Name Male/Female Soc. Sec. # Birthdate Relationship. Name Male/Female Soc. Sec. # Birthdate Relationship

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1 Application for Affordable Housing Managed by Catholic Housing Communities; 12 E. 5 th Ave; Spokane, WA Phone: (509) Fax: (509) APPLICATION TO RENT Size of Unit Required: (circle one) Studio 1BR 2BR 3BR Name the apartment community you are applying for: (A separate application must be completed for each apartment community you are seeking tenancy.) *Each adult over the age of 18 must complete a separate application.* Applicant s (LEGAL) Name Male/Female Soc. Sec. # Birthdate State Driver s License or Photo ID # Spouse/Co-Applicant s Name Male/Female Soc. Sec. # Birthdate State Driver s License or Photo ID # Other persons to occupy rental property: Social Security numbers must be added for ALL applicants. RESIDENCE / RENTAL HISTORY Please list ALL residences for the past 3 years. Include rentals, living with friends/relatives, shelters, institutions, group homes, hospitals, etc. A list of all states where you have resided is also required. Attach additional paper if necessary Applicant s Present Address City State Postal Code Move-In Applicant s Present Phone # $ $ Monthly Pymt Deposit Paid Present Landlord Landlord Phone # Applicant s Previous Address City State Postal Code Move-In Move-Out $ $ Monthly Pymt Deposit Paid Previous Landlord Landlord Phone # Applicant s Previous Address City State Postal Code Move-In Move-Out $ $ Monthly Pymt Deposit Paid Previous Landlord Landlord Phone # List All States in which you have resided EMPLOYMENT HISTORY / GROSS INCOME $ Yrs. Mo s. EMPLOYER: Previous Employment Second Job Salary / Wage # of Hrs/Wk Supervisor s Name How Long? Address City State Postal Code Phone # Occupation / Department OTHER INCOME - Monthly Pension $ Social Security $ Unemployment $ Child Support $ Public Assistance $ Other $ Source ASSETS Name of Bank or Savings and Loan Address, City, State, Postal Code $ $ $ $ $ $ Checking Balance Savings Balance C.D. Escrow Balance Stock Value Other Income (Interest/Dividends) earned from all assets per year $ Real Estate Holdings-Market Value$ ELIGIBILITY DETERMINATIONS YES NO Have you, or anyone who will be occupying the unit, ever been convicted of a criminal offense? If YES: City/State: Offense (s) Sentence Completed: YES NO Are you or anyone who will be residing in the unit subject to register as a lifetime sex offender in any state? YES NO Have you been asked to vacate by current/previous landlord? If YES: City/State: Apartment Name: : Page 1 of 5

2 Application for Affordable Housing - Page 2 ELIGIBILITY DETERMINATIONS (cont d.) Are you currently an illegal user of a controlled substance? Have you ever been convicted of the illegal manufacture or distribution of a controlled substance? Has your assistance or tenancy in a subsidized housing program ever been terminated for fraud, non-payment of rent or failure to cooperate with recertification procedures? Are you currently a full or part time student of higher education? If yes, name of school: Are you currently paying over 50% of your income for rent and utilities? Have you been displaced by government action or by a presidential declared Disaster? Are you currently homeless or at-risk of homelessness for preference qualification? (If yes, verification required.) Are you 62 years of age or older? (If yes, verification required.) Are you claiming disabled status for admission and deduction qualifications? (If yes, verification required.) Do you wish to be on the waiting list for and require the features of an accessible unit? (If yes, verification required and please specify below.) Mobility Visual Hearing Other: Do you currently hold a Section 8 voucher or receiving subsidy? (if yes, please specify.) Do you currently have a pet or service animal residing with you? (If yes, please specify.) How did you learn about this housing? NOTE: The application must be complete, signed by applicant, and returned to Catholic Housing Communities before you can be placed on a waiting list. To remain on a waiting list, you must make contact to the community(s) in which you have applied every six months. In accordance with State and Federal laws you are hereby notified that an investigation may be made by Screening Reports, Inc. of the information you provide on this Application. You have the right to dispute the accuracy of information provided by Screening Reports, Inc. or by the entities you have disclosed above, and, upon written request, the right to a complete and accurate disclosure of the nature and scope of the investigation and/or a written summary of your rights under the WA Fair Credit Reporting Act. Direct all inquiries to: Screening Reports, Inc., Better NOI, 220 Gerry Dr., Wood Dale, IL I/We certify that to the best of my/our knowledge all statements made herein are true and correct. I/We authorize Screening Reports, Inc. to obtain such credit reports, verification of rental and employment history it deems is necessary to verify all information set forth in the above Application, and provide an investigative report to the undersigned Landlord. I/We further understand that false, fraudulent or misleading information disclosed above may be grounds for denial of tenancy or subsequent eviction. I am aware that an incomplete application causes a delay in processing and may result in denial of tenancy. -Applicant -Co-Applicant -Catholic Housing Communities Agent Catholic Housing Communities (Non-Profit) sponsored by Catholic Charities follows the Equal Opportunity Housing practices prescribed by the Fair Housing Act and Washington State. We do not discriminate against any person because of race, color, religion, sex, marital status, disability, familial status, national origin, age, sexual orientation, gender identity, and military status in the admission or access to or treatment or employment in their federally assisted programs and activities. As such, we are required to provide reasonable auxiliary aids and services necessary for effective communication with persons with disabilities when requested.the person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development s regulations implementing Section 504 (24 CFR, part 8 dated June 2, 1988): Housing Director, 12 E. 5 th Ave. Spokane, WA 99202, (509) , fax (509) A copy of the Tenant Selection Plan for each property is available upon request. EQUAL HOUSING OPPORTUNITY FOR OFFICE USE ONLY /Time Received: Received By: Income Limit: ELI VL Low Applicant Applied for: Sec 8 Sec 236 WFF S+C MR Page 2 of 5

3 TENANT DECLARATION FORM Attachment 6 INSTRUCTIONS: Complete this format for each member of the household listed on the Family Summary Sheet. LAST NAME FIRST NAME MIDDLE NAME RELATIONSHIP TO HEAD OF HOUSHOLD SEX DATE OF BIRTH ADMISSION NUMBER (If applicable, this is an 11-digit number found on INS I-94, Departure Record.) SOCIAL SECURITY NUMBER REGISTRATION NUMBER NATIONALITY (Enter the foreign nation or country to which you owe legal allegiance. This is normally, but not always the country of birth.) SAVE VERFICATION NUMBER (to be entered by owner if and when received) INSTRUCTIONS: Complete the Declaration below by printing or typing the person s first name, middle initial and last name in the space provided. Then review the blocks designated below and complete either block 1, 2, or 3: DECLARATION I, hereby declare, under penalty of perjury, that I am: (print or type first name, middle initial, last name) 1. a citizen or national of the United States If you checked this block, no further information is required. Sign and date below and forward this form to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult who resides in the assisted unit and who is responsible for the child should sign and date below. Check here if adult signed for a child: 2. a noncitizen with verifiable immigration status in the category, check below: (i) A noncitizen lawfully admitted for permanent residence, as defined by section 101(a)(20) of the Immigration and Nationality Act (INA) as an immigrant, as defined by section 101(a)(15) of the INA (8 U.S.C. 1001(a) and 1101(a)(15), respectively.) [Immigrants] (This category includes a noncitizen admitted under section 210 or 210A of the INA (8 U.S.C or 1161), [special agricultural worker], who has been granted lawful resident status); (ii) A noncitizen who entered the United States before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the United States since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under section 249 of the INA (8 U.S.C. 1259); (iii) A noncitizen who is lawfully present in the United States pursuant to an admission under section 207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under section 208 of the INS (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under section 203(a) (7) of the INA (8 U.S.C. 1153(a) (7)) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity; (iv) A noncitizen who is lawfully present in the United States as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under section 212(d) (5) of the INA (8 U.S.C. 1182(d) (5)) [parole status]; (v) A noncitizen who is lawfully present in the United States as a result of the Attorney General s withholding deportation under section 243(h) of the INA (8 U.S.C (h)) [threat to life or freedom]; or (vi) A noncitizen lawfully admitted for temporary or permanent residence under section 245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A]. If you checked this block and you are 62 years of age or older and receiving assistance on June 19, You should submit a proof of age document, together with this format, and sign here: Page 3 of 5

4 OR If you checked this block and you are under 62 years of age, you must submit the following documents: a. Verification Consent Format (Attachment 8) AND b. One of the following documents: (1) Form 1-551, Alien Registration Receipt Card (for permanent resident aliens); (2) Form 1-94, Arrival-Departure Record, with on the following: (i) Admitted as Refugee Pursuant to section 207 ; (ii) Section 208 or Asylum (iii) Section 243(g) or Deportation stayed by Attorney General ; (iv) Paroled Pursuant to Sec. 212(d) (5) of the INA; (3) If Form 1-94, Arrival-Departure Record, is not annotated, then accompanied by one of the following documents: (i) (ii) (iii) (iv) A final court decision granting asylum (but if no appeal is taken); A letter from an INS asylum officer granting asylum (if application is filed on or after October 1, 1990) or from an INS district director grant asylum (if application filed before October 1, 1990); A court decision granting withholding or deportation; or A letter from INS asylum officer granting withholding or deportation (if application filed on or after October 1, 1990). (4) Form 1-688, Temporary Resident Card, which must be annotated section 245A or section 210 ; (5) Form 1-688B, Employment Authorization Card, which must be annotated Provision of Law 274a.12 ; (6) A receipt issued by the INS indicating that an application for issuance of a replacement document in one of the above-list categories has been made and the applicant s entitlement to the document has been verified. If this block is checked, sign and date below and submit the documentation required above with this format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult residing in the unit and responsible for the child should sign and date the format. If for any reason, the documents shown in paragraph b. above are not currently available, complete the request for extension block below. Check her if adult signed for a child: REQUEST FOR EXTENSION I hereby certify that I am a noncitizen with eligible Immigration status, as noted in block 2 above, but the evidence needed to support my claim is temporarily unavailable. Therefore, I am requesting additional time to obtain the necessary evidence. I further certify that diligent and prompt efforts will be undertaken to obtain this evidence. Check if adult signed for a child: OR 3. not contending eligible immigration status and I understand that I am not eligible for financial assistance. If you checked this block, no further information is required and the person named above is not eligible for assistance. Sign and date below and forward this format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult living in the unit and responsible for the child should sign and date below. Check here if adult signed for a child: Page 4 of 5

5 Optional and Supplemental 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 OMB Control # Exp. (11/30/2015) 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. Check this box if you choose not to provide the contact information. Applicant Name: Mailing Address: Telephone No: Name of Additional Contact Person or Organization: Cell Phone No: Address: Telephone No: Address (if applicable): Cell Phone No: Relationship to Applicant: Reason for Contact: (Check all that apply) Emergency Unable to contact you Termination of rental assistance Eviction from unit Late payment of rent Assist with Recertification Process Change in lease terms Change in house rules Other: 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 , 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 of Applicant 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 ). 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 ) 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 , 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 (05/09)

6 Spokane Locations: Offering service-enriched, affordable housing for seniors, families, and persons with disabilities in thirteen counties of Eastern Washington. Name & Address Contact Info Eligibility Requirements Apartment Sizes Cathedral Plaza 1120 W Sprague Phone: Fax: BR Bernadette Place 925 W Dean #2 The Delaney 242 W Riverside Ave Phone: Fax: Phone: Fax: Developmentally Disabled 55+ and older Only Studios,1BR Fahy Garden 1411 W Dean Phone: Fax: or Disabled Studios,1BR Fahy West 1523 W Dean Phone: Fax: or Disabled Studios,1BR The O Malley 707 E Mission Spokane WA Phone: Fax: or Disabled 1BR Summit View 820 N Summit Blvd Spokane WA Phone: Fax: Family Housing 1BR - 3BR Eastern Washington Locations: Name & Address Contact Info Eligibility Requirements Apartment Sizes Austen Manor 1222 Chestnut Clarkston WA Phone: (509) Fax: (509) BR Desert Haven 335 N 3rd Othello WA Phone: (509) Fax: (509) Farm Worker - Family 2BR 4BR Garden Court 420 W Alder St #13 Walla Walla WA Phone: (509) Fax: (509) or Disabled Studios, 1BR, 2BR Mike Foye 420 W Alder St #13 Walla Walla WA Phone: (509) Fax: (509) or Disabled Studios, 1BR, 2BR Pioneer Square 220 SE Kamiaken St Pullman WA Phone: (509) Fax: (509) or Disabled 1BR The Rhodena 230 S Wynne St Colville WA Phone: (509) Fax: (509) Family Housing 2BR, 3BR Tepeyac Haven 801 N 22 nd Ave #51 Pasco WA Phone: (509) Fax: (509) Farm Worker Family 2BR 4BR Page 5 of 5