INTAKE FORM

All occupants must be 55 years of age or older.
Required documents for all applicants:
Picture ID and Social Security Card.
A statement of benefit from all sources of income. This statement must show the gross monthly amount you
receive. The net amount must match the deposit on your bank statement. The statement must be from the
current year and have your name on it.
Three months of bank statements, the most current, from all accounts and include every page of the statement.
The statements must show your name and the financial institution’s name on the statement. The deposit(s) on
these statements from your source of income must match the income statement(s) you provide. All deposits (of
any amount) must be explained as to the source of this money. You may write on your statement next to the
deposit where the funds came from (gift from son, cashed in coins, casino winning, sold fishing pole, as an
example).
If you file a tax return, you must provide a copy of the return (including all documents used to report your
income, W-2, 1099s). If you self-prepared your return, we will need a transcript from the IRS. The IRS office
can provide you a transcript. If you did not file a tax return, complete the affidavit “Unfiled Tax Return
Affidavit” in this application package.
W2 wage earners:
Provide 3 current and consecutive pay stubs dated within the last six months.
Verification of Employment form in the application packet must be completed by your employer and signed by
them. You do not fill this form out, they do.
Tip employees must complete the Unreported Earned Income Affidavit Form in the application packet or write
a statement indicating all tips are declared in pay check.
Self Employed Wage earner or 1099 Wage Earner, please ask for a list of your required documents.
Thank you for your interest in Riverside.
Jamie Jo Taylor
Property Manager, Riverside
Equal Housing Opportunity
We Do Business in Accordance With the Fair Housing Act
(The Civil Rights Act of 1968, as amended by the Fair Housing Amendments Act of 1988)
Anyone who feels he or she has been discriminated against should send a complaint to:
U.S. Department of Housing and Urban Development,
Assistant Secretary for Fair Housing and Equal Opportunity, Washington, DC 20410
1
LAMEY BRIDGE SENIOR DEVELOPMENT, LLC
DBA RIVERSIDE
RENTAL APPLICATION
DATE OF APPLICATION: __________________
APPLICANT INFORMATION:
LAST NAME: ________________________ FIRST NAME: _____________________ MIDDLE NAME: _____________________
PHONE: _______________________ Email: __________________________________________
MARITAL STATUS (Please circle)
SINGLE
MARRIED
DIVORCED
SEPARATED
WIDOWED
U.S. CITIZEN: YES ____ NO ____ DATE OF BIRTH: ________________ SS # ____________________________
CURRENT ADDRESS WHERE YOU RESIDE: __________________________________________
CITY: _____________________________________STATE ______ ZIP: ________________COUNTY: ______________________________
Own: ____ Rent: ____ Neither: _____ (staying with a friend or relative)
LANDLORD INFORMATION (if renting):
NAME: _________________________________________ PHONE#: ________________________________ FAX#: ________________________
STREET: ____________________________________________________________________
CITY: ____________________________________ STATE: _______ ZIP: _____________________________ COUNTY: _____________________
HOW LONG? ____________; CURRENT RENT: __________________; CURRENT LEASE EXPIRES: _________________________
APPLICANT’S EMPLOYMENT INFORMATION:
Are you a W-2 wage earner: YES
NO
1099 employee? YES
NO
Self Employed as owner/operator: YES
NO
EMPLOYER NAME: ______________________________________ PHONE: ____________________________ FAX# ________________________
STREET ADDRESS: _______________________________________________________________________________________________________
CITY: ______________________________________________ STATE: _________ ZIP: ___________ COUNTY: ___________________________
EMPLOYER’S PHONE#: ________________________________________
FAX#: _______________________________________
POSITION/TITLE: ________________________ HRS PER WEEK: _________ INCOME: ________________ PER ________ (Hr/Week/Mo./Year/etc)
LENGTH OF EMPLOYMENT: _______ YRS ______ MO
START DATE: ________________________ END DATE: _________________________
PREVIOUS EMPLOYER(S) NAME & ADDRESS (IF LESS THAN 2 YEARS) ____________________________________________________________
2
CO-APPLICANT INFORMATION:
LAST NAME: ________________________ FIRST NAME: _____________________ MIDDLE NAME: _____________________
PHONE: _______________________ Email: __________________________________________
MARITAL STATUS (Please circle)
SINGLE
MARRIED
DIVORCED
SEPARATED
WIDOWED
U.S. CITIZEN: YES ____ NO ____ DATE OF BIRTH: ________________ SS # ____________________________
CO-APPLICANT’S CURRENT ADDRESS WHERE YOU RESIDE:
__________________________________________
CITY: _____________________________________STATE ______ ZIP: ________________COUNTY: ______________________________
Own: ____ Rent: ____ Neither: _____ (staying with a friend or relative)
CO-APPLICANT’S LANDLORD INFORMATION (if renting):
NAME: _________________________________________ PHONE#: ________________________________ FAX#: ________________________
STREET: ____________________________________________________________________
CITY: ____________________________________ STATE: _______ ZIP: _____________________________ COUNTY: _____________________
HOW LONG? ____________; CURRENT RENT: __________________; CURRENT LEASE EXPIRES: _________________________
CO-APPLICANT’S EMPLOYMENT INFORMATION:
Are you a W-2 wage earner: YES
NO
1099 employee? YES
NO
Self Employed as owner/operator: YES
NO
EMPLOYER NAME: ______________________________________ PHONE: ____________________________ FAX# ________________________
STREET ADDRESS: _______________________________________________________________________________________________________
CITY: ______________________________________________ STATE: _________ ZIP: ___________ COUNTY: ___________________________
EMPLOYER’S PHONE#: ________________________________________
FAX#: _______________________________________
POSITION/TITLE: ________________________ HRS PER WEEK: _________ INCOME: ________________ PER ________ (Hr/Week/Mo./Year/etc)
LENGTH OF EMPLOYMENT: _______ YRS ______ MO
START DATE: ________________________ END DATE: _________________________
PREVIOUS EMPLOYER(S) NAME & ADDRESS (IF LESS THAN 2 YEARS) ____________________________________________________________
3
Monthly Income
INCOME FROM ALL APPLICABLE SOURCES MUST BE LISTED AND DOCUMENTATION MUST BE MAINTAINED WITH THE APPLICATION
Gross Monthly Income
Base Employment
Part-time income
Tips / Bonuses
Social Security
SSI
Disability
Alimony
Pension
Annuity
1099 - Self Employment
Interest/ Dividend Income
Unemployment
Welfare
Other
TOTAL INCOME:
Applicant
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
Applicant
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
Co-Tenant
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
Co-Applicant
Totals
Co-Applicant
Totals
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
Monthly Expenses and Liabilities
MONTHLY EXPENSES
Monthly Expenses
Rent
Utilities
Telephone
Cell Phone
Car Payments
Car Insurance
Other Insurance
Childcare
School Lunch
Child Support/ Alimony
Credit Card Payments
Student Loan Payments
Medical
Other Loan Payments
Other
TOTAL EXPENSES:
Applicant
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ Yes
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
__ No
Applicant
Co-Applicant
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
__ Yes __ No
Declarations (Answering “Yes” to these questions does not automatically disqualify you. Please attach explanation.)
Applicant
Have you ever filed for Bankruptcy? _______ (yes/no) Have you ever been evicted from any tenancy? ______ (yes/no)
Have you ever willfully and intentionally refused to pay rent when due? __________
4
Co-Applicant
Have you ever filed for Bankruptcy? _______ (yes/no) Have you ever been evicted from any tenancy? ______ (yes/no)
Have you ever willfully and intentionally refused to pay rent when due? __________
Only the applicant and/or co-applicant may live, reside,
or occupy the apartment you are applying for.
Guests/visitors are restricted to no more than 7 consecutive days.
I DECLARE THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT. I AGREE THAT LBSD MAY
TERMINATE ANY AGREEMENT ENTERED INTO IN RELIANCE ON ANY MISSTATEMENT OR OMISSION
CONTAINED ABOVE.
APPLICANT AUTHORIZATION AND CERTIFICATION
I understand that by completing and submitting this application, I am authorizing LAMEY BRIDGE SENIOR
DEVELOPMENT, LLC and/or its partner(s) to evaluate my actual need for assistance and my willingness to
participate with program requirements. I understand that the evaluation may include visits, periodic credit
checks, employment verification, and verification of other information included in this application. I hereby
authorize LAMEY BRIDGE SENIOR DEVELOPMENT, LLC and/or its partner(s) to perform all such
verification it deems necessary. By signing below, I certify that I have answered the questions in the
application truthfully. I understand that if I have not answered all the questions truthfully, my application may
be denied. I also understand even if I am selected to receive assistance, I may be disqualified from the
program at a later date if it is discovered that I have not been truthful in this application. I agree to notify
LAMEY BRIDGE SENIOR DEVELOPMENT, LLC and/or its partner(s) in writing of any changes to the
information in this application within two (2) weeks of such change. I understand that such changes could
affect the outcome of this application. Further, I understand that I may choose to exclude any specific entity
from being contacted in writing. If I choose to revoke this authorization at any time, I will do so in writing.
The original or a copy of the application will be retained by LAMEY BRIDGE SENIOR DEVELOPMENT, LLC
and/or its partner(s) even if the application is not approved.
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.
Applicant: ___________________________________
Date: _______________
Co-Applicant: ____________________________________
Date: _______________
5
MISSISSIPPI LONG TERM WORKFORCE HOUSING PROGRAM
Consent and Release Form, Nonpublic Personal Information Form
I (Applicant/Co-Applicant) do hereby consent to and authorize Lamey Bridge Senior Development, dba Riverside, its
partners, affiliates, agents, contractors and their respective assigns (collectively “LBSD”), and the Mississippi
Development Authority and its employees, agents, and contractors (collectively “MDA”) as part of my application for the
Long Term Workforce Housing Program (the “Program”), to request, access, review, disclose, release and share any and
all Nonpublic Personal Information (“NPI”), whether provided by me in this application or by additional outside third parties
with whom I may or may not have a relationship, as necessary for final determination of my eligibility for and the amount
of assistance under the Program. I understand and acknowledge that any party disclosing information to LBSD and MDA
on my behalf is not responsible for any negligent misrepresentation or omission, and I agree to hold any such disclosing
party harmless from and against all claims, actions, suits or other proceedings, and any and all losses, judgments,
damages, expenses or other costs (including reasonable counsel fees and disbursements), arising from or in any way
relating to their disclosure.
As part of this consent, I further authorize LBSD, MDA, and any other financial institution, lender, insurer, other
government agency (federal or state), credit bureau, financial service provider or any other third party to obtain, use and
disclose any of my NPI in their possession, as necessary, to enable LBSD and MDA to administer the Program and to
enable LBSD to process my application.
I understand and acknowledge that MDA and LBSD may obtain, use and disclose any NPI received in its investigation of
my application with third parties, including those referenced above, as necessary for final determination of my eligibility for
and the amount of assistance under the Program.
I acknowledge that I have received and reviewed MDA’S and LBSD’s privacy policies as they relate to my NPI and my
right to privacy associated therewith. I also understand and acknowledge that, as part of those policies, my consent may
be revoked at any time with written notice to, as applicable, MDA or LBSD. I further understand and acknowledge that
any such revocation of this consent may affect my ability to receive assistance under the Program.
By completing and signing this application, I acknowledge and agree to the above and agree that this consent may be
furnished on my behalf to any financial institution, lender, insurer, government agency (federal or state), credit bureau,
financial service provider or other third party.
_______________________________ ___________________________________
___________
Applicant Signature
Date
Printed Name
_______________________________ ___________________________________
___________
Co-Applicant Signature
Date
Printed Name
IT IS ILLEGAL TO DISCRIMINATE AGAINST ANY PERSON BECAUSE OF RACE, COLOR, RELIGION, SEX,
DISABILITY, FAMILIAL STATUS (HAVING ONE OR MORE CHILDREN), OR NATIONAL ORIGIN.
Equal Housing Opportunity
We Do Business in Accordance With the Fair Housing Act
6
(The Civil Rights Act of 1968, as amended by the Fair Housing Amendments Act of 1988)
Anyone who feels he or she has been discriminated against should send a complaint to:
U.S. Department of Housing and Urban Development,
Assistant Secretary for Fair Housing and Equal Opportunity, Washington, DC 20410
LONG TERM WORKFORCE HOUSING PROGRAM
Privacy Policy
Your privacy is important to Lamey Bridge Senior Development, LLC, dba Riverside (LBSD), and maintaining your
trust and confidence is one of our highest priorities. We respect your right to keep your personal information confidential
and understand your desire to avoid unwanted solicitations. We hope that by taking a few minutes to read this policy, you
will have a better understanding of what we do with the information you provide us and how we keep it private and secure.
LBSD collects certain personal information about you because it is necessary for us to use that information when
preparing forms and communicating with the various agencies as a part of the Long Term Workforce Program.
Examples of sources from which we collect information include:



Application information, interviews and phone calls with you,
Letters or e-mails from you, and
Other questionnaires completed during the Long Term Workforce Housing Program
As a general rule, we do not disclose personal information about our clients or former clients to anyone. However, to the
extent permitted by law certain nonpublic information about you may be disclosed to our partners, affiliates, agents,
contractors and their respective assigns and to the Mississippi Development Authority, its employees, agents and
contractors as necessary for final determination of your eligibility for and the amount of assistance under the Long Term
Workforce Housing Program.
LBSD protects all of its clients’ confidential information. We use commercially reasonable safeguards on our computer
system to prevent unauthorized access of confidential information. Although security cannot be guaranteed, we maintain
physical, electronic, and procedural safeguards that comply with applicable professional standards.
NOTE: TRANSMISSION BY ELECTRONIC MAIL (EMAIL) OF SOCIAL SECURITY NUMBERS IS PROHIBITED.
COMPLETED CONSENT FORMS MUST BE TRANSMITTED BY FACSIMILE TRANSMISSION, HAND DELIVERY,
POSTAL SERVICE OR OTHER OVERNIGHT DELIVERY SERVICES.
_______________________________ ___________________________________
Applicant Signature
Printed Name
___________
Date
_______________________________ ___________________________________
Co-Applicant Signature
Printed Name
___________
Date
7
INFORMATION FOR FEDERAL MONITORING PURPOSES
Please read this statement before completing the box below:
The following information is requested by the federal government in compliance with equal opportunity and fair
housing laws. You are not required to furnish this information, but are encouraged to do so. The law provides that
there is neither discrimination on the basis of this information, nor on whether you choose to furnish it or not.
However, if you choose not to furnish it, under federal regulations we are required to note race and sex on the basis
of visual observation or surname. If you do not wish to furnish the information, please check the box below.
Applicant
Co-Applicant
__ I do not wish to furnish this information.
__ I do not wish to furnish this information.
Race/National Origin
__ American Indian or Alaskan Native
__ Asian or Pacific Islander
__ White, not of Hispanic origin
__ Black, not of Hispanic origin
__ Hispanic
__ Other (please specify)
Race/National Origin
__ American Indian or Alaskan Native
__ Asian or Pacific Islander
__ White, not of Hispanic origin
__ Black, not of Hispanic origin
__ Hispanic
__ Other (please specify)
Gender
__ Male
Gender
__ Male
__ Female
__ Female
Birth Date:
Birth Date:
Marital Status:
__ Married
__ Separated
__ Unmarried (includes single, divorced, widowed, and
never married
Marital Status:
__ Married
__ Separated
__ Unmarried (includes single, divorced, widowed, and
never married
8
Emergency Contact Information
Applicant’s Name: ____________________________________________
Applicant’s Phone: ____________________________________________
Applicant’s Emergency Contact Information:
Name: ________________________________________
Cell Phone: __________________________
Relationship: ____________
Home Phone: _____________________
Work Phone: _________________________
Name: ________________________________________
Cell Phone: __________________________
Relationship: ____________
Home Phone: _____________________
Work Phone: _________________________
Co-Applicant’s Name: ____________________________________________
Co-Applicant’s Phone: ____________________________________________
Co-Applicant’s Emergency Contact Information:
Name: ________________________________________
Cell Phone: __________________________
Relationship: ____________
Home Phone: _____________________
Work Phone: _________________________
Name: ________________________________________
Cell Phone: __________________________
Relationship: ____________
Home Phone: _____________________
Work Phone: _________________________
LB 32 (A) Emergency Contact Form
9
Renters Insurance
Riverside strongly urges every resident to obtain Renters Insurance for the protection of their property.
The insurance policy should be maintained for the life of the lease.
I certify that I have read and understand the foregoing Riverside Renters Insurance policy. I certify that I
understand that while renters insurance is not a requirement to reside in a unit at Riverside, management does
strongly urge me to obtain a policy to protect myself in the event of disaster or theft.
Applicant
___________________________________
Applicant Signature
_____________
Date
___________________________________
Printed Name
Co-Applicant
___________________________________
Co-Applicant Signature
_____________
Date
___________________________________
Printed Name
LB 33 (A) Renters Insurance Form
10
Fair Credit Reporting Act Consent Form
I understand that in compliance with the FAIR CREDIT REPORTING ACT the processing of this application includes, but is
not limited to, making any inquiries deemed necessary to verify the accuracy of the information I provided, including
procuring consumer reports from consumer credit reporting agencies and obtaining credit information from other credit
institutions.
I hereby grant Lamey Bridge Senior Development LLC, DBA Riverside the right to process this application for the purpose
of obtaining a Rental/Lease agreement with this property. Additionally, I authorize all corporations, companies, law
enforcement agencies, academic institutions, and current and former employers to release information they may have
about me and release them from any liability and responsibility from doing so.
Applicant
SIGNATURE ___________________________________
Print name: ___________________________________
DOB __________________ SS # ___________________________________
Address _______________________________________________________
City __________________________________ State ____________ Zip ____________________
Co-Applicant
SIGNATURE ___________________________________
Print name: ___________________________________
DOB __________________ SS # ___________________________________
Address _______________________________________________________
City __________________________________ State ____________ Zip ____________________
LB 28 (B) Fair Credit Reporting
11
HOUSEHOLD MEMBERS AFFIDAVIT
Applicant name: ___________________________
Birth date: _____________
Co-Applicant name: ________________________
Birth date: _____________
Relationship to Applicant: _______________________
This program requires us to certify all of your income and eligibility information as part of determining your
household’s eligibility. Program requirements state we must verify each income source as well as other claims
of eligibility. We must determine this prior to granting your eligibility.
I hereby declare the above listed live within my household for more than 51% of the time. They are included in
my household number and their income calculated into my household income.
I hereby declare the above listed are 55 years of age or older.
I understand NO OTHER PERSON(s) will reside with me during the term of my lease.
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Dated this the ______ day of _________________ 20____.
Applicant signature ________________________________
Printed name: _____________________________________
Co-Applicant signature ________________________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
MDA-LTWH
12
HOUSEHOLD RELEASE AND CONSENT FORM
I __________________________________, applicant
and or ______________________________, co-applicant
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:
MDA Long Term Workforce Housing Program
(Owner or Agent)
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 and income.
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 applicant. The information gathered
may be released to the particular sub-recipient auditing the Long Term Workforce Housing including, but not
limited to: Department of Housing and Urban Development (HUD), Office of Inspector General (OIG), and /or
Mississippi Development Authority (MDA).
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
Welfare Agencies
Alimony Providers
State Unemployment Agencies
Veterans Administration
Social Security Administration
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 I/We have a right to review this file and correct any information that is incorrect.
SIGNATURES
_____________________________ ___________________________
__________
Applicant
Date
print name
_____________________________ ___________________________
__________
Co-Applicant
Date
print name
Note: This general consent may not be used to request a copy of a tax return. If a copy of a tax return is
needed, IRS Form 4506, a request for a copy of tax form, must be prepared and signed separately.
Rev 1/ Household Release and Consent Form
07/13/09
13
UNEMPLOYMENT COMPENSATION VERIFICATION
TO:
MS Employment Security Commission
P.O. Box 23088
Jackson, MS 39217
Telephone: 601-321-6000
Fax:
601-321-6433
Applicant:
Name: ___________________________________________
Social Security Number: _________________________
FROM: Riverside Senior Development
11975 Seaway Rd, Ste. A-140
Gulfport, MS 39503
Phone: 228-896-3386
Fax:
228-896-3326
____________________________________________________________
Analyst Signature
In order to comply with federal regulations requesting verification of all income and allowances for residents of the MS Gulf Coast
Renaissance Housing Program, please complete the following information and return it as soon as possible to the above address in the
envelope provided, or FAX to 228-896-3326. Thank You.
UNEMPLOYMENT BENEFITS COMPENSATION INFORMATION
1.
Current Status (please check one)

Currently receiving benefits

Has been determined ineligible for benefits

Has been disqualified until: ___________

Has not filed a claim

Has no current claim

Has a claim that is currently being contested
2.
GROSS Weekly Payment
$_______________________________________
3.
Date of initial claim
________________________________________
4.
Duration of benefits (# of weeks left)
________________________________________
5.
Is the above signed eligible for further benefits? (circle one)
6.
If yes, how many weeks?
________________________________________
7.
GROSS Weekly Amount
$_______________________________________
8.
If no, on what date do the benefits terminate?
________________________________________
YES
NO
________________________________________________
Signature of person verifying information
________________________________________
Title
________________________________________________
Phone Number
________________________________________
Date
14
UNEMPLOYMENT COMPENSATION VERIFICATION
TO:
MS Employment Security Commission
P.O. Box 23088
Jackson, MS 39217
Telephone: 601-321-6000
Fax:
601-321-6433
Co-Applicant:
Name: ___________________________________________
Social Security Number: _________________________
FROM: Riverside Senior Development
11975 Seaway Rd, Ste. A-140
Gulfport, MS 39503
Phone: 228-896-3386
Fax:
228-896-3326
____________________________________________________________
Analyst Signature
In order to comply with federal regulations requesting verification of all income and allowances for residents of the MS Gulf Coast
Renaissance Housing Program, please complete the following information and return it as soon as possible to the above address in the
envelope provided, or FAX to 228-896-3326. Thank You.
UNEMPLOYMENT BENEFITS COMPENSATION INFORMATION
9.
Current Status (please check one)

Currently receiving benefits

Has been determined ineligible for benefits

Has been disqualified until: ___________

Has not filed a claim

Has no current claim

Has a claim that is currently being contested
10. GROSS Weekly Payment
$_______________________________________
11. Date of initial claim
________________________________________
12. Duration of benefits (# of weeks left)
________________________________________
13. Is the above signed eligible for further benefits? (circle one)
YES
NO
14. If yes, how many weeks?
________________________________________
15. GROSS Weekly Amount
$_______________________________________
16. If no, on what date do the benefits terminate?
________________________________________
________________________________________________
Signature of person verifying information
________________________________________
Title
________________________________________________
Phone Number
________________________________________
Date
15
VERIFICATION OF EMPLOYMENT
Employed applicants must have employer complete this form.
Applicant name: _________________________
Address: _____________________________ City: ______________ State: ___ Zip: _____
Name of Employer: ____________________________________________________________
Address: _____________________________ City: ______________ State: ___ Zip: _____
Name of person completing form: ________________________ Title: __________________
Phone: ________________________
Verification of Present Employment (please print)
Applicant’s start date of employment: ________________
Present Position: _________________________________
Probability of continued employment: ____________________________________________
Current gross base pay is $_______________ Annual
Monthly
Weekly
Hourly
If paid hourly, average hours per week are: ______________________________________
Current Gross Earnings year to date through ________________ are $_________________
If overtime or bonus is applicable, is its continuance likely?
Overtime: ____ yes ____ no
Bonus: ____ yes ____ no
______________________________________
Employer’s signature
____________________
Date
16
VERIFICATION OF EMPLOYMENT
Employed applicants must have employer complete this form.
Co-Applicant name: _________________________
Address: _____________________________ City: ______________ State: ___ Zip: _____
Name of Employer: ____________________________________________________________
Address: _____________________________ City: ______________ State: ___ Zip: _____
Name of person completing form: ________________________ Title: __________________
Phone: ________________________
Verification of Present Employment (please print)
Applicant’s start date of employment: ________________
Present Position: _________________________________
Probability of continued employment: ____________________________________________
Current gross base pay is $_______________ Annual
Monthly
Weekly
Hourly
If paid hourly, average hours per week are: ______________________________________
Current Gross Earnings year to date through ________________ are $_________________
If overtime or bonus is applicable, is its continuance likely?
Overtime: ____ yes ____ no
Bonus: ____ yes ____ no
______________________________________
Employer’s signature
____________________
Date
17
CERTIFICATION OF INCOME
Applicant name: ________________________________________
I hereby certify I receive the following sources of income:
_____ Wages from employment (includes commissions, tips, bonuses, fees, etc.)
Must have VERIFICATION OF EMPLOYMENT form completed by employer
_____ Income from operation of a business
_____ Income from rental of real or personal property
_____ Income from interest or dividends, IRA’s, mutual funds, royalties or any other assets
_____ Income from Social Security, annuities, insurance policies, retirement funds, pensions, or death benefits
_____ Income from unemployment or disability payments
_____ Income from public assistance payments
_____ Income from periodic allowances such as alimony, child support, or gifts received from persons not
living in my household
_____ Income from sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.)
_____ Income from any other source not named above. Source: _____________________________________
CERTIFICATION OF ZERO INCOME
_____ I currently have no income of any kind, and there is no imminent change expected in my financial status
or employment status during the next 12 months.
I will be using the following sources of funds to pay for housing and other necessities:
_________________________________________________________________________________________
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Dated this the ______ day of _________________ 20____.
Applicant signature ________________________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
18
CERTIFICATION OF INCOME
Co-Applicant name: ________________________________________
I hereby certify I receive the following sources of income:
_____ Wages from employment (includes commissions, tips, bonuses, fees, etc.)
Must have VERIFICATION OF EMPLOYMENT form completed by employer
_____ Income from operation of a business
_____ Income from rental of real or personal property
_____ Income from interest or dividends, IRA’s, mutual funds, royalties or any other assets
_____ Income from Social Security, annuities, insurance policies, retirement funds, pensions, or death benefits
_____ Income from unemployment or disability payments
_____ Income from public assistance payments
_____ Income from periodic allowances such as alimony, child support, or gifts received from persons not
living in my household
_____ Income from sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.)
_____ Income from any other source not named above. Source: _____________________________________
CERTIFICATION OF ZERO INCOME
_____ I currently have no income of any kind, and there is no imminent change expected in my financial status
or employment status during the next 12 months.
I will be using the following sources of funds to pay for housing and other necessities:
_________________________________________________________________________________________
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Dated this the ______ day of _________________ 20____.
Co-Applicant signature ________________________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
19
MDA - LTWH
UNREPORTED INCOME AFFIDAVIT
Applicant name: ___________________________________
You have applied to participate in the Long Term Workforce Housing Program. This Program requires
certification of your income and eligibility information as part of determining your household’s eligibility.
Program requirements state we must verify each income source as well as other claims of eligibility.
We must determine this prior to granting your eligibility.
COMPLETE THIS FORM IN ITS ENTIRETY
I hereby declare the following income information to be true and correct to the best of my knowledge. Income
counted towards income eligibility for the Long Term Workforce Housing Program is anticipated total/gross
income.
I did not file taxes on my income for the years of ___________ through ___________
I work for cash and have no other formal accounting system to account for this income.
Name of Business: __________________________________________ Start Date: _____________________
Type of Business: ______________________________
Position Held: _____________________________
Anticipated Total/Gross Weekly Income: $__________________
Anticipated Total/Gross Weekly Tips $_______________
Anticipated Total/Gross Weekly Commissions $__________________
Business Address: __________________________________________________________________________
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understands that providing false information herein constitutes
an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.
Applicant signature __________________________
Date _______________
Print name _________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
Rev. 1/Unreported Income
08/13/08
20
MDA - LTWH
UNREPORTED INCOME AFFIDAVIT
Co-Applicant name: ___________________________________
You have applied to participate in the Long Term Workforce Housing Program. This Program requires
certification of your income and eligibility information as part of determining your household’s eligibility.
Program requirements state we must verify each income source as well as other claims of eligibility.
We must determine this prior to granting your eligibility.
COMPLETE THIS FORM IN ITS ENTIRETY
I hereby declare the following income information to be true and correct to the best of my knowledge. Income
counted towards income eligibility for the Long Term Workforce Housing Program is anticipated total/gross
income.
I did not file taxes on my income for the years of ___________ through ___________
I work for cash and have no other formal accounting system to account for this income.
Name of Business: __________________________________________ Start Date: _____________________
Type of Business: ______________________________
Position Held: _____________________________
Anticipated Total/Gross Weekly Income: $__________________
Anticipated Total/Gross Weekly Tips $_______________
Anticipated Total/Gross Weekly Commissions $__________________
Business Address: __________________________________________________________________________
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understands that providing false information herein constitutes
an act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement.
Co-Applicant signature __________________________
Date _______________
Print name _________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
Rev. 1/Unreported Income
08/13/08
21
MDA – LTWH9/10/2009
UNFILED TAX RETURN AFFIDAVIT
Applicant name: ________________________________________
You have applied to participate in the Long Term Workforce Housing Program. This Program requires
certification of your income and eligibility information as part of determining your household’s eligibility.
Program requirements state we must verify each income source as well as other claims of eligibility. We must
determine this prior to granting your eligibility.
COMPLETE THIS FORM IN ITS ENTIRETY
I hereby declare the following income information to be true and correct to the best of my knowledge. Income
counted towards income eligibility for the Long Term Workforce Housing Program is anticipated total/gross
income.
I did not file taxes on my income for the years of ____________ through ____________.
Reasons for unfilled tax returns:
_____ Not required to file
_____ Have not Filed
_____ Unreported cash earnings
_____ Filed Self-Prepared Tax Return with No Deductions
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understands that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Applicant signature ________________________________
Date: ________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
Rev.0/Unfiled Tax Return Affidavit
9/10/2009
22
MDA – LTWH9/10/2009
UNFILED TAX RETURN AFFIDAVIT
Co-Applicant name: ________________________________________
You have applied to participate in the Long Term Workforce Housing Program. This Program requires
certification of your income and eligibility information as part of determining your household’s eligibility.
Program requirements state we must verify each income source as well as other claims of eligibility. We must
determine this prior to granting your eligibility.
COMPLETE THIS FORM IN ITS ENTIRETY
I hereby declare the following income information to be true and correct to the best of my knowledge. Income
counted towards income eligibility for the Long Term Workforce Housing Program is anticipated total/gross
income.
I did not file taxes on my income for the years of ____________ through ____________.
Reasons for unfilled tax returns:
_____ Not required to file
_____ Have not Filed
_____ Unreported cash earnings
_____ Filed Self-Prepared Tax Return with No Deductions
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understands that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Co-Applicant signature ________________________________
Date: ________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
Rev.0/Unfiled Tax Return Affidavit
9/10/2009
23
SAME NAME AFFIDAVIT
Applicant, list all names appearing on all documents past and present. This includes maiden
names, hyphenated names, etc.
I, __________________________________________, applicant for Riverside, do hereby state the names listed
below are one and the same person as:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Dated this the ______ day of _________________ 20____.
Applicant signature ________________________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
24
SAME NAME AFFIDAVIT
Co-Applicant, list all names appearing on all documents past and present. This includes maiden
names, hyphenated names, etc.
I, __________________________________________, co-applicant for Riverside, do hereby state the names
listed below are one and the same person as:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the
best of my knowledge. The undersigned further understand(s) that providing false representations herein
constitutes an act of fraud. False, misleading or incomplete information may result in the termination of a lease
agreement.
Dated this the ______ day of _________________ 20____.
Co-Applicant signature ________________________________
Printed name: _____________________________________
SWORN TO AND SUBSCRIBED before me on this the ____ day of _____________, 20____
________________________________________
NOTARY PUBLIC
My Commission Expires: ________________
25
Credit and Criminal Background Check Authorization
A fee of $35.00 per applicant or $25.00 per applicant if married with the same last name ($50 total) will be due
at time of application for a Credit Check and Criminal Background Check.
Riverside does not lease units to any convicted felons, and if any such convictions are located during my
background check my application to Riverside well be terminated.
Payment of cash, money order or personal check is accepted.
I, __________________________________ applicant do hereby give Lamey Bridge Senior Development,
LLC DBA Riverside permission to complete a Credit Check and a Criminal Background Check on my behalf
for the purposes of qualifying me as a potential tenant at Riverside.
I, __________________________________ co-applicant do hereby give Lamey Bridge Senior Development,
LLC DBA Riverside permission to complete a Credit Check and a Criminal Background Check on my behalf
for the purposes of qualifying me as a potential tenant at Riverside.
___________________________________
Applicant Signature
______________________
Date
___________________________________
______________________
Co-Applicant Signature
Date
******************************************************************************************
Staff Use Only
Payment received $______________
check ___
cash ___
MO ___
Form LB 28 (A) Credit Check and Criminal Background
26