HD-2.

Property Name: Sunset Townhomes

Address: 1001 Boyd Ave
Newton, KS 67114
Phone: 316-283-5191 Fax: 316-283-1137

Applicant Questionnaire

Household Information
List all household members that are applying to live in this apartment with you.

Name Relationship to Social Security Birth date

First, Middle Initial, Last Head of Household M/F Number Month, Date, Year

Current Address:

Daytime Phone: Evening Phone:

YES NO

□ □ 1. Do you expect any additions to the household within the next twelve months? (Include unborn
children) (HD 5.17)

Name & Relationship: ______________________ Explanation: ________________________________

□ □ 2. Is there anyone living with you now who won’t be living with you at this property?

Name & Relationship: ______________________ Explanation: _______________________________

□ □ 3. Are you SEPARATED, but not divorced from your spouse? (Answer “no” if living with spouse, single,
Legally divorced or widowed) (HD 5.6)

□ □ 4. Do you have full custody of your child(ren)?

Explanation:

□ □ 5. Are there any absent household members who under normal conditions would live with you? (For
example, a household member away in the military.)
Explanation:

□ □ 6. Does your household have or anticipate having any pets other than those used as service animals?

□ □ 7. Do you have medical/handicapped expenses?

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 HD-2.0

Rental History
YES NO

□ □ 8. Have you or any one else named on this application filed for bankruptcy?

Explanation:

□ □ 9. Have you or any one else named on this application been convicted of a felony?

Explanation:

□ □ 10. Have you or any one else named on this application been convicted for dealing or manufacturing
illegal drugs?
Explanation:

□ □ 11. Have you or any one else named on this application been convicted of property damage?

Explanation:

□ □ 12. Have you or any one else named on this application been evicted from a rental unit of any type
including an apartment, home, mobile home or trailer?
Explanation:

Housing References
List the past THREE years of housing references. (If additional space is required, use the back of this page.)

Landlord’s Name/Address Your Address Own/Rent Dates

Name: Own □ From:

Address: Rent □ To:

( )
Name: Own □ From:
Address: Rent □ To:

Phone: ( )
Name: Own □ From:
Address: Rent □ To:

Phone: ( )

Personal Reference
List a personal reference other than a relative.

Name:
Address:
Phone: Relationship: Years Known:

© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 5/16/08

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 Vehicle Identification
List vehicle information for all vehicles that are owned or operated by any household member.
Tag/License Plate # State Issued Make/Model/Year

Vehicle #1:
Vehicle #2:

Emergency Contact
List someone in the area that is not already on the application.

Name:
Address:

Phone: Relationship: Years Known:

Income Information
Income is counted for anyone 18 or older (unless legally emancipated). However, if the income is unearned income such as a grant or benefit, it
is counted for all household members including minors. PLEASE COMPLETE ALL PARTS.

Include all income anticipated for the next 12 months.

Do YOU or ANYONE in your household receive OR expect to receive income from:
YES NO
□ □ 13. Employment wages or salaries? (Include overtime, tips, bonuses, commissions and payments received in cash.)
(HD 4.1)
Household Member Name of Company Amount
Address & Phone

□ □ 14. Self-employment? (Include overtime, tips, bonuses, commissions and payments received in cash.)
(HD 5.1 )
Household Member Type of Business Amount

□ □ 15. Regular pay as a member of the Armed Forces?

(HD 4.8)
Household Member Base Name & Branch Amount

□ □ 16. Unemployment benefits or workman’s compensation?

(HD 4.2)
Household Member Contact Person Amount

Address & Phone

© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 5/16/08

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 □ □ 17. Cash Assistance (ie TANF, General Relief, ABD)? DO NOT INCLUDE FOOD STAMPS
(HD 4.6)
Household Member Contact Person Amount
Address & Phone
.

□ □ 18. (a) Do you have COURT ORDERED Child Support or Alimony? Complete Parts A, B, & C
If yes, If no, (We must count court-ordered support whether or not it is received unless legal action has been taken to remedy. We must also
(HD 4.5) (HD 5.4) count support that is not court-ordered rather received directly from payor.)

Household Member Name of Payor Amount

Address & Phone

□ □ (b) Do you RECEIVE Child Support or Alimony and how is it received? (Check all that apply)
*REQUIRED Child Support Enforcement Name of Agency:
Agency
Court of Law Name of Court:
Directly from Individual Name of Person:
*REQUIRED Other Explain:

□ □ (c) If money is not actually received, are you taking legal action to remedy?
(If yes, obtain court papers)

□ □ 19. Social Security, SSI or any other payments from the Social Security Administration?
(HD 4.7)
Household Member SSA Office Amount
Address & Phone

□ □ 20. Regular payments from a Veteran’s benefit, pension, disability or death benefits, IRA, retirement
funds or annuities?
(HD 4.14)
Household Member Source of Benefit Amount
Address & Phone

□ □ 21. Regular payments from a severance package?

(HD 4.3)
Household Member Source of Benefit Amount
Address & Phone

□ □ 22. Regular payments from any type of settlement? (For example, insurance settlements.)
(HD-4.3)
Household Member Source of Benefit Amount

□ □ 23. Regular gifts or payments from anyone outside of the household?

(HD 5.17) (This includes anyone supplementing your income or paying any of your bills.)
Household Member Source of Benefit Amount
___________________________ _______________________
___________________________ _______________________
□ □ 24. Educational grants, scholarships, or other student benefits?
(HD 4.16)
Household Member Source of Benefit Amount

© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 5/16/08

All Rights Reserved

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 □ □ 25. Regular payments from lottery winnings or inheritances?
(HD 4.3)
Household Member Source of Benefit Amount

□ □ 26. Regular payments from rental property or other types of real estate transactions?
(HD 4.3)
Household Member Source of Benefit Amount

□ □ 27. Do you have any assets or any other income sources / types not listed? Do you have any assets in
foreign countries?
(HD 4.3)
Household Member Source of Benefit Amount

□ □ 28. Do you or any other household members expect any changes to your income in the next 12 months?
Explanation:

Asset Information:
Include all assets held and the income derived from the asset. INCLUDE ALL ASSETS HELD BY ALL HOUSEHOLD MEMBERS
INCLUDING MINORS. Please Complete ALL Questions, CIRCLE WHICH ITEM APPLIES TO YOUR HOUSEHOLD

Do YOU or ANYONE in your household hold:

YES NO
□ □ 29. Checking or savings account?
(HD 4.10)
Household Member NAME OF BANK Amount
Account Number

□ □ 30. CDs, money market accounts or treasury bills?

(HD 4.10)
Household Member NAME OF BANK Amount
Account Number

□ □ 31. Stocks, bonds or securities?

(HD 4.11)
Household Member NAME OF BANK Amount
Account Number
□ □ 32. Trust funds? Life Insurance? (Whole or Universal) **Do Not include Term Insurance**
(HD 4.13)
Household Member Source of Benefit Amount

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All Rights Reserved

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 □ □ 33. Pensions, IRAs, Keogh or other retirement accounts?
(HD 4.12)
Household Member Source of Benefit Amount
Account Number

□ □ 34. Do you have any cash on hand?

(HD 5.17)
Household Member Source of Benefit Amount

□ □ 35. Real estate, rental property, land contracts/contract for deeds or other real estate holdings?
(HD 4.15 & HD 5.10) (This includes your personal residence, mobile homes, vacant land, farms, vacation homes or commercial property.)
Household Member Source of Benefit Amount
Address

□ □ 36. Personal property held as an investment?

(HD 5.17) (This includes paintings, coin or stamp collections, artwork, collector or show cars, and antiques. This does not include your personal
belongings such as your car, furniture or clothing.)
Household Member Source of Benefit Amount
Address

□ □ 37. A safe deposit box?

(HD 5.17)
Household Member Source of Benefit Amount

□ □ 38. Have you or any other household members disposed of or given away any asset(s) for LESS than
(HD 5.8) fair market value within the past 2 years?

Household Member: Amount:

Explanation:

Applicant Status
The following questions pertain to specific eligibility requirements of the Housing Credit Program.

YES NO
□ □ 39. Are you or any other ADULT household members claiming zero income?
(HD 5.3)

Household Member:

Explanation:

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 □ □
(HD 5.11 & HD 5.12)
□ □
(HD 6.18, HD 6.19, & HD 6.20))
□ □
Expenses and Deductions
□ □
(HD 6.12 & HD 6.13)
□ □
□ □
(HD 6.2, HD 6.3, HD 6.4)
□ □
□ □
□ □
(HD 6.9)
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc.
All Rights Reserved
40. Are you or any other household members (INCLUDING MINORS) currently a FULL-TIME
STUDENT? Have you been, or do you expect to be, a student for five months during the calendar
year? Please circle YES or NO
Are you or any other household members currently a PART-TIME STUDENT OR expect to be one
in the next 12 months? Please circle YES or NO
Are you or any other household members currently a student of higher education? Please circle
YES or NO
If yes, list Household Member(s):
Name of School:
41. Will you or any ADULT household member require a LIVE-IN CARE attendant to live
independently?
Name of Attendant:
Relationship (if any):
42. Will your household be receiving or applying for SECTION 8 rental assistance at time of move-in?
Name of Agency:
43. Do you have child care expenses for children under the age of 13 because you work, are actively
seeking employment or attending school?
If yes, name and address of provider:
Amount paid per month:
Is any portion paid by another person
or agency?
If yes, name and address of provider:
44. Do you pay for a Care Attendant or any equipment for a handicapped member of the household
necessary to permit that person or someone else in the household to work?
If yes, name and address of provider:
Amount paid per month:
Is any portion paid by another person
or agency?:
If yes, name and address of provider:
45. Do you have Medicare?
Amount paid per month:
46. Do you have any other kind of medical insurance?
If yes, name and address of insurer:
Amount paid per month:
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 □ □ 47. Do you receive medical assistance?
(HD 6.10)

□ □ If yes, do you have a monthly spend-down?

Amount paid per month:

□ □ 48. Do you pay for prescription medication?

(HD 6.8)

If yes, name and address of pharmacy:

Amount paid per month:

□ □ 49. Do you have any non-prescription (over-the-counter) medication that your doctor has requested
you to use on a regular basis? (i.e. insulin, aspirin, etc.)
(HD 6.11)

Amount paid per month:

□ □ 50. Do you have any outstanding medical bills on which you are paying?

(HD 6.7)

If yes, indicate the types of bills owed:

Owed to, name and address:

Amount:

□ □ 51. Do you expect to have an extraordinary medical/dental expense in the next 12 months?

(HD 6.7)

Amount:

If yes, list the amount and types of expense:

Name and facility where this can be verified:

Doctor’s name and address:

Please bring receipts for your non-prescription medications.

Signature Clause
© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 5/16/08
All Rights Reserved

8
___________________ and The Yarco Companies do not discriminate on the basis of disability status, race, color, religion, sex, familial status, sexual orientation, or
national origin, in the admission or access to, or treatment or employment in, its federally assisted programs and activities. We adhere to all Equal Housing
Opportunity Guidelines. We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage
and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of handicap, race, color, religion, sex,
familial status, sexual orientation or national origin.
It is the right of all individuals with a disability to request a Reasonable Accommodation. Note: For any assistance, you may contact the
Community Manager or our 504-coordinator Marsha Abrams at 816-561-4240. For the Telecommunication Relay Services, dial 711,
or the local relay center as provided by your local phone company.
Penalties for Misusing a Form: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent
statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD the PHA, or the owner) may be subject to
penalties for unauthorized disclosures or improper uses of information collected based on a consent form. Use of information collected based on a verification form is
restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains, or discloses any information under false pretenses concerning an
applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information
may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the
unauthorized disclosure or improper use.

Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions
are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

I understand that management is relying on this information to prove my household’s eligibility for the Housing Program. I
certify that all information and answers to the above questions are true and complete to the best of my knowledge. I consent to
release the necessary information to determine my eligibility. I understand that providing false information or making false
statements may be grounds for denial of my application. I also understand that such action may result in criminal penalties. I
authorize my consent to have management verify the information contained in this application for purposes of proving my
eligibility for occupancy. I will provide all necessary information including source names, addresses, phone numbers, account
numbers where applicable and any other information required for expediting this process. I understand that my occupancy is
contingent on meeting management’s resident selection criteria and the Housing Credit Program requirements.
All ADULT household members must sign below:

Signature Date

Signature Date

Management Signature Date

For Office Use Only

Date Received: ________________________ Calculations: _________________________________________________________________

© Copyright 1995-1998 Elizabeth Moreland Consulting, Inc. 5/16/08

All Rights Reserved