Preliminary Application Form
Nicetown Court PRELIMINARY APPLICATION FORM Preferred Community: Nicetown Court I
Nicetown Court II
BOTH
Last Name
First Name
MI
Relation to Head
Sex M/F
Head of Household
H
*Ethnicity **Race Circle one each 1 2
PT/FTStudent
Thank you for your interest in living at Nicetown Courts. Please fill out this form to give us basic information about your housing needs. This information will allow us to place your name on our waiting list. Completed preliminary applications will be entered on the waiting list in the order received. The waiting list will then be processed in order according to the requested unit type and availability of units. Please answer all questions. Preliminary Applications with missing information will not be accepted.
Birth Date
Age
Social Security Number
Handicapped or Disabled (Circle One if applies) H
D
H
D
H
D
H
D
H
D
H
D
H
D
1 2 3 4 5 6 1 2
2 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 4 1 2 3 4 5 6 1 2 5 1 2 3 4 5 6 1 2 6 1 2 3 4 5 6 1 2 7 1 2 3 4 5 6
*Ethnicity: Hispanic or Latino (1) Yes (2) No **Race (choose one); (1) White (2) American Indian/Alaska Native (3) Asian (4) Black/African American (5) Other (6) Native Hawaiian/Pacific Islander This information is required for statistical purposes for the Department of Housing & Urban Development. However, there is no penalty for persons that do not complete the Ethnicity or Race section in this Pre-Application.
Please indicate the size of apartment for which you wish to be considered (Check any that applies. Please note that certain types of apartments are only available in certain parts of the property): One Bedroom Two Bedroom Three Bedroom Four Bedroom Mailing Address (Included City, State and Zip Code) Contact Info: Home: _____________________ Work: __________________ Cell: _____________________ Email: _____________________________________________ Do you expect a change in your family composition within next year? Yes No If Yes, explain _____________________________________ If change is due to pregnancy, what is expected due date? __________________________________________________ What is your primary language? English Spanish Other _______________________ Do you need an interpreter?
Yes No
Is an accessible unit needed?
Yes No
If yes, specify Hearing Mobility Vision Other If hearing, do you require an interpreter? Yes No If English is not your primary language, can you speak or read English fluently? Yes No If yes, check one or both: Speak Read If yes, specify language ________________________________
Nicetown Courts Management Office 4340 Germantown Ave Philadelphia, PA 19140 Telephone: 215-307-4884 Fax: 215-455-1535 www.nicetowncourtii.com
Nicetown Court Do you currently have a PHA Voucher? Have you ever been evicted? Yes No Yes No If yes, why? ___________________________________ Have you or any member of your household been convicted of manufacturing or producing methamphetamine? Yes No If yes, please list name: ________________________________________ Are you or is any member of your household required to register under any state’s sex offender registration program? Yes No If yes, is this a lifetime registration requirement? Yes No
Sources of Income - Please specify the gross monthly amounts for the following: Applicant’s Monthly Income
Source of Income
Spouse’s Monthly Income
Salary
$
$
Social Security
$
$
Supplemental Security Income
$
$
Pension/Retirement Income Name of Fund ______________________
$
$
Pension/Retirement Income Name of Fund ______________________
$
$
Other Pension or Annuity Name of Fund ______________________
$
$
Unemployment
$
$
Worker’s Compensation
$
$
TAFDC/Welfare Assistance (per Month)
$
$
Child Support (per Month)
$
$
Alimony (per Month)
$
$
Other Household Member’s Income
NAME
Amount
$ $ $ $ $ $ $ $ $ $ $
TOTAL MONTHLY INCOME: $ __________________ Applicant Certification 1. I/We certify that the information given to Nicetown Courts Management on this preliminary application is correct and complete to the best of my/our knowledge and belief. I/We understand that such information will be verified and any false statements made on this application will cause me/us to be disqualified for admission. I/we also understand that false statements or information are punishable under Federal law. 2. I understand that if this application is not filled out completely, it will not be accepted. 3. I understand that this is a preliminary application and the information provided does not guarantee housing. I also understand that addition information and verifications will be necessary to complete the application process. Signature of Applicant:________________________________________________________ Date: ____________________ Signature of Spouse/Other Adult:_______________________________________________ Date: ____________________ Signature of Other Adult: _____________________________________________________ Date: ____________________
Nicetown Courts Management Office 4340 Germantown Ave Philadelphia, PA 19140 Telephone: 215-307-4884 Fax: 215-455-1535 www.nicetowncourtii.com
Nicetown Court II
BOTH
Last Name
First Name
MI
Relation to Head
Sex M/F
Head of Household
H
*Ethnicity **Race Circle one each 1 2
PT/FTStudent
Thank you for your interest in living at Nicetown Courts. Please fill out this form to give us basic information about your housing needs. This information will allow us to place your name on our waiting list. Completed preliminary applications will be entered on the waiting list in the order received. The waiting list will then be processed in order according to the requested unit type and availability of units. Please answer all questions. Preliminary Applications with missing information will not be accepted.
Birth Date
Age
Social Security Number
Handicapped or Disabled (Circle One if applies) H
D
H
D
H
D
H
D
H
D
H
D
H
D
1 2 3 4 5 6 1 2
2 1 2 3 4 5 6 1 2 3 1 2 3 4 5 6 1 2 4 1 2 3 4 5 6 1 2 5 1 2 3 4 5 6 1 2 6 1 2 3 4 5 6 1 2 7 1 2 3 4 5 6
*Ethnicity: Hispanic or Latino (1) Yes (2) No **Race (choose one); (1) White (2) American Indian/Alaska Native (3) Asian (4) Black/African American (5) Other (6) Native Hawaiian/Pacific Islander This information is required for statistical purposes for the Department of Housing & Urban Development. However, there is no penalty for persons that do not complete the Ethnicity or Race section in this Pre-Application.
Please indicate the size of apartment for which you wish to be considered (Check any that applies. Please note that certain types of apartments are only available in certain parts of the property): One Bedroom Two Bedroom Three Bedroom Four Bedroom Mailing Address (Included City, State and Zip Code) Contact Info: Home: _____________________ Work: __________________ Cell: _____________________ Email: _____________________________________________ Do you expect a change in your family composition within next year? Yes No If Yes, explain _____________________________________ If change is due to pregnancy, what is expected due date? __________________________________________________ What is your primary language? English Spanish Other _______________________ Do you need an interpreter?
Yes No
Is an accessible unit needed?
Yes No
If yes, specify Hearing Mobility Vision Other If hearing, do you require an interpreter? Yes No If English is not your primary language, can you speak or read English fluently? Yes No If yes, check one or both: Speak Read If yes, specify language ________________________________
Nicetown Courts Management Office 4340 Germantown Ave Philadelphia, PA 19140 Telephone: 215-307-4884 Fax: 215-455-1535 www.nicetowncourtii.com
Nicetown Court Do you currently have a PHA Voucher? Have you ever been evicted? Yes No Yes No If yes, why? ___________________________________ Have you or any member of your household been convicted of manufacturing or producing methamphetamine? Yes No If yes, please list name: ________________________________________ Are you or is any member of your household required to register under any state’s sex offender registration program? Yes No If yes, is this a lifetime registration requirement? Yes No
Sources of Income - Please specify the gross monthly amounts for the following: Applicant’s Monthly Income
Source of Income
Spouse’s Monthly Income
Salary
$
$
Social Security
$
$
Supplemental Security Income
$
$
Pension/Retirement Income Name of Fund ______________________
$
$
Pension/Retirement Income Name of Fund ______________________
$
$
Other Pension or Annuity Name of Fund ______________________
$
$
Unemployment
$
$
Worker’s Compensation
$
$
TAFDC/Welfare Assistance (per Month)
$
$
Child Support (per Month)
$
$
Alimony (per Month)
$
$
Other Household Member’s Income
NAME
Amount
$ $ $ $ $ $ $ $ $ $ $
TOTAL MONTHLY INCOME: $ __________________ Applicant Certification 1. I/We certify that the information given to Nicetown Courts Management on this preliminary application is correct and complete to the best of my/our knowledge and belief. I/We understand that such information will be verified and any false statements made on this application will cause me/us to be disqualified for admission. I/we also understand that false statements or information are punishable under Federal law. 2. I understand that if this application is not filled out completely, it will not be accepted. 3. I understand that this is a preliminary application and the information provided does not guarantee housing. I also understand that addition information and verifications will be necessary to complete the application process. Signature of Applicant:________________________________________________________ Date: ____________________ Signature of Spouse/Other Adult:_______________________________________________ Date: ____________________ Signature of Other Adult: _____________________________________________________ Date: ____________________
Nicetown Courts Management Office 4340 Germantown Ave Philadelphia, PA 19140 Telephone: 215-307-4884 Fax: 215-455-1535 www.nicetowncourtii.com
