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To Be Completed by each Household Member ages 18 and older.
PLEASE ANSWER ALL QUESTIONS! Do not leave any space blank, write “No or N/A” where appropriate.

1. FAMILY DATA

Current Address
Landlord Address
Previous Address (if current address less than 3 years)
Current Marital Status:
Have you ever used another name?

Directions to Member: Please complete the table below listing each member of the household, whether or not those members are related. Include all members who you anticipate will live with you at least 50% or more of the time during the next 12 months. (A full time student is anyone who is enrolled for at least five calendar months for the number of hours or courses, which are considered full-time attendance by that institution. The five months need not be consecutive).

If you need additional space for answers to any paragraph listed below, attach additional sheets and make sure you include a reference to the paragraph number and your name.

2. HOUSEHOLD COMPOSITION (List each person living in the unit):

List
Name(s)
Relationship to Head
Date of Birth
Gender (M/F)
Full Time Student (Y/N)
Employed (Y/N)
Social Security Number
 
Do all of the above household members reside in the household 100% of the time?
If no, please list those not living in the household 100% of the time
Anticipated changes in household size within the next 12 months?
Anticipated change in number of students within the next 12 months?
Are all occupants’ full time students?
Do you have a pet?
Name

3. CURRENT EMPLOYMENT INFORMATION

Employer’s Name
Address
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Salary Frequency
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ADDITIONAL EMPLOYMENT
Employer’s Name
Address
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Salary Frequency
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IF CURRENTLY UNEMPLOYED, LIST PREVIOUS EMPLOYMENT
Current Employer’s Name
Current Employer’s Address
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Salary Frequency
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4. SOURCE OF INCOME

Is income received from any of the following? Please mark “yes” or “no” for each source of income.
Bonuses
Bonusese Frequency
Tips
Tips Frequency
Commission /fees
Commission /fees Frequency
Overtime pay
Overtime Pay Frequency
Typical overtime worked throughout the year
Typical Overtime - Pay Frequency
Occasional or seasonal overtime
Occasional Overtime - Pay Frequency
Workers compensation
Unemployment
Name

5. OTHER SOURCES OF INCOME

Is income received from any of the following sources? Please mark “yes” or “No” for each source of income.
Wages, Salary, etc. thru Employment
Income from a Business or Profession
Social Security
SSI
AFDC or other Public Assistance
Alimony
Child Support
Unemployment Compensation
Unemployment Compensation
Workers' Compensation
Severance Pay
Retirement Income
Annuities Income
Insurance Policies Income
Disability or Death Benefits
Income from Rental Property
Regularly Recurring monetary gifts
Scholarships
Grants
Educational Entitlements
Regular, Special Armed Forces Allowances
Work Study Programs
Regular Occurring Allowance
Long Term Care Payments
Pensions
Income from Training Programs
Resident Students
Severance Pay
Other Income
Name

6. HOUSEHOLD ASSETS

Do you or anyone in the household have any of the following assets? Please mark “Yes” or “No” for each source of income.
Checking Accounts
Savings Accounts
Certificates of Deposits*
Money Market Funds
Mutual Funds/Stock*
Treasury Bills
IRA 401K*
Company Retirement Accounts*
Annuities Income*
Life Insurance Policies (Whole Life)*
Pension Funds*
Trust Accounts
If yes, is it revocable?
Personal Property Held for Investment
Mortgage or Deed of Trust
Cash held in Safety Deposit Boxes, etc.
House/Real Estate*
Rental Property
Other Investments
Have you received any lump sum payments such as the following:
Inheritances
Lottery or other Winnings
Insurance Settlements
Workers' Compensation Settlements
Social Security Disability Settlements
Unemployment Compensation Settlements
VA Disability Settlements
Severance Pay
Capital Gains
Other
Name
For each “Yes” marked above, please complete the following:
Household member name
Type of asset
Value (see note)
Interest / Income
 
Note: *When listing the cash value of any of the items that have an asterisk, please keep in mind penalties for withdrawal, or any fees deducted to convert the asset to cash. For example, if you owned a home, and sold it, how much cash would you have after you paid off the mortgage, the realtor etc.? That’s the amount you should list in the “ value” column.
Have you disposed of any assets for less than it’s worth within the last two year?
Consent

**ELIGIBILITY OF STUDENTS**

The following rules apply to qualify as a student (only if the entire household is comprised of full-time students, would one of the following exceptions need to be used to qualify the household).

Full-time students cannot be considered low-income unless:

  1. They are married and have filed a joint federal tax return
  2. The household receives AFDC benefits
  3. They are involved in certain federal or state job training
  4. They are a single parent and his/her minor children and non of the tenants are a dependent of third party
Consent
We would like to know how you heard about us?
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GENERAL CONSENT

I / We (Name), the undersigned, hereby authorize all persons or companies in the categories listed below to release, without liability, information regarding employment, income, and / or assets to _Office of Special Housing Needs_ for purposes of verifying information on my / our apartment rental application.

INFORMATION COVERED

I / we understand that previous or current information regarding me / us may be needed. Verifications and inquiries that may be requested include, but are not limited to: personal identity, employment, income, assets, or medical or childcare allowances. I/We understand that this authorization cannot be used to obtain any information about me/us that is not pertinent to my eligibility for and continued participation as a Qualified Tenant.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED

The groups or individuals that may be asked to release the above information include, but are NOT limited to:

  • Past and Present Employers
  • Veterans Administration
  • Public Housing Agencies
  • Welfare Agencies
  • Retirement Systems
  • State Unemployment Agencies
  • Social Security Administration
  • Support and Alimony Providers
  • Banks and Other Financial Institutions
  • Medical and Child Care Providers
  • Current and Previous Landlords

CONDITIONS

I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will stay in effect for a year and one month from the date signed. I/We understand that I/we have a right to review this file and correct any information that is incorrect.

Applicant / Resident Name
Applicant Consent
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Co-Applicant / Resident Name
Co-Applicant Consent
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Business Hours

Monday - Thursday 8:00AM to 4:30PM
Friday from 8:00AM to Noon

550 Meeting Street.
Charleston, SC 29403

(843) 720-3970
info@chacity.org

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