1 RESIDENT ELIGIBILITY APPLICATION (REA). Property Name: Unit #: Household Name: Certification Type: Current HH Size: Effective Date of Certification: Initial Certification Number of Bedrooms: Original Certification Date: Re-Certification THE FOLLOWING SECTION IS TO BE COMPLETED ENTIRELY BY THE APPLICANT/ RESIDENT . HOUSEHOLD COMPOSITION: SSN. Hshld Date of Birth *See page 4. Fulltime Student Mbr First Name Last Name MI mm-dd-yyyy Last 4 digits Status **. Head Yes No 2. Yes No 3. Yes No 4. Yes No 5. Yes No 6. Yes No 7. Yes No ** Have you in this calendar year or will you in the next calendar year, be a fulltime student for five months or more? Household Member's Name: Contact Phone: Contact E-mail: Income Source or Employer: Phone: Address: Position: Hire Date: Supervisor: Income/Salary: $. Household Member's Name: Contact Phone: Contact E-mail: Income Source or Employer: Phone: Address: Position: Hire Date: Supervisor: Income/Salary: $.
2 RESIDENT ELIGIBILITY APPLICATION | Rev. January 2014 tonbar Page 1 of 4. RESIDENT ELIGIBILITY APPLICATION (REA). An Adult household members (see Instructions page for definition of Adult) must complete an REA. Adults should list all their income/assets for the next 12 month period beginning on the anticipated date of move-in or recertification. Property Name: Unit #: Household Member Name: HOUSEHOLD MEMBER: (please check one) 1 (Head) 2 3 4 5 6 7. INCOME INFORMATION: Yes No Annual Gross Income 1. I have a job or a verifiable start date within the next 12 months and receive wages, salary, overtime pay, commissions, fees, tips, bonuses, and/or other compensation: Annual Gross Wages/Salary $. Annual Overtime $. Annual Bonus/Commission/Tips $. 2. I am presently employed at an additional job. (NOT self-employed) $. 3. I am self employed. (Attach signed tax return and appropriate schedules).
3 Name of Business: $. (use net income from business). 4. I am receiving or I have applied or will apply in the next 12 months: (check all that apply) Social Security (SSA);. Supplemental Social Security (SSI); or WA State (SSI). $. 5. The household receives unearned income from family members age 17 or under (example: Social Security, trust fund disbursements, bank accounts, etc.). Name of Member(s): $. 6. Do you receive child support? If no and there are children in the household, are you eligible for child support or is there a court order for child support? Yes No $. Number of court-ordered child support cases: 7. I receive alimony/spousal payments. $. 8. I receive Public Assistance Income (TANF, GAU, FIP, ADATSA). $. 9. I receive unemployment, Labor & Industries or disability benefits (not SSI). $. 10. I am a member of the Armed Forces (Active, National Guard or Reserves).
4 $. 11. I am receiving income from a pension, annuity, retirement fund, insurance policy payments, death benefits or Veteran's Benefits (not GI Bill benefits). Source of Benefits: a.) $. b.) $. 12. I am receiving money regularly from family, church, friends, or any other form or regular/periodic income (such as rent and utility payments). $. 13. I receive income from real or personal property (attach signed tax return with Schedule E). $. RESIDENT ELIGIBILITY APPLICATION | Rev. January 2014 tonbar Page 2 of 4. Property Name: Unit #: Household Member Name: 14. I hold a contract for real estate sold. If yes, provide a copy of the contract and an amortization schedule. (Only count interest portion of payment.) $. 15. I have income or sources of income, other than those listed above. If yes, list type below: a.) $. b.) $. ASSET INFORMATION: Yes No Balance or Value Interest Earned 16.
5 I have a checking account(s). If yes, list bank(s). a.) $ $. b.) $ $. 17. I have a savings account(s). If yes, list bank(s). a.) $ $. b.) $ $. 18. I have a Money Market account(s). If yes, list sources/bank names a.) $ $. b.) $ $. 19. I have treasury bills, certificate(s) of deposit (CDs), or stocks/bonds (NOT held in a retirement account). If yes, list sources/bank names a.) $ $. b.) $ $. 20. I have a trust fund. Revocable Non-Revocable If yes, list bank(s)/trustee $ $. 21. I have an IRA/Keogh Account/401K. If yes, list financial entity(ies). a.) $ $. b.) $ $. 22. I have a pension or annuity asset. (NOT receiving income currently.). If yes, list bank(s). a.) $ $. b.) $ $. 23. I own or am in the process of selling or have sold real estate in the last 2 years. If yes, attach explanations and supporting documentation. $ $. 24. I have a whole life or universal life insurance policy.
6 If yes, how many policies? $ $. RESIDENT ELIGIBILITY APPLICATION | Rev. January 2014 tonbar Page 3 of 4. Property Name: Unit #: Household Member Name: 25. I own personal property held strictly as investment assets (arts, coins, etc.) If yes, attach appraisals. $ $. 26. I have disposed of assets within the last two years for less than fair-market value. If yes, attach explanation. $ $. 27. I have funds not held in a financial institution. $ $. 28. I have assets other than those listed above. If yes, list type below: a.) $ $. b.) $ $. * This property has requested your Social Security number on this and other forms on behalf of the Washington State Housing Finance Commission. Internal Revenue Service regulations allow us to ask for this information. Your Social Security number will be used for income ELIGIBILITY verification purposes only. Equivalent identification would be a Work Visa, Alien Registration Receipt Card, Temporary RESIDENT Card, IRS Individual Taxpayer Identification Number (ITIN), or Employment Authorization Card.
7 Failure to provide your Social Security number or equivalent number could hinder or delay this property's ability to review your APPLICATION for housing. I understand that any changes to my household income and/or composition after the date of my signature but prior to initial occupancy must be disclosed immediately to management staff. Under penalty of perjury, I certify that the information presented in this APPLICATION is true and accurate to the best of my knowledge and belief. I further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination of the lease agreement and/or prosecution. Signatures must be those of the Applicant/ RESIDENT , except where Power of Attorney (POA) documentation authorizes another individual to sign legal documents. If so, copies of current POA, government-issued photo ID, and address and phone number of the POA must be included in the certification.
8 Applicant/ RESIDENT Signature Print Applicant/ RESIDENT Name Date I certify that I have observed the above-signed Applicant/ RESIDENT complete, sign, and date this document. Property Representative Signature Print Property Representative Name Date Reasonable Accommodation: If a third party is required to assist with the completion of this document, add their signature, printed name, relationship, phone number and date to the bottom of this page. I certify that I have assisted the above-signed Applicant/ RESIDENT complete this document as a reasonable accommodation. Third Party Signature Print Third Party Name Relationship Phone # Date RESIDENT ELIGIBILITY APPLICATION | Rev. January 2014 tonbar Page 4 of 4.