FOR STATISTICAL USE ONLY .	
4. Head of household Race (Enter One)
1 = White
2 = Black
3 = American Indian/Alaskan Native
4 = Asian or Pacific Islander	5. Head of Household Ethnicity:
1 = Hispanic
2 = NonHispanic	6. Head of Household Gender
1 = Male
2 = Female	7. Head of Household Marital Status
Status
1 = Single
2 = Married	
8. Name and Address of Employer	Type of Business	Self Employed
Yes	
		No	
			
Business Phone Number	Position/Titlee	No. Yrs. on Job	Yrs in this line of
work	
			
1. Co-Applicant's Name	Social Security No.	Home Phone	
2. Present Street Address	City	State	Zip Code	No. Yrs at Present
Address	
3. Former Street Address (if at
present address for less than 2 yrs.)	City	State	Zip Code	No. Yrs at Former
Address	
4. Name and Address of Employer	Type of Business	Self-employed
Yes	
		No	
Business Phone Number	Position/Title	No. Yrs. on Job	Yrs. In this line of
work	
Current Housing Status: Provide the name, address, and phone number of all your landlords for the past 3 years.
Current Landlord:______________________________________________________Phone: ____________________________
Address:________________________________________________________________________________________________
Previous Landlord: ______________________________________________________Phone: ___________________________
Address: ______________________________________________________________________________________

FRANKLIN COURT
RENTAL APPLICATION FORM

The information collected below will be used to determine if you qualify as a resident. It will not be
1. Applicant's Name	Social Security No.	Home Phone	
2. Present Street Address	City	State	Zip Code	No. Yrs at Present
Address	
3. Former Street Address (if at

□ Currently Homeless (for reporting purposes only)

present address for less than 2 yrs.)	City	State	Zip Code	No. Yrs. at Former
Address	
disclosed without your consent.

ANNUAL INCOME

Source	

Applicant	

Co-Applicant	
Other
HOUSEHOLD
Members 18
YRS OR OLDER

TOTAL	
1. Gross Salary					
2. Overtime Pay					
3.Commissions/Fees/Tips
    Bonuses					
4. Unemployment Benefits					
5. Workers Compensation,etc					
6. Social Security, Pensions,
     Retirement Funds, etc.,
     Received Periodically 					
7.  TANF Payments					
8. Alimony, Child Support					
9. Interest and/or Dividends					
10. Net Income from business       					
11. Net Rental Income					
12. Other:					

TOTAL					

ASSETS	
CASH
VALUE	Income
From
Assets	
Name of Financial Institution	
Account
Number	
Checking Accounts					
Savings					
Certificate of Deposit					
Mutual Funds/Stocks/Bonds
IRA’s or Investments					
Real Estate					
Other:					
TOTAL:					
           
                  ____Have_____Have not disposed of any asset(s) valued at  $1,000 or more in the past two years for less 
                 than the fair market value of the item. If yes, Please list the asset value under the “other” column in 
                 the above listing of  assets.

Member No.	Full Name	Relationship	Birth date  M/D/Y	 Social Security No.	
Head Of Household					
2					
3					
4					
5					
6					
7					
8					

Preferences:        ________Live or work in Butler County

                            ________Displacement – have been displaced by government action or a
					     Presidentially declared disaster

Are you or any members of your household currently using an illegal controlled substance?_______
If so, explain______________________________________________________________________

Have you or any member of your household been convicted of illegal usage, distribution or manufacture of a controlled substance?_________   If so, explain__________________________________________

Have you or any member of your household ever been convicted of any felony or misdemeanor other than traffic violation?________  If yes, explain_______________________________________________ 

Head/Spouse or Co Applicant:    List any other names you have used other than the one you are presently using:____________________________________________________________________________

Have you ever  resided in any Public Housing unit or received Section 8 Rental Assistance in Butler County or any other county/state?____________If yes, pease list counties/state and dates________________
_________________________________________________________________________________

Do you owe any unpaid rent/damages to any Public Housing Agency?___________If yes, list Agency and amount __________________________________________________________________________

Are there any special housing needs or accommodations that the household will require? Examples are a unit for mobility impaired, a unit for visually impaired, a unit for hearing impaired, or grab bars, wheel-in-showers. 
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The information provided above is true and complete to the best of my/our knowledge and belief. I/we consent to the disclosure of income and financial information from my/our employer and financial references for purposes of income and asset verification related to my/our application for tenancy.  I/we understand that if I/we furnish false or incomplete information I/we can be fined up to $10,000 or imprisoned up to five years, or lose the subsidy HUD pays and have my/our rent increased. I/we have read the privacy act notice.
  Applicant__________________________________________ Date__________________________________
 Co-Applicant_______________________________________ Date__________________________________

If you are in need of special services, please call us at 724-287-6797     or TDD 1-800-545-1833 Ext 772
If you have a grievance complaint regarding this application, you may call:
            			 PITTSBURGH FIELD
      					(412) 644-6965
TDD# 1-800-927-9275
                                                                                             1-800-669-9777 Toll-Free Complaints
Managed by:    Butler County Housing Authority   					
114 Woody Drive   (located in Pullman Square)
Butler PA 16001     1 -800-433-6327 or 724-287-6797 
www.housingauthority.com       

It is the applicants responsibility to notify the Housing Authority Office for all changes of addresses, telephone numbers and status of preference changes.

All applications will be reviewed and a preliminary determination and an approximate  waiting time will be 
accessed by letter to the applicant within two weeks of the date your application is received in the Housing 
Authority Office.

We/I acknowledge the Housing Authority may be considering information from any one or all of the following
but not limited to:  Sources to determine eligibility:  Interviews, Landlord References, Home Housekeeping 
visits, Credit Report, Registry Check and/or Criminal Reports.

The information provided above is true and complete to the best of my/our knowledge and belief. I/we consent 
to the disclosure of income and financial information from my/our employer and financial references for 
purposes of income and asset verification related to my/our application for tenancy.  I/we understand that 
if I/we furnish false or incomplete information I/we can be fined up to $10,000 or imprisoned up to five years,
 or lose the subsidy HUD pays and have my/our rent increased. I/we have read the privacy act notice.

 Applicant________________________________________________ Date____________________________

Spouse/ Co-Applicant_______________________________________ Date____________________________

If you are in need of special services, please call us at 724-287-6797     or TDD 1-800-545-1833 Ext 772
If you have a grievance complaint regarding this application, you may call:

PITTSBURGH FIELD
 (412) 644-6965
  TDD# 1-800-927-9275
                                                                                                1-800-669-9777 Toll-Free Complaints

Managed by:    Butler County Housing Authority   					
   114 Woody Drive           (located in Pullman Square)
   Butler PA 16001    
1 -800-433-6327 or 724-287-6797
TDD:  1-800-545-1833