Fieldstone Cottages Rental Application

Step 1 of 13

Applicant/Head of Household Information

Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Prefer not to disclose

Social Security Number(Required)

Are you enlisted in the U.S. Military or are you a veteran of the U.S. Military?(Required)

Yes

Are you a victim of a recent presidentially declared disaster?(Required)

Yes

UNIT SIZE/FEATURES: The owner/agent will take your unit preferences/requirements into consideration. The owner/agents occupancy standards indicate a minimum of one person per bedroom and maximum of two people per bedroom. Please indicate unit size preferences below. Please indicate any necessary special features below.

Unit Size(Required)

Studio Unit

1 Bedroom Unit

2 Bedroom Unit

3 Bedroom Unit

4 Bedroom Unit

Special Features(Required)

Mobility Accessible Unit

Communication Accessible Unit (Hearing)

Communication Accessible Unit (Visual)

Special features: Please list below:

Other Special Features(Required)

HOUSEHOLD INFORMATION

Please list below all information for each additional household member who will also occupy the unit. List adult members (18 years of age and older) first then minor children. If applicant is to be the only occupant, please enter NONE.

Household Information

Name	Relationship to Head	Social Security Number	Date of Birth	Gender	Student?	List all states lived in	Actions

There are no Entries.

Maximum number of entries reached.

Do you anticipate a change in household composition during the next 12 months?(Required)

Yes

Will any of the above household members live anywhere except in the apartment?(Required)

Yes

Will any other persons live in the apartment on a less than full-time basis?(Required)

Yes

No`

If you answered “Yes” to any of the above questions, please explain:(Required)

PETS & ASSISTANCE/COMPANION ANIMALS INFORMATION

Please review the property pet/assistance animal rules. The presence of any animal must be approved before housing the animal in the unit.

1. Do you plan to house an animal in the unit?(Required)

Yes

2. Is this animal required to live in the unit to alleviate the system(s) of a disability for a household member?(Required)

Yes

PETS & ASSISTANCE/COMPANION ANIMALS INFORMATION

ANIMAL TYPE	BREED	HEIGHT	WEIGHT	Actions

There are no Entries.

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MISCELLANEOUS INFORMATION

FAILURE TO RESPOND TO ANY OF THE FOLLOWING QUESTIONS MAY JEOPARDIZE THE APPROVAL OF THIS APPLICATION.

1. Are you currently enrolled at an institution of higher education for the purpose of obtaining a degree, certificate, or another program leading to a recognized educational credential?(Required)

Yes

If yes, is it:(Required)

Full Time

Part Time

2. Have you or any other adult members ever used any name(s) or Social Security Number(s) other than the one you are currently using.(Required)

Yes

Please explain(Required)

3. Are you a current user of illegal drugs?(Required)

Yes

4. Are you currently using marijuana?(Required)

Yes

5. Do you abuse alcohol to the extent that you are a danger to others’ health, safety, or right to peaceful enjoyment?(Required)

Yes

6. Have you or any member of your household ever been convicted of any drug offense?(Required)

Yes

If yes, who? Please explain:(Required)

7. Have you or any member of your household ever been convicted of a crime?(Required)

Yes

If yes, indicate if conviction was a felony, misdemeanor or check both if you have been convicted of both.(Required)

Felony

Misdemeanor

Please Explain:(Required)

8. Have you or any member of your household been convicted of a sex crime or are a registered sex offender?(Required)

Yes

If yes, who? Please Explain:(Required)

Where registered?(Required)

9. Are you or any member of your household subject to a lifetime state sex offender registration program in any state?(Required)

Yes

10. Does anyone in your household currently have any felony charges pending against them?(Required)

Yes

If yes, who? Please explain:(Required)

11. For you and each household member 18 year of age or older, please list all states in which each family member has ever lived.

Name	State	Actions

There are no Entries.

Maximum number of entries reached.

PREFERENCES: Depending on Tenant Selection Plan

The owner/agent places household in units based on the date and time the completed application is received and the household’s eligibility for preference. Please indicate if you qualify for any of the preferences indicated below.

I currently live on this property and am requesting a new unit(Required)

Yes

I am a victim of a recent presidentially declared disaster.(Required)

Yes

LANDLORD INFORMATION & RESIDENTIAL HISTORY

YOU MUST PROVIDE A MINIMUM OF TEN (10) YEARS OF RESIDENTIAL HISTORY

Have you, or another person living with you, ever broken a lease or been evicted from any housing? If yes, explain:(Required)

With regards to your PRESENT housing, do you(Required)

Rent

Own

Live with family

Other

Monthly Rent(Required)

Please enter a number greater than or equal to 0.

Monthly Mortgage Payment(Required)

Please enter a number greater than or equal to 0.

Monthly Costs(Required)

Please enter a number greater than or equal to 0.

Please explain(Required)

Are you receiving rental subsidy (Section 8) on this housing?(Required)

Yes

Current Landlord’s Name(Required)

Current Landlord’s Address(Required)

Current Landlord’s Telephone(Required)

Include Area Code

How long at this address

From(Required)

(Month/Year)

To(Required)

(Month/Year)

Reason for leaving:(Required)

Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents, etc.)(Required)

Yes

Do you currently have any outstanding overdue balances owed to this landlord?(Required)

Yes

Have you given this landlord notice that you will be moving?(Required)

Yes

Have you been evicted or is this landlord attempting to evict you or another person living with you?(Required)

Yes

With regards to your PREVIOUS housing, did you

With regards to your PREVIOUS housing, did you:	Previous Landlord’s Address	Actions

There are no Entries.

Maximum number of entries reached.

EMPLOYMENT INFORMATION

1. Are you currently employed?(Required)

Yes

2. Is any member of your household who will be residing in the unit currently employed?(Required)

Yes

3. Do you currently have a job offer from a new employer?(Required)

Yes

If yes, what date will you start?(Required)

Anticipated Salary(Required)

(Amount/Year)

Employment Information

Head of Household

Present Employer(Required)

Phone(Required)

Name of Immediate Supervisor(Required)

Employer Address(Required)

Occupation(Required)

Starting Date of Employment(Required)

MM slash DD slash YYYY

Salary(Required)

Per(Required)

Hour

Week

Month

Year

Previous Employer(Required)

Phone(Required)

Name of Immediate Supervisor(Required)

Employer Address(Required)

Occupation(Required)

Starting Date of Employment(Required)

MM slash DD slash YYYY

Salary(Required)

Per(Required)

Hour

Week

Month

Year

Spouse or Other Family Member

Present Employer(Required)

Phone(Required)

Name of Immediate Supervisor(Required)

Employer Address(Required)

Occupation(Required)

Starting Date of Employment(Required)

MM slash DD slash YYYY

Salary(Required)

Per(Required)

Hour

Week

Month

Year

Previous Employer(Required)

Phone(Required)

Name of Immediate Supervisor(Required)

Employer Address(Required)

Occupation(Required)

Starting Date of Employment(Required)

MM slash DD slash YYYY

Salary(Required)

Per(Required)

Hour

Week

Month

Year

Please list the total ANNUAL EMPLOYMENT INCOME of all members of your household:

Name of Recipient	Actions

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Maximum number of entries reached.

INCOME & BENEFITS

Please list the total BENEFIT INCOME of all members of the household. OTHER SOURCES OF INCOME ARE LISTED ON THE NEXT PAGE.

Social Security Head of Household

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Social Security Other Household Member

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

SSI Head of Household

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

SSI Other Household Member

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Disability Head of Household

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Disability Other Household Member

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Pension Benefits Other Household Member

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Retirement Benefits Head of Household (Periodic Distributions From Annuities or IRAs)

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Retirement Benefits Other Household Member

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Veterans Benefits

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Death Benefits

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Public Assistance (DO NOT include food stamps & Medicaid)

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

Other Benefit Income Source Not Listed

Received?(Required)

Yes

Amount

Frequency

Name of Household Member

OTHER INCOME

Do you or any other member of the household receive recurring or periodic income from any of the following sources?

Self-Owned Business

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Gifts or Recurring Cash Contributions (Including Rent & Utility Payments)

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Worker’s Compensation

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Unemployment Benefits

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Severance Pay

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Payment from Insurance Policies

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Military Reserve or National Guard Pay

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Alimony

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Child Support

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Periodic Payments from Lottery or Long-Term Care Insurance

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Other (Please Specify)

Received?(Required)

Yes

Amount

Frequency

Organization Name

Household Member

Are you entitled to alimony?(Required)

Yes

Regular contributions from organizations or from individuals not living in the unit? Contribution from family for rent, child care or other bills(Required)

Please enter a number greater than or equal to 0.

Do you receive financial aid for education assistance?(Required)

Yes

Annual amount of education assistance(Required)

Do you have any rental property or business property income?(Required)

Yes

If yes, give name and address of rental or business:

Name(Required)

Address(Required)

Amount of Income/Rent received per Month(Required)

Asset Information

Have you or any member of the household disposed (sold or given away) any assets valued at $1,000.00 or more (including cash donations) in the past two (2) years?(Required)

Yes

If yes, please describe the asset, its value, and the date of disposition:(Required)

Have you given any money to charities in the past two (2) years?(Required)

Yes

Please provide information on any of the following assets held:

Checking Account

Current Balance or Cash Value

Bank/Institution Name

Household Member

Checking Account

Current Balance or Cash Value

Bank/Institution Name

Household Member

Savings Account

Current Balance or Cash Value

Bank/Institution Name

Household Member

Savings Account

Current Balance or Cash Value

Bank/Institution Name

Household Member

Money Market

Current Balance or Cash Value

Bank/Institution Name

Household Member

Money Market

Current Balance or Cash Value

Bank/Institution Name

Household Member

Certificate of Deposit

Current Balance or Cash Value

Bank/Institution Name

Household Member

Certificate of Deposit

Current Balance or Cash Value

Bank/Institution Name

Household Member

Credit Union Shares

Current Balance or Cash Value

Bank/Institution Name

Household Member

Stocks/Bonds

Current Balance or Cash Value

Bank/Institution Name

Household Member

Treasury Bills

Current Balance or Cash Value

Bank/Institution Name

Household Member

Rental Property

Current Balance or Cash Value

Bank/Institution Name

Household Member

Real Estate (Ex: House, Land, Mobile Home or Camp)

Current Balance or Cash Value

Bank/Institution Name

Household Member

Safe Deposit Box

Current Balance or Cash Value

Bank/Institution Name

Household Member

Deeds or Trusts

Current Balance or Cash Value

Bank/Institution Name

Household Member

Annuities

Current Balance or Cash Value

Bank/Institution Name

Household Member

Real Estate on which you hold the mortgage

Current Balance or Cash Value

Bank/Institution Name

Household Member

IRA, 401-K or Keogh Accts

Current Balance or Cash Value

Bank/Institution Name

Household Member

Mutual Funds

Current Balance or Cash Value

Bank/Institution Name

Household Member

Personal Property held as investment

Current Balance or Cash Value

Bank/Institution Name

Household Member

Life Insurance

Current Balance or Cash Value

Bank/Institution Name

Household Member

Is there a trust fund in your name or have you established a trust fund for someone else?(Required)

Yes

Are assets stored in the safety deposit box such as US Savings Bonds, cash, stocks, etc.(Required)

Yes

Do you have access to any other assets, property, insurance policies, businesses, etc.?(Required)

Yes

If yes, please provide a description of the asset(s) and the current asset value below:(Required)

This section left blank for any additional information you would like to provide.

VEHICLE INFORMATION

Name on Driver’s License

Driver’s License Number

State Issued

State

Date Issued

MM slash DD slash YYYY

Expires

MM slash DD slash YYYY

License Plate Number

State Issued

State

Date Issued

MM slash DD slash YYYY

Expires

MM slash DD slash YYYY

Make

Model

Color

Do you currently have insurance on the vehicle?

Yes

How did you find out about these apartments?

APPLICANT CERTIFICATION

By signing this document, I certify that the unit I/we occupy will by my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility. I/we authorize the owner/manager to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in the application are true and complete. I/we understand that providing false statements or information is punishable under Federal Law. I agree that if any information herein contained is false, the lease made on the strength of this application may, at the option of the landlord, be terminated at any time.

I would like to request a complete copy of the owner/agents resident selection criteria.(Required)

Yes

If yes, which option do you prefer?(Required)

Paper Copy

Electronic Copy

Fieldstone Cottages does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.

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)

Name: Lisa Bennett
Address: 2870 Alum Creek Dr. Colombus OH, 43207
Telephone: (614) 452-4184 Toll Free 877-726-2153
TDD/TTY: 711 Voice Relay

It is the policy of Beacon 360° Management and Fieldstone Cottages to provide housing on an equal opportunity basis. We do not discriminate on the basis of race, religion, color, creed, sex, familial status, national origin, handicap, or sexual preference. If you feel that you have been discriminated against during this application process, please call the Beacon 360° Management main office at (614) 452-4184. Compliance Coordinator.

AUTHORIZATION/ACKNOWLEDGEMENT

I/We understand that the information contained in this application is being collected to determine my/our eligibility for residency. I/We authorize the owner/management agent of to verify all information provided on this application and my/our signature is consent to obtain such verification. I/We certify that all information and answers to the above questions are true and complete to the best of my/our knowledge. I/we consent to the release of the necessary information to determine eligibility.

I/We authorize any person, law enforcement or credit checking agency having any information regarding me/us to release any and all such information to the owner/management agents or their agents or credit checking agencies. I/We understand that the credit report (rental history, arrest and/or conviction records, including pedophile and sex offender records and retail credit history) will be done through a credit bureau contracted with the apartment community. I/we understand that a check will be made of the sex offender registry in all states which I/we have resided.

I/We do hereby swear and attest that all of the information contained herein is true and correct.

WARNING: “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 Contract Administrator, and any owner (or an employee of HUD, the Contract Administrator, or the owner) may be subject to penalties for unauthorized disclosure of improper uses of information collected based on the consent form. Use of the information collected based on the verification forms is restricted to the purposes cited thereon. 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 $5,000.00. 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 Contract Administrator, 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 42 U.S.C. 208(a) (6), (7) and (8). Violation of these provisions are cited as violations for 42 U.S.C. 408 (a)(6), (7), & (8).

Head of Household(Required)

Date(Required)

MM slash DD slash YYYY

Spouse/Co-Applicant

Date

MM slash DD slash YYYY

Other Household Member

Date

MM slash DD slash YYYY

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