Rent With Us Step 1 of 6 16% Applicant Contact InformationHead of Household*Head of Household First Middle Initial Last Current Address*Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Phone NumberType of Phone* Cell Home Work Email*Email Address How did you hear about us?*How did you hear about us? Property of Interest*Property InterestSelect a PropertyBrandywine Lofts - South Burlington, VTFarmstead Lofts - South Burlington, VTBriarwood - Middlebury, VTCasavant Overlook - Winooski, VTCedars Senior Living - Queensbury, NYMahoney Grove ApartmentsMaples Senior Living - Rutland, VTPackard Lofts - Burlington, VTParc Terrace - Winooski, VTPark Village - Brandon, VTParker Village - Littleton, NHPines Senior Living- South Burlington, VTQuail Hollow Senior Living - West Lebanon, NHResidences at Great Cedars - Winooski, VTSt. Johnsbury House Senior Living - St. Johnsbury, VTSugarwood - Middlebury, VTValley View - Vergennes, VTWhite Rock Senior Living - Bow, NHWillow - Vergennes, VTAdditional Properties of InterestAdditional Properties of Interest Bedroom Size Needed* Desired Date of Occupancy* MM slash DD slash YYYY Household Composition All household members (including those part-time) must be listed below:Household Member #1 (Head of Household)*Household Member #1 (Head of Household) First Middle Initial Last Date of Birth* MM slash DD slash YYYY Social Security Number*Social Security Number Driver's License Number* Driver's License State* Student?*Student? Yes No Household Member #2Household Member #2 First Middle Initial Last Relationship to Head of Household Date of Birth MM slash DD slash YYYY Social Security Number Driver's License Number(if 18 years or older) Driver's License State(if 18 years or older) Student?Student? Yes No Household Member #3Household Member #3 First Middle Initial Last Relationship to Head of Household Date of Birth MM slash DD slash YYYY Social Security Number Driver's License Number(if 18 years or older) Driver's License State(if 18 years or older) Student?Student? Yes No Household Member #4Household Member #4 First Middle Initial Last Relationship to Head of Household Date of Birth MM slash DD slash YYYY Social Security Number Driver's License Number(if 18 years or older) Driver's License State(if 18 years or older) Student?Student? Yes No Household Member #5Household Member #5 First Middle Initial Last Relationship to Head of Household Date of Birth MM slash DD slash YYYY Social Security Number Driver's License Number(if 18 years or older) Driver's License State(if 18 years or older) Student?Student? Yes No 1. Have there been any changes in the household in the last twelve months?*1) Have there been any changes in the household in the last twelve months? Yes No If you answered yes, please explain:If you answered yes, please explain:2. Do you anticipate any changes to the household composition in the next twelve months?*2) Do you anticipate any changes to the household composition in the next twelve months? Yes No If you answered yes, please explain:If you answered yes, please explain:3. Is there someone not listed previously who would normally be living in the household?*3) Is there someone not listed previously who would normally be living in the household? Yes No If you answered yes, please explain:If you answered yes, please explain:4. Has any member of the household been convicted of a felony?*4) Has any member of the household been convicted of a felony? Yes No If you answered yes, please explain:If you answered yes, please explain:5. Will all of the persons in the household be or have been full-time students during five calendar months this year or plan to be in the next calendar year at an education institution (other than a correspondence school) with regular faculty and students?*5) Will all of the persons in the household be or have been full-time students during five calendar months this year or plan to be in the next calendar year at an education institution (other than a correspondence school) with regular faculty and students? Yes No If you answered yes, please explain:If you answered yes, please explain:6. Has any member of the household been evicted from housing?*6) Has any member of the household been evicted from housing? Yes No If you answered yes, please explain:If you answered yes, please explain:7. Has any member of the household ever declared bankruptcy?*7) Has any member of the household ever declared bankruptcy? Yes No If you answered yes, please explain:If you answered yes, please explain:8. Per Vermont State regulations all landlords are required to collect data on homelessness. Are you currently homeless or at risk of homelessness?*8) Per Vermont State regulations all landlords are required to collect data on homelessness. Are you currently homeless or at risk of homelessness? Yes No If you answered yes, please explain:If you answered yes, please explain:Residential History Please indicate your place(s) of residence for the past three years below:Current Address*Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Landlord Name & Contact Info*Landlord Name, Phone Number, Email Address Rent or Own?* Rent Own Dates of Residency* Monthly Rent/Mortgage* Previous Address #1*If you have been at your current address for 3+ years, please fill out N/A in the fields below. If you have not been at your current address for 3 years, please fill out below. Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Landlord Name & Contact Info*Landlord Name, Phone Number, Email Address Rent or Own?* Rent Own Dates of Residency* Monthly Rent/Mortgage* Previous Address #2 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Landlord Name & Contact InfoLandlord Name, Phone Number, Email Address Rent or Own? Rent Own Dates of Residency Monthly Rent/Mortgage Previous Address #3 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Landlord Name & Contact InfoLandlord Name, Phone Number, Email Address Rent or Own? Rent Own Dates of Residency Monthly Rent/Mortgage Living Needs 9) What is the household's reason for moving?*9) What is the household's reason for moving?10) Will any household member require any reasonable accommodations?*10) Will any household member require any reasonable accommodations? Yes No If you answered yes, please explain:If you answered yes, please explain:11) How many vehicles do you have? None 1 vehicle 2 vehicles 3+ vehicles 1st Vehicle Description*1st Vehicle Description 2nd Vehicle Description2nd Vehicle Description 3rd Vehicle Description3rd Vehicle Description 12) Does your household have any pets?*12) Does your household have any pets? Yes No 1st Pet Description1st Pet Description 2nd Pet Description2nd Pet Description 3rd Pet Description3rd Pet Description Income & Assets 13) Do you anticipate any changes in your income in the next twelve months?*13) Do you anticipate any changes in your income in the next twelve months? Yes No If you answered yes, please explain:If you answered yes, please explain:14) Is any member of the household likely to receive assistance (monetary or not) from someone who is not a member of the household?*14) Is any member of the household likely to receive assistance (monetary or not) from someone who is not a member of the household? Yes No If you answered yes, please explain:If you answered yes, please explain:15) Does the household currently have a Section 8 Housing Choice voucher?*15) Does the household currently have a Section 8 Housing Choice voucher? Yes No If you answered yes, which Public Housing Authority?If you answered yes, which Public Housing Authority? 16) Is anyone in the household currently employed?16) Is anyone in the household currently employed? Yes No If yes, please complete the following for each household member that is employed.Household Member #1 Name*Household Member #1 Name First Last Household Member #1 Employer* Household Member #1 Income* Household Member #2 NameHousehold Member #2 Name First Last Household Member #2 Employer Household Member #2 Income Household Member #3 NameHousehold Member #3 Name First Last Household Member #3 Employer Household Member #3 Income Household Member #4 NameHousehold Member #4 Name First Last Household Member #4 Employer Household Member #4 Income 17) Is anyone in the household responsible for paying child support or alimony?*17) Is anyone in the household responsible for paying child support or alimony? Yes No If you answered yes, please provide monthly amounts:If you answered yes, please provide monthly amounts: Please provide all sources of income for all members of the household below. Include and identify as Employment Wages, SSDI, SSI, Pension, Investment Distribution, Long Term Medical Care, Interest Income, Alimony or Child Support, or Other:Household Member #1 Name*Household Member #1 Name First Last Source of IncomePlease select sources of income below:Employment Wages (EW)Social Security (SSDI)Supplemental Security (SSI)Pension (P)Investment Distribution (ID)Long Term Medical Care (LTMC)Interest Income (II)Alimony or Child Support (ACS)Other (O)Gross Monthly AmountPlease enter income associated with selected sources above:Section BreakHousehold Member #2 NameHousehold Member #2 Name First Last Source of IncomePlease select sources of income below:Employment Wages (EW)Social Security (SSDI)Supplemental Security (SSI)Pension (P)Investment Distribution (ID)Long Term Medical Care (LTMC)Interest Income (II)Alimony or Child Support (ACS)Other (O)Gross Monthly AmountPlease enter income associated with selected sources above:Section BreakHousehold Member #3 NameHousehold Member #3 Name First Last Source of IncomePlease select sources of income below:Employment Wages (EW)Social Security (SSDI)Supplemental Security (SSI)Pension (P)Investment Distribution (ID)Long Term Medical Care (LTMC)Interest Income (II)Alimony or Child Support (ACS)Other (O)Gross Monthly AmountPlease enter income associated with selected sources above:Household Member #4 NameHousehold Member #4 Name First Last Source of IncomePlease select sources of income below:Employment Wages (EW)Social Security (SSDI)Supplemental Security (SSI)Pension (P)Investment Distribution (ID)Long Term Medical Care (LTMC)Interest Income (II)Alimony or Child Support (ACS)Other (O)Gross Monthly AmountPlease enter income associated with selected sources above:Emergency Contact 18) List someone in the area that is not already on the applicationName*Emergency Contact Name First Last Address*Emergency Contact Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Emergency PhoneRelationship Years Known Certification I understand that the information contained in this application will be used to determine my eligibility for housing. I grant consent for the management to make any and all inquiries to verify the information, with rental, criminal and credit screening services, and to contact previous and current landlords or other sources for credit, and verification of other information which may be released to appropriate Federal, State and Local Agencies. I authorize management to obtain one or more “credit and consumer reports” as defined in the Fair Credit Reporting Act, 15 U.S.C. Section 1681 a(d), seeking information on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. In the event my application is approved, I also give my consent to have Summit Properties and/or its assigned credit bureau to obtain additional credit reports and other information after approval of my credit, both in connection with same Transaction or an extension of credit; to obtain credit reports, criminal background checks and other information for account review purposes and other legitimate purposes associated with the account. Furthermore, I understand that providing any false or misleading information will make me ineligible for rental assistance and may result in prosecution by the United States Government. Therefore, I certify that all of the above information is true and complete to the best of my knowledge and belief. All members of the household who are 18 years of age or older must sign this application below:Primary Applicant's Name*Primary Applicant's Name First Last Today's Date*Today's Date MM slash DD slash YYYY Attestation By checking this box, I hereby submit this online application for an apartment and in doing so, certify that this information is correct and authorize you to contact any references that I have listed and perform a credit check with Credit Profile & Security Corp. CAPTCHAUntitled First Choice Second Choice Third Choice Δ