Tenant Application

479 782-7268

Tenant Application

Page 1 of 9

Application for Admission and Rental Assistance

To which location are you applying:

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ARKANSAS SENIOR CARE
3572 HIGHWAY 10, CASA, AR 72025
PHONE: 501-233-6713 -- FAX 479-495-3443

Please return application to Parklane, 1000 M Street, Danville, AR 72833

Thank you for your interest in our apartment community.

LOCATION: Casa Retirement Center is nestled among scenic Highway 10 between Ola and Perryville. Casa is a small community with quiet surroundings.

SIZE OF UNITS AND PRICE: Each roomy apartment is equipped with central heat and air, frost-free refrigerators, electric ranges and electric smoke alarms. The kitchen area is spacious and adjoins the living room . All units are one-bedroom apartments with a large bathroom.

Rental Management, Inc. under the US Department of Housing and Urban Development's PRAC program that will pay a portion of your rent, if you qualify. You would be obligated to pay 30% of your gross monthly income. The rent payment includes all utilities.

AMENITIES AND ACTIVITIES: Handicapped accessible units are available. Each unit is equipped with an emergency system to alert management there is a problem. We are an active sponsor in the "Drug Free Week" campaign and enforce a "One-Strike" drug policy. Meals-on-Wheels are available through the Perry County Senior Citizen Center which also provide transportation upon request.

MAINTENANCE AND UPKEEP: The property has a full maintenance staff to take care of maintenance calls immediately and a 24-hour emergency call service.

We encourage you to fill out the attached application for consideration in our community. We hope you choose Casa Retirement Center as your home. Your application will get our immediate attention.

Please provide with your completed application a copy of social security cards, birth certificates and driver's license or picture I D's for all applicable members of your household. You will also need to provide vehicle registration and proof of vehicle insurance.

Robin Prophet
Manager

Casa Retirement Center does not discriminate on the basis of handicapped status in the admission or access to or treatment or employment in, its federally
assisted programs and activities.

Robin Prophet has been designated as the contact person at Casa Retirement Center, 3752 Highway 10, Casa, AR 72025 phone: 501-233-6713 or TOO#
TOLL FREE 1-800-235-7959 to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban
Development's Section 504 (24CFR Part 8 dated June 2. 1988).

Dardanelle Retirement Center
907 North 7th Street, Dardanelle, AR 72834
PHONE: 479-229-1586

Please return application to Robin Prophet, 1000 M Street, Danville, AR 72833

Thank you for your interest in our apartment community.We comply with all equal opportunity housing guidelines. Rental Management, Inc. under the US Department of Housing and Urban Development's Section 8 & Section202 programs will pay a portion of your rent, if you qualify. You would be obligated to pay 30% of your gross monthly income. The rent payment includes all utilities.

LOCATION: Dardanelle Retirement Center has a great location just one block off Highway 22. It is convenient to Walmart and Harps.

SIZE OF UNITS: We have efficiency (studio) and one bed room apartments. Each roomy apartment is equipped with central heat and air, frost-free refrigerators, electric ranges and smoke alarms. The kitchen in the one bedroom apartments, which includes a dining area, is just off the living room. The studio apartments have no dining area.

AMENITIES AND ACTIVITIES: Our community includes a fully equipped laundry facility.

MAINTENANCE AND UPKEEP: Dardanelle Retirement Center offers a maintenance staff to take care of maintenance calls in a timely manner and a 24-hour emergency call service.APPLy We encourage you to fill out the attached application for consideration in our community.
We hope you choose Dardanelle Retirement Center as your home. Your application will get ourimmediate attention.

Robin Prophet
Manager

Casa Retirement Center does not discriminate on the basis of handicapped status in the admission or access to or treatment or employment in, its federally
assisted programs and activities.

WELCOME TO GORMAN TOWERS

Please return application to Gorman Towers, 5800 Grand Avenue, Fort Smith, AR 72904

Thank you for your interest in our apartment community. Persons 62 years and older, and 18 years of age or older with a mobility impairment meet the requirements to live at Gorman Towers.

LOCATION: Gorman Towers is a gated community located at 5800 Grand Avenue, Fort Smi6th, AR, with easy access to Interstate 540. We are centrally located to major medical facilities, Central Mall Shopping Center, Grocery stores, and major through fares making travel in the city more convenient for you. We are an eight story high-rise apartment complex filled with wonderful residents exemplifying a family atmosphere.

SIZE OF UNITS AND PRICE: Each apartment is especially designed for the elderly and mobility impaired. We have 142 one-bedroom apartments with 17 of these being accessible for the mobility impaired, 8 two-bedroom apartments all with ample storage space. Approximately 700 square feet of living space in the one-bedroom and approximately 1000 square feet in the 2-bedroom apartments.

RENTAL ASSISTANCE: If you qualify, HUD will pay all or part of your rent, which is calculated on 30% of your gross adjusted income.

AMENITIES AND ACTIVITIES: Our apartment community includes paved walk area, beauty shop, 24 hour security, monitored emergency call system connecting each apartment to the office, garbage disposals, a large patio equipped with 2 grills, a beautiful gazebo, three fully equipped coin operated laundries, numerous social activities throughout the month, transportation to grocery stores, medical facilities, etc, vegetable or flower gardens for resident to utilize, library and a computer learning center with internet access.

MAINTENANCE AND UPKEEP: Gorman Towers maintenance staff responds to maintenance call immediately and professionally and are on call 24 hours daily to meet your individual needs. We are staffed with dedicated employees extending themselves to assure your needs will be met.
We encourage you to visit our facility. We hope you choose Gorman Towers as your HOME when your particular need arises. Please bring with your completed application a picture ID, birth certificate and social security card. If you have a vehicle, please bring your registration and proof of insurance. Your need will get our immediate attention.

Belinda Elam
Manager

Gorman Towers does not discriminate on the basis of handicapped status in the admission or access to or treatment or employment in, its federally assisted programs and activities.

Belinda Elam has been designated as the contact person at Gorman Towers, 5800 Grand Avenue, Fort Smith, AR 72904 Telephone number:(479) 452-7670, TDD # TOLL FREE 1-800-235-7959, to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development's Section 504 (24CFR Part 8 dated June 2, 1988).

MAGAZINE APARTMENTS
15 CARR STREET, MAGAZINE, AR 72943
PHONE: 479-969-8647 -- FAX 479-272-4907

Please return application to Magazine Apartments, 15 Carr Street, Magazine, AR 72943

Thank you for your interest in our apartment community.

LOCATION: Magazine Apartments is nestled among scenic Highway 10 between Danville and Booneville. Magazine is a small community with quiet surroundings.

SIZE OF UNITS AND PRICE: Each roomy apartment is equipped with central heat and air, frost-free refrigerators, electric ranges and electric smoke alarms. The kitchen area is spacious and adjoins the living room . We offer one and two bedroom apartments with a large bathroom.

Rental Management, Inc. under the US Department of Housing and Urban Development's Section 8 program that will pay a portion of your rent, if you qualify. You would be obligated to pay 30% of your gross monthly income. The rent payment does not include electricity and water.

AMENITIES AND ACTIVITIES: We are an active sponsor in the "Drug Free Week" campaign and enforce a "One-Strike" drug policy.

MAINTENANCE AND UPKEEP: The property has a full maintenance staff to take care of maintenance calls immediately and a 24-hour emergency call service.
We encourage you to fill out the attached application for consideration in our community. We hope you choose Magazine Apartments as your HOME. Your application will get our immediate attention.

Robin Prophet
Manager

Gorman Towers does not discriminate on the basis of handicapped status in the admission or access to or treatment or employment in, its federally assisted programs and activities.

Robin Prophet has been designated as the contact person at 15 Carr Street, Magazine. AR 72943 phone number (479) 969-8647., TDD # TOLL FREE 1-800-235-7959, to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development's Section 504 (24CFR Part 8 dated June 2, 1988).

PARK LAKE APARTMENTS
1753 EAST ZION ROAD, FAYETTEVILLE, AR 72703
PHONE 479-442-7683**FAX 479-442-3857

SECTION 8 INSTRUCTIONS FOR APPlICATION THIS DOCUMENT OUTLINES THE APPLICATION PROCESS FOR SECTION 8.

Thank you for your interest in our apartment community.

APPLYING FOR HUD HOUSING ASSISTANCE: Read carefully and be sure to sign and date all pages.

NOTICE OF CONSENT FOR THE RELEASE OF INFORMATION: All members of your family 18 or older must sign this Consent for Release of Information.

INSTRUCTIONS FOR THE RACE AND ETHNIC DATA REPORTING: Read the instructions and complete the form. A completed form must be submitted for each person who will occupy the unit.

APPLICATION FOR ADMISSION AND RENTAL ASSISTANCE: Every blank of the application must be filled out. If something doesn't pertain to you, put "NA" on the blank line. For character references, please give the names of two (2) people who you know well.
No relatives.

EXPENSE REPORT: Give an estimate of your monthly expenses.

ASSET/INCOME QUESTIONNAIRE: All questions must be answered with a YES or NO.

SPRINGDALE POLICE. WASHINGTON COUNTY SHERIFF'S OFFICE AND NATIONAL CRIMINAL BACKGROUND: We will run a criminal background check on each household member 18 and older. If you have a felony you probably will not qualify.

RENTAL HISTORY: You must have three (3) years favorable rental history. Rental history must be free of evictions, damage to property, owing another property, fraud at another Section 8 property. If you do not have rental history, we must have three (3) character reference letters, typed on business letterhead from former employers, teachers, minister, etc. No relatives

DOCUMENTS REQUIRED: With your completed application, please submit birth certificates and social security cards for all household members. Also submit the proof of vehicle insurance and vehicle registration.

Elaine Willard-Tayrien, Resident Manager

Park Lake Apartments does not discriminate on the basis of handicapped status in the admission or access to or treatment or employment in, its federally assisted programs and activities.

Elaine Willard-Tayrien has been designated as the contact person at Park Lake Apartments, 1753 Zion, Fayetteville, AR 72703 Telephone number: (479) 442-7683, TDD # TOLL FREE 1-800-235-7959, to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development's Section 504 (24CFR Part 8 dated June 2, 1988).

{Park Lane Apartments:validation}

PARKLANE APARTMENTS
1000 M Street, Danville, AR 72833
479-495-2022

IMPORTANT INFORMATION: Thank you for your interest in our apartment community. We encourage you to fill out the attached application for consideration. Please keep in mind by HUD regulations we have 30 days from the date the application is turned in to complete the verification process. This includes all income, assets, references and any other circumstances that affect eligibility. Because of the time limits imposed by HUD, we will not comment on the progress of your application until it is completed, we need additional information, or you are accepted or denied.

LOCATION: Our community is located just off Highway 10 and about 15 minutes from Scenic Highway 7. We are close to the local factories and the heart of Danville.

TYPES OF UNITS: Our roomy apartments are available in one, two, or three bedrooms. All utilities are included in rental payment.

RENTAL ASSISTANCE: The rent is based on 30% of your monthly gross income.

MAINTENANCE & UPKEEP: We offer 24-hour emergency maintenance service.
DOCUMENTS: With your completed application you must provide a Social Security card and birth certificate for every person whose name appears on the application. You must also provide a Three (3) written character references, driver's license or any government issued photo ID for all household members 18 years of age or older. We must also have proof of registration and proof of insurance on all vehicles to be kept on the property.

ROBIN PROPHET
MANAGER

PENALTIES FOR MISUSING THIS CONSENT

Title 18, Section 1001 of the US Code states that a person Is guilty of a felony for knowingly and willingly make false and fraudulent statements to any department of the United States Government, HUD, the PHA, and any owner (or any employee of HUD, the PHA or the owner may be subject to penalties for unauthorized disclosures or Improper uses of Information collected based on the consent form. Us of the Information collected based on this verification form Is restricted to the purpose sited above. 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. 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 HUD1 the PHA, 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 (f)( g) and (h). Violation of these provisions are cited as violations of 42 U.S.C.408 f, g and h.

If you are an individual with handicaps or a disability, you may inform the owner of this fact and may request the owner make reasonable accommodation in
nonessential policies or practices to enable you equal opportunity.
Parklane Apartments does not discriminate on the basis of handicapped status in the admission or access to or treatment of employment in its federally assisted
programs and activities.
Robin Prophet has been designated as the contact person at Parklane Apartments, 1000 M Street, Danville, AR 72833. Telephone number: 479A95-2022,
TDD Toll Free 800-235-7959, to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban
Development's Section 504 (24CFR Part 8 dated June 2, 1988).

River Park Apartments
1750 West Moline, Malvern, AR 72104,
Phone: 501-337-1600

Thank you for your interest in our apartment community.
LOCATION: River Park Apartments is nestled just off 1-30 and Highway 2708 on West Moline Street. River Park is a small community with quiet surroundings. It is located next to the Senior Citizen's Center of Malvern.
SIZE OF UNITS AND PRICE: Each roomy apartment is equipped with central heat and air, frost-free refrigerators, electric ranges and electric smoke alarms. The kitchen area is spacious and adjoins the living room. All units are one-bedroom apartments with a large bathroom.
Rental Management, Inc. under the US Department of Housing and Urban Development's PRAC program that will pay a portion of your rent, if you qualify. You would be obligated to pay 30% of your gross monthly income. The rent payment does not include the electric bill.
AMENITIES AND ACTIVITIES: Handicapped accessible units are available. Each unit is equipped with an emergency system to alert management there is a problem. The property includes a fully equipped coin operated laundry on-site. We are an active sponsor in the "Drug Free Week" campaign and enforce a "One-Strike" drug policy.
Meals-on-Wheels are available through the Senior Citizen Center which also provide transportation upon request.
MAINTENANCE AND UPKEEP: The property has a full maintenance staff to take care of maintenance calls immediately and a 24-hour emergency call service.
We encourage you to fill out the attached application for consideration in our community. We hope you choose River Park as your HOME. Your application will get our immediate attention.
Please provide with your completed application a copy of social security cards, birth certificates and driver's license or picture ID for all applicable members of your household. You will also need to provide vehicle registration and certification of vehicle insurance.

Robin Prophet
Manager

If you are an individual with handicaps or a disability, you may inform the owner of this fact and may request the owner to make reasonable accommodation in nonessential policies or practices to enable you equal opportunity.
River Park Apartments does not discriminate on the basis of handicapped status in the admission or access to or treatment or employment in, its federally assisted programs and activities.
Robin Prophet has been designated as the contact person at River Park, 1750 West Moline, Malvern, AR 72104, Phone: 501-337-1600 or TDD# TOLL FREE 1-800-235-7959 to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development's Section 504 (24CFR Part 8 dated June 2, 1988).

Rental Management, Inc.
Application for Admission and Rental Assistance

PLEASE ANSWER ALL QUESTIONS COMPLETELY. IF ACCEPTED AS A RESIDENT, THIS APPLICATION WILL BECOME A PART OF YOUR RESIDENT FILE. GIVING FALSE OR INCOMPLETE INFORMATION MAY RESULT IN THE REJECTION OF YOUR APPLICATION.

RACE OF HEAD OF HOUSEHOLD: FOR STATISTICAL PURPOSES ONLY

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ETHNICITY

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SECTION 202/PRAC ELIGIBILITY REQUIREMENT:

Are you or a household member 62 years old or older?

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Are you or a household member disabled or handicapped?

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Are you an adult having a physical, mental or emotional impairment that is expected to be long-continued and indefinite duration, substantially impedes the ability to live independently and is of a nature that such ability could be improved by more suitable housing conditions?

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Do you have a developmental disability, as defined in Section 102(7) of the Developmental Disabilities Assistance and Bill of Rights?

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Do you have a chronic mental illness that is severe and persistent mental or emotional impairment?

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APPLICANT: LAST NAME

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APPLICANT: FIRST NAME

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APPLICANT: MI

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SPOUSE'S LAST NAME

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SPOUSE'S FIRST NAME

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SPOUSE'S MI

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CURRENT ADDRESS:

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CITY

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STATE

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ZIP CODE

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HOME PHONE:

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CELL PHONE:

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MESSAGE PHONE

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Email Address:(*)

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HOUSEHOLD COMPOSITION AND CHARACTERISTICS

LIST THE HEAD OF HOUSEHOLD AND ALL OTHER MEMBERS WHO WILL BE LIVING IN THE UNIT. GIVE THE RELATIONSHIP OF EACH FAMILY MEMBER TO THE HEAD OF HOUSEHOLD.

How many people with be living in the unit? (include head of household)

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Person 1

FULL NAME

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Relationship

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Birthday

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Age

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Sex

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Social Security Number

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Person 2

FULL NAME

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Relationship

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Birthday

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Age

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Sex

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Social Security Number

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Person 3

FULL NAME

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Relationship

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Birthday

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Age

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Sex

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Social Security Number

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Person 4

FULL NAME

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Relationship

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Birthday

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Age

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Sex

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Social Security Number

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Person 5

FULL NAME

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Relationship

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Birthday

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Age

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Sex

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Social Security Number

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Do you plan to have anyone living with you in the future who is not listed above?

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Please explain:

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RENTAL HISTORY

(3 YEARS)

History #1

Name of Property

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Contact Person

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Landlord Address

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City

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State

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Zip Code

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Phone Number

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Beginning Date Rented

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Ending Date Rented

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History #2

Name of Property

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Contact Person

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Landlord Address

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City

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State

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Zip Code

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Phone Number

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Beginning Date Rented

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Ending Date Rented

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OTHER QUESTION

4. Has your assistance or tenancy ever been terminated for fraud, non payment of rent or failure to cooperate with recertification process?

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If yes, explain

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Have you or a member of your household ever been convicted of a felony?

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If yes, explain

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Have you or a member of your household ever been convicted of a misdemeanor?

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If yes, explain

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Have you or a member of your household engaged in the sale, use, and/or possession of illegal drugs or excessive alcohol?

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If yes, explain

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CHARACTER REFERENCES

Reference 1

FULL NAME

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Phone Number

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Address

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City

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State

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Zip Code

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Reference 2

FULL NAME

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Phone Number

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Address

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City

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State

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Zip Code

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5. INCOME

A. BENEFIT PAYMENTS:

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This includes lump-sum payments received because of delays in processing benefits, but not lump-sum payments received under settlements with insurance companies or lump-sum payment so Social Security or Supplemental Security Income.

SSI

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Worker's Comp

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Retirement Fund

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Death Benefits

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Annuities

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Insurance Payments

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Pensions

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Disability Pay

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Unemployment

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SOURCE

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FAMILY MEMBER

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AMT.

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How often?

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SOURCE

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FAMILY MEMBER

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AMT.

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How often?

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SOURCE

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FAMILY MEMBER

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AMT.

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How often?

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B. EMPLOYMENT INCOME:

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(List employment information for all household members)

Wages

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Commissions

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Salaries

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Self-employed

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Fees

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Tips

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Bonuses

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Work for cash

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Tenant Name:

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Employer:

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Phone Number

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Fax Number

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Tenant Address

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Tenant City

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Tenant State

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Tenant Zip Code

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Job Title:

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Supervisor's Name:

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Does anyone in your household work for someone who pays cash?

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If yes, please explain and list name, address and phone number of the person paying cash:

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C. INTEREST: dividends, and other income from household assets:

Interest from bank accounts/bonds

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Dividends from stocks/mutual funds

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Income distributed from trust funds

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Money from renting household assets

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Any other interest, dividends, rent

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EMPLOYMENT INCOME:

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(List employment information for all household members)

LOTTERY WINNINGS:

Paid in periodic payments

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E. MONEY REGULARLY GIVEN BY PERSONS NOT LIVING IN THE UNIT

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This includes rent or utility payments regularly paid by someone on behalf of the household, but doesn't include annual rent credits or rebates paid to senior citizens.

F. ANY OTHER SOURCE OF INCOME:

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If yes, please explain:

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6. ASSETS:

Do you have any of the following:

A. Checking account

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B. Savings account

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C. Money Market Funds

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D. Trusts

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E. IRA/KEOGH Accounts/retirement

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F. Stocks/bonds

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G. Certificate of deposit

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H. Equity in rental property

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I. Personal property held as invest

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J. Cash held (safety deposit box)

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List name of all bank accounts which have anyone in your household's name listed on the account:

BANK:

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ACCOUNT NUMBER:

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BANK:

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ACCOUNT NUMBER:

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BANK:

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ACCOUNT NUMBER:

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BANK:

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ACCOUNT NUMBER:

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BANK:

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ACCOUNT NUMBER:

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Have you disposed of any assets (land, homes, bank accounts) for less than fair market value in the past two (2) years

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If yes, please explain:

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Are any assets held jointly with another person?

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If yes, please explain:

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7. EXPENSES:

A. We'd like you to give us an estimate of the amount of money you spend each month. Tell us the approximate amount you spend each month for:

Rent:

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Food:

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Transportation:

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Health Care:

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Debts:

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Miscellaneous:

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B. The following information does not require a description of the disability or handicap because the description is beyond the scope of our inquiry under Federal Regulation. There is an automatic $400 deduction from your annual income in calculating the rent and other rent payment benefits connected to the following questions in this section.

C. Do you pay for an in-home aide to care for a handicapped/disabled household member to enable someone in the household to work:

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D. Do you pay for equipment for a handicapped/disabled household member to work or enable another household member to work?

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E. Do you pay Medicare premiums?

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F. Do you pay other medical insurance premiums other than medicare

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This does not include Life or Burial Insurance. If yes, please list below:

NAME OF COMPANY

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FULL MAILING ADDRESS

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PHONE NUMBER

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POLICY NUMBER

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Are you currently paying outstanding medical bills? (doctors, hospitals, dentists, glasses)

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If yes, please list below

NAME OF MEDICAL PROVIDER

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FULL MAILING ADDRESS

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PHONE NUMBER

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ACCOUNT NUMBER

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NAME OF MEDICAL PROVIDER

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FULL MAILING ADDRESS

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PHONE NUMBER

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ACCOUNT NUMBER

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Do you pay for medication on a regular basis?

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If yes, please list below

NAME OF PHARMACY

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FULL MAILING ADDRESS

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PHONE NUMBER

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ACCOUNT NUMBER

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NAME OF PHARMACY

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FULL MAILING ADDRESS

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PHONE NUMBER

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ACCOUNT NUMBER

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I. Do you pay for non-prescription medications (aspirin, Mylanta, etc) recommended by your physician?

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If yes, We will need you to provide receipts with over-the-counter medical form

J. Do you anticipate any health care related expenses in the next 12 months which are not covered by Health Insurance?

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If yes, please explain:

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K. Do you have an assistive animal approved by your physician?

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If yes, please provide receipts for the care of animal (shots, food, etc)

8. IN CASE OF EMERGENCY NOTIFY: NAME RELATIONSHIP

NAME

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Relationship

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Address

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City

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State

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Zip Code

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Home Phone

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Work Phone

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Cell Phone

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9. IN YOUR ABSENCE WHO CAN ACT IN YOUR BEHALF:

NAME

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Relationship

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Address

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City

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State

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Zip Code

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Home Phone

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Work Phone

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Cell Phone

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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 and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willingly 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. 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 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 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).**

Confirmation of location you are applying:(*)

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Contact Us

Address Information

P.O. BOX 1526
17 North 6th Suite 207
Fort Smith, AR 72902

Office Hours

9:00 AM to 5:00 PM
Monday through Friday

Contact Us

dholland@rentalmanagement-inc.com
Phone: 479-782-7268
Fax: 479-782-7260

Property Contacts

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