME) to Head GENDER (MM/DD/YY) Social Security # STUDENT?
1. [ ] YES [ ] NO
HEAD
2. [ ] YES [ ] NO
3. [ ] YES [ ] NO
4. [ ] YES [ ] NO
5. [ ] YES [ ] NO
6. [ ] YES [ ] NO
7. [ ] YES [ ] NO
8. [ ] YES [ ] NO

Will ALL of the persons in the household be or have been full-time students during five calendar months of this
year or plan to be in the next calendar year at an educational institution (other than a correspondence school)
with regular faculty and students?  Yes  No

Have there been any changes in household composition in the last twelve months?  Yes  No
If yes, explain:
Do you anticipate any changes in household composition in the next twelve months?  Yes  No
If yes, explain:
Is there someone not listed above who would normally be living with the household?  Yes  No
If yes, explain:

IF YES, answer the following questions….

Are any full-time student(s) married and filing a joint tax return?  Yes  No
Are any student(s) enrolled in a job-training program receiving assistance under the
Job Training Partnership Act?  Yes  No
Are any full-time student(s) a TANF or a title IV recipient?  Yes  No
Are any full-time student(s) a single parent living with his/her minor child who is not
a Dependant on another’s tax return and whose children are not dependents of anyone
other than a parent?  Yes  No
Is any student a person who was previously under the care and placement of a foster
care program (under Part B or E of Title IV of the Social Security Act)?  Yes  No

Application
Page 2 of 7
 C. INCOME

List ALL sources of income for ALL Members as requested below. If a section doesn’t apply, cross out or write NA.
Gross Monthly
Household Member Name Source of Income
Amount
Social Security $
Social Security $
Social Security $
$
SSI Benefits $
SSI Benefits $
SSI Benefits $

Pension (list source) $

Pension (list source) $

Veteran’s Benefits (list claim #) $

Veteran’s Benefits (list claim #) $

Unemployment Compensation $
Unemployment Compensation $

Title IV/TANF $
GPA (General Public Assistance) $
Contributions to the Household (monetary or not) $

Full-Time Student Income (18 & Over Only) $

Financial Aid (grants & scholarships $
exceeding of the amount of tuition may have to
be included in total income)

Interest Income (source) $

Interest Income (source) $

Long Term Medical Care Insurance Payments in

excess of $180/day $

Scheduled Payments from Investments $

Application
Page 3 of 7
 Monthly
Household Member Name Source of Income
Amount
Employment amount $
Employer:
Position Held
How long employed:

Employment amount $
Employer:
Position Held
How long employed:

Employment amount $
Employer:
Position Held
How long employed:

Employment amount $
Employer:
Position Held
How long employed:

Alimony
Are you legally entitled to receive alimony?  Yes  No
If yes, list the amount you are entitled to receive. $
Do you receive alimony?  Yes  No
If yes list amount you receive. $

Child Support
Are you legally entitled to receive child support?  Yes  No
If yes list the amount you are entitled to receive. $
Do you receive child support?  Yes  No
If yes, list the amount you receive. $

Other Income $
Other Income $
Other Income $

TOTAL GROSS ANNUAL INCOME (Based on the monthly amounts listed above x 12) $
TOTAL GROSS ANNUAL INCOME FROM PREVIOUS YEAR $
Do you anticipate any changes in this income in the next 12 months?  Yes  No
Is any member of the household legally entitled to receive income assistance?  Yes  No
Is any member of the household likely to receive income or assistance (monetary or not)
from someone who is not a member of the household as listed on Page 2 etc)?  Yes  No
If yes to any of the above, explain:

Is the income received?  Yes  No

Application
Page 4 of 7
 D. ASSETS
If your assets are too numerous to list here, please request an additional form.
If a section doesn’t apply, cross out or write NA.
Checking Accounts # Bank Balance $
# Bank Balance $
# Bank Balance $

Savings Accounts # Bank Balance $

# Bank Balance $
# Bank Balance $

Trust Account # Bank Balance $

# Bank Balance $
Certificates # Bank Balance $
# Bank Balance $
# Bank Balance $

# Bank Balance $
Credit Union
# Bank Balance $

# Maturity Date Value $

Savings Bonds # Maturity Date Value $
# Maturity Date Value $

Life Insurance Policy # Cash Value $

(WHOLE or UNIVERSAL POLICIES ONLY) # Cash Value $
Do not list Death Policies #
Mutual Funds Name: #Shares: Interest or Dividend $ Value $
Name: #Shares: Interest or Dividend $ Value $
Name: #Shares: Interest or Dividend $ Value $

Name: #Shares: Dividend Paid $ Value $

Stocks
Name: #Shares: Dividend Paid $ Value $
Name: #Shares: Dividend Paid $ Value $

Bonds Name: #Shares: Interest or Dividend $ Value $

Name: #Shares: Interest or Dividend $ Value $
Investment Appraised
Property Value $

Application
Page 5 of 7
Real Estate Property: Do you own any property?  Yes  No
If yes, Type of property
Location of property (Address)
Appraised Market Value (+) $
Mortgage or outstanding loans balance due (-) $
Amount of annual insurance premium (-) $
Amount of most recent tax bill (-) $
Does any member of the household have an asset(s) owned jointly with a person who is
NOT a member of the household as listed on Page 2?  Yes  No
If yes, describe:
Do they have access to the asset(s)?  Yes  No
Have you sold/disposed of any property in the last 2 years?  Yes  No
If yes, Type of property:
Market value when sold/disposed $
Amount sold/disposed for $
Date of transaction:

Have you disposed of any other assets in the last 2 years (Example: Given away money to relatives, set up
Irrevocable Trust Accounts)?
 Yes  No
If yes, describe the asset:
Date of disposition:
Amount disposed $
Do you have any other assets not listed above (excluding personal property)?  Yes  No
If yes, please list:
E. ADDITIONAL INFORMATION

Are you or any member of your family currently using an illegal substance?  Yes  No
Have you or any member of your family ever been convicted of a felony?  Yes  No
If yes, describe:
Are you or any member of your family subject to a state lifetime sex offender
Registration program in any state?  Yes  No
List all of the states that applicants have resided in for HUD State Lifetime Sex Offender Requirements:

Have you or any member of your family ever been evicted from any housing?  Yes  No
If yes, describe
Have you ever filed for bankruptcy?  Yes  No
If yes, describe
Will you take an apartment when one is available?  Yes  No
Briefly describe your reasons for applying:
Application
Page 6 of 7
 F. REFERENCE INFORMATION
Name:
Address:
Current Landlord Phone:
How Long?
Name:
Address:
Prior Landlord Phone:
How Long?
Credit Reference #1:
Address: Phone #:
Credit Reference #2:
Address: Phone #:
EMERGENCY CONTACT
In case of emergency notify: Relationship:
Address: Phone #:
G. VEHICLE & PET INFORMATION (if applicable)
List any cars, trucks, or other vehicles owned. Parking will be provided for one vehicle. Arrangements with
Management will be necessary for more than one vehicle.
Type of Vehicle: License Plate #:
Year/Make: Color:
Type of Vehicle: License Plate #:
Year/Make: Color:
Do you own any pets? Yes No
If yes, describe:

CERTIFICATION
I/We hereby certify that I/We Do/Will Not maintain a separate subsidized rental unit in another location. I/We further certify that this will be my/our
permanent residence. I/We understand I/We must pay a security deposit for this apartment prior to occupancy. I/We understand that my eligibility for
housing will be based on applicable income limits and by management’s selection criteria. I/We certify that all information in this application is true to
the best of my/our knowledge and I/We understand that false statements or information are punishable by law and will lead to cancellation of this
application or termination of tenancy after occupancy. All adult applicants, 18 or older, must sign application.

_________________________________________________________________ ___________________
(Signature Head of Household) (Date)

_________________________________________________________________ ___________________
(Signature Co-Head of Household) (Date)

_________________________________________________________________ ___________________
(Signature Adult Household Member) (Date)

_________________________________________________________________ ___________________
(Signature Adult Household Member) (Date)

Application
Page 7 of 7
 OMB Control # 2502-0581
Exp. (02/28/2019)
Supplemental and Optional Contact Information for HUD-Assisted Housing Applicants

SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING

This form is to be provided to each applicant for federally assisted housing

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.

Applicant Name:
Mailing Address:

Telephone No: Cell Phone No:

Name of Additional Contact Person or Organization:

Address:

Telephone No: Cell Phone No:

E-Mail Address (if applicable):

Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency Assist with Recertification Process
Unable to contact you Change in lease terms
Termination of rental assistance Change in house rules
Eviction from unit Other: ______________________________
Late payment of rent
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.

Check this box if you choose not to provide the contact information.

Signature of Applicant Date

The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.

Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)