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: ______________________________________________________________________________________

HISTORIC LAFAYETTE APARTMENTS
RENTAL APPLICATION FORM

The information collected below will be used to determine if you qualify as a resident. It will not be
disclosed without your consent.
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	

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.

Are any adults full-time students?     Yes——— No———

HOUSEHOLD COMPOSITION List of household and all members who live in your home
Give the relationship of each family member to the head.

Member No.	
Full Name	
Relationship	Birthdate
M/D/Y	           SocialSecurity No.	
Head Of Household					
2					
3					
4					
5					

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.
  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:
PHILADELPHIA FIELD              PITTSBURGH FIELD
   (215) 656-0663                            (412) 644-6965
TDD# (215) 656-3450                 TDD# 1-800-927-9275
                                                                                                                              1-800-669-9777 Toll-Free Complaints

Managed by: Butler County Housing Authority
114 Woody Drive
Butler PA 16001
1 -800-433-6327 or 724/287-6797

Historic Lafayette Apartments are located on South Main Street in Butler, PA. 
This historic building has 59 affordable, uniquely designed apartments designated for 
people ages 55 and older. If you or someone you know is looking for maintenance 
free, friendly environment style of living, then Historic Lafayette Apartments may be 
what you are looking for! To obtain an application or to learn more about other 
housing options located throughout Butler County contact:

Housing Authority County of Butler
114 Woody Drive
Butler, PA 16001
724.287.6797 or 1.800.433.6327
TDD: 1.800.545.1833 x772
www.housingauthority.com

Income Guidelines:
Individual:   $35,640
Family of 2: $40,740