Application Information

Application for Admission and Rental Assistance
To apply for housing, we require you download the application and complete the document in blue ink. Link is here:

Using the English to English translation, please select DOWNLOAD TO APPLY NOW and print application.

https://cdngeneral.rentcafe.com/dmslivecafe/3/1327684/3_1327684_11972434.pdf(opens in new window)

This page is designed to provide you with language assistance should you experience Limited English Proficiency (LEP).
Using the recently printed ENGLISH application document, the information below will be your ability to select the information
in your preferred language. By using this page, you will have a step by step guide for completing each section of the rental application.
Again, please use the TRANSLATE THIS PAGE function found at the bottom of this page under LINKS.

PLEASE READ INSTRUCTIONS BELOW BEFORE COMPLETING

All Items must be complete in order to determine your eligibility. Failure to complete all sections will result in the application being denied. Application must be completed using BLUE ink. If an item does not apply to you, please check N/A next to the question. Do not use white-out. Please use one line on corrections and initial corrections made. Completed applications can be returned via email to APPLICATIONS4COLONIALFARMS@EBMC.COM, to the site directly or via an email attachment to the site manager's email listed on downloaded application.

APPLICANT INFORMATION

I/We are applying for housing in a : bedroom unit. (Please indicate bedroom size).

If you wish to be place on a Waiting List for a different bedroom size, a separate application is required.

Do You or a Member of Your Household Have a Verifiable Special Need? .

If yes, List Need:

If you have limited English, please identify your language of preference for each adult HH member

First Name: Last Name:

Street Address:

Mailing Address:

Phone 1: Phone 2: Phone 3:

Email 1: Email 2:

PLEASE NOTE: The information you provide on the application will be treated as confidential. It includes both information necessary for determining your eligibility for housing and information required for statistical purposes. The race, ethnicity and gender information are requested to assure the Federal government that Federal laws prohibiting discrimination against applicants are complied with. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you, in any way. Any information found to be incomplete and/or falsified will cause the application to be denied and not processed.

For Marketing Purposes, Please Let Us Know How You Heard About Us:

[] Newspaper Ad [] Drove By [] Word of Mouth [] Web Site [] Resident Referral [] Other:

State Your Current Living Situation:

[] Own my Home [] Live with Family/Friend [] Renting [] Lacking Fixed Nighttime Residence [] Fleeing Violence

Applicant Household Information: List below All of the People You Expect to Reside in Your Household at Move-In

FULL NAME	RELATIONSHIP to HEAD of HOUSEHOLD (HOH) S-Spouse CH-Co-Head D-Dependent O-Other	CITIZENSHIP *Enter One of the Following:* EC-Citizen EN-Eligible Non-Citizen IC-Ineligible Chile IN-Ineligible Non-Citizen IP-Ineligible Parent	GENDER Male Female *Leave Blank-if you choose not to report*	DATE of BIRTH	SOCIAL SECURITY NUMBER	STUDENT Of Higher Education Yes or No
	HOH					[] Yes [] No
						[] Yes [] No
						[] Yes [] No
						[] Yes [] No
						[] Yes [] No
						[] Yes [] No
						[] Yes [] No
						[] Yes [] No
						[] Yes [] No

RENTAL HISTORY (Last 3 years)

Present Landlord/Contact Name
Address
Phone
Fax
Email
Move-In and Move Out Dates
Reason for Moving Out

Previous Landlord/Contact Name
Address
Phone
Fax
Email
Move-In and Move Out Dates
Reason for Moving Out

Previous Landlord/Contact Name
Address
Phone
Fax
Email
Move-In and Move Out Dates
Reason for Moving Out

HOUSEHOLD COMPOSITIONS and CHARACTERISTICS

[] Yes [] No Are you expecting any future additions to your household due to pregnancy, adoption, foster child (ren) or custody of children? If yes, explain:
[] Yes [] No Do you have any household members away at school, who will live at your residence during school recesses? If yes, their name:
[] Yes [] No Are any household members 18 years of age or older, that are Full-Time Students:

If yes, List Name and Age:

[] Yes [] No Are there any family members who are temporarily absent from the household due to:

[] Employment [] Military Service [] Foster Care [] Nursing Home [] Hospital

[] Yes [] No Are there any family members who are permanently confined in a nursing home? If yes, will you still be including/counting this individual as part of the household? [] Yes [] No
[] Yes [] No Do you require a Live-In Attendant and have a doctor’s verification showing medical need?
[] Yes [] No Are you or any household member currently in the US military or a US military veteran?
[] Yes [] No Are you or any household member a Presidentially Declared Disaster victim?
[] Yes [] No Do you or any household member currently live in, or have you ever lived in Public or HUD assisted housing or in HUD’s Housing Choice Voucher/Certificate Program? If yes, List below

Landlord and/or Complex Name & Phone Number:

Property Address: Move-In Date: Move-Out Date:

[] Yes [] No Do you or any household member owes any monies to HUD, an apartment community, and or previous landlord? If yes, List Name, Address and Amount Owed:
[] Yes [] No Have you ever committed fraud in a HUD-assisted housing program, been asked to repay money for knowingly misrepresenting information, or been evicted from any rental? If yes, explain:
[] Yes [] No Are you or any household member subject to lifetime sex offender registration requirement any/a state?
If Yes, Name(s) of Household Member, State and Explain:
List ALL States family members have lived in:
[] Yes [] No Do you or any household member have a criminal or juvenile record? If yes, Name(s) of Household Member (s) and Explain:

IF you answered “YES” to any questions listed above in the Criminal Background Section of this application, Please provide an explanation below. Include the date, circumstances, and nature of the offenses, as we verify criminal record in the following jurisdictions: AL, AK, AZ, AR, CA, CO, CT, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI, WY

[] Yes [] No Have you or any household member ever been convicted or adjudicated of a misdemeanor/felony or any other criminal activity, including a violation of the Controlled Substances Act. This also includes harassment, sexual assault, drug abuse, & any other crimes. If yes, Name(s) of Household Member (s) and Explain:
[] Yes [] No Are you or any household member a current user of a non-prescribed controlled substance, including any marijuana substances.
[] Yes [] No Are you or any household member currently engaged or exhibit a pattern of alcohol abuse, which may threaten the health & safety of residents or staff or hinders the peaceful enjoyment of the housing premises.
[] Yes [] No Have you or any household member ever used any other name, alias and/or social security number, other than the one listed on this application? If yes, Name(s) Used and by Which Household Member, Social Security Number Used and Explain:

DISABLED HOUSEHOLDS and REASONABLE ACCOMODATIONS

Elderly families are defined by HUD as families where the head, spouse, or co-head is 62 years of age, or 18 years of age and a person with disabilities. If you wish to be considered as an elderly family due to a disability, HUD requires that we receive your consent to verify your disability. In addition, persons with disabilities have the right to request reasonable accommodations, which include changes, exceptions, or adjustments to a program, service, building, dwelling unit, or workplace that -will allow a qualified disabled person to participate fully in a program, take advantage of a service, live in a dwelling, or perform a job. Please complete both questions below.

[] Yes [] No Are you 18 years of age & considered a disabled person and give consent to have your disability verified?
[] Yes [] No Do you or any household member require any special accommodations in your unit, or have the need for an accessible unit? If yes, Explain:

EXPENSES/ALLOWANCES

[] Yes [] No Do you have expenses for childcare of an aged 12 or younger? If yes, what are your out of pocket childcare costs? [] Weekly $ [] Monthly $

Provider:

Address:

Phone: Email:

[] Yes [] No Do you pay for a care attendant or for any equipment for any handicapped or disabled household member(s) that are necessary to permit that person or someone else in the household to work?

If yes, provide information: What are your out of pocket expenses? [] Weekly $ [] Monthly $

Type of Equipment:

Name of Company/Attendant:

Address:

Phone: Email:

[] Yes [] No Are any of the above expenses paid for or reimbursed by an outside agency? If yes, provide information: Amount reimbursed, frequency and which expense

Name of Company/Attendant:

Address:

Phone: Email:

ELDERLY FAMILIES – ONLY (Head of Household or Spouse is 62 years of age or older and/or Disabled)

[] Yes [] No Do you or any household member(s) paid for Medicare? If yes, what is the monthly amount?
[] Yes [] No Do you or any household member(s) have any other type of medical insurance? If yes, what is the monthly amount? .

Name of Carrier/Company:

Address:

Phone: Policy #:

[] Yes [] No Do you or any household member have any outstanding medical bills? If yes, provide list
[] Yes [] No Do you or any household members expect to incur any medical expenses within the next 12 months? If yes, explain
[] Yes [] No Do you or any household member use a pharmacy on a regular basis? If yes, provide information

Name of Pharmacy: Phone:

Address:

TOTAL HOUSEHOLD INCOME

DOES ANY MEMBER of THE HOUSEHOLD

[] Yes [] No WORK [[] Full-Time [] Part-Time [] Seasonally. If Yes, List Household Member(s) Name(s): 1. 2.

3. 4.

[] Yes [] No Expect to work ANY period during the next 12 months? If Yes, explain:
[] Yes [] No Work for someone who pays in CASH? If yes, explain:
[] Yes [] No Does anyone regularly give the household cash or any other financial help? If yes, explain:
[] Yes [] No Does anyone regularly pay any of the household’s bills; such as rent, utilities, phone, etc.? If Yes, explain:
[] Yes [] No Do you receive death benefits under someone else social security number?

If Yes, List number:

Below list all money earned or received by each member of your household, such as wages, self-employment, unemployment, child support, alimony, family financial support, Social Security/SSI, Workman's Compensation, retirement benefits, pensions, trusts, annuities, AFDC, Welfare, Veterans benefits, Military Pay, insurance benefits, etc.

HOUSEHOLD MEMBER NAME	INCOME SOURCE (S)	HOURLY	WEEKLY	MONTHLY	ANNUALLY

[] Yes [] No Do you or any household member (including children) have Assets such as Cash, Checking, Savings, CD’s, 401K, Trusts, etc.? If Yes, List information below.

ACCOUNT TYPE	HOUSEHOLD MEMBER NAME	ACCOUNT NUMBER	BANK/INSTITUTION NAME	CURRENT VALUE	ANNUAL INCOME FROM ASSET
Cash/Deposit Box				$	$
Pre-Paid Debit Card (Visa/MC)				$	$
EBT/Welfare/CalWORKs				$	$
Checking				$	$
Savings				$	$
Money Market				$	$
Unemployment Card				$	$
CD’s Stocks/Bonds				$	$
Trusts				$	$
Retirement/Pension Fund				$	$
Life Insurance (Whole/Universal)				$	$
Funeral/Burial Insurance/Account				$	$
Real Estate				$	$
Other:				$	$
Other:				$	$
Other:

[] Yes [] No Have you or any household member disposed of or given away any asset(s) for less than fair market value during the past two years? If Yes, Asset disposed of or given away

Fair Market Value $ Sales Price (if applicable) $

[] Yes [] No Have you or any household member sold any real estate (U.S.A. or Another Country) in the last two years? If Yes, describe
[] Yes [] No Do you or any household member Own or have an interest in any real estate or mobile home (U.S.A. or Another Country)? If Yes, describe

HOUSEHOLD VEHICLES

MAKE	MODEL	YEAR	COLOR	TAG/ EXPIRATION	STATE	VEHICLE INSURANCE COMPANY	VEHICLE INSURANCE POLICY #

Emergency Contacts

In cases of emergency, management requests that you provide the information below. An emergency is broadly defined as a case where management feels a resident's well-being is threatened and/or where management feels a resident's actions/conduct appear to be a lease violation. Some examples of this type of emergency are non-payment of rent; perceived criminal activity against persons\property; perceived abuse of an illegal substance; behavior violating the quiet enjoyment of other residents; and, housekeeping that violates safe and sanitary rules. An emergency is also defined as an urgent need for assistance or relief, or when there are unforeseen circumstances that call for immediate action.

In Case of Emergency

First Family Member/Friend to Notify is:

Full Name: Relationship:

Address: Phone 1:

Email: Phone 2:

Emergency Contacts (Cont.)

Second Family Member/Friend to Notify is:

Full Name: Relationship:

Address: Phone 1:

Email: Phone 2:

Please describe any other information that will help us to process this application (add additional sheet if necessary):

Certification and Consent to Release of Information

NOTE: All household members 18 and older must sign this Application. By signing this application, I/We certify the accuracy of the information contained herein. I/WE understand that the Department of HUD is authorized to collect this information to determine eligibility, appropriate bedroom size, and the amount my family will pay for rent. I/We also understand that this will be my only residence. I/We authorize management to contact my present/prior landlords for information regarding my tenancy, and to access records pertaining to me which may be on file with credit bureau authorities. I/We authorize a criminal background check and a check of the state/national sex offender registry for all adult family members. I/We understand that all information I have listed is subject to verification and that a final decision on eligibility cannot be made until all verifications are complete. I/We understand that it is a crime to knowingly provide false information for the purpose of obtaining or maintaining occupancy in and/or, for the purpose of securing a lower rent in a subsidized housing unit, and that the penalty for knowingly providing false information is up to five years in prison and/or $10,000 fine upon conviction.

I/We hereby do swear and attest that all the information herein about me is true and correct. I understand that if no unit is currently available and I/We are placed on the waiting list, I/We must update all information about me and my household at the time a unit becomes available and is offered.

Applicant Signature (HOH) Date

Applicant Signature (Spouse/Co-Head) Date

Applicant Signature (Other Adult) Date

Owner/Agent Signature Date

Managing Agent's Fair Housing and Section 504 Designated Representative: It is the policy of this company to provide housing on an equal opportunity basis. We do not discriminate on the basis of race, color, national origin, ancestry, sex, age, disability, religion, familial status, marital status, sexual orientation, gender identity, or medical condition. If you feel you have been discriminated against in the processing of this application, please call the following representative of this company: EBMC 504 Coordinator at Compliance@Ebmc.com

Application Information

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