Nymore Evergreen Acres ~ Bemidji, MN

Nymore Evergreen Acres ~ Bemidji, MN
An applicant may be interviewed only after a completed Application is received. Completed Applications are processed in order of date and time received. You may contact the rental office for assistance in completing the Application.
Applicant's Full Name*
Applicant's Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant's Phone Number*
Applicant's Email*
example@example.com
Applicant's Full Name*

First NameMiddle NameLast Name
Applicant's Date of Birth*

MonthDayYear
Date
Applicant's Social Security Number*
Applicant's Sex*
Is there any additional applicants? (include everyone that will reside in unit)*

YesNo
2nd Applicants Full Name*
Relationship to Head*
2nd Applicants Date of Birth*

MonthDayYear
Date
2nd Applicants Social Security Number*
2nd Applicants Sex*
Is there any additional applicants? (include everyone that will reside in unit)*

YesNo
3rd Applicants Full Name*
Relationship to Head*
3rd Applicants Date of Birth*

MonthDayYear
Date
3rd Applicants Social Security Number*
3rd Applicants Sex*
Is there any additional applicants? (include everyone that will reside in unit)*

YesNo
4th Applicants Full Name*
Relationship to Head*
4th Applicants Date of Birth*

MonthDayYear
Date
4th Applicants Social Security Number*
4th Applicants Sex*
Is anyone in this household a full-time student?*

YesNo
If yes, Name(s)*
REFERENCE INFORMATION
Current Landlords Name
Landlords Address
Landlord's Phone Number
Previous Landlords Name
Previous Landlords Address
Previous Landlords Phone Number
HOUSEHOLD INCOME

List all sources of income for ALL household members..
Name of Household Member
Name of Employer
Monthly Gross $
Is there any additional Employers for Applicant's?*
Name of Household Member
Name of Employer
Monthly Gross $
Is there any additional Employers for Applicant's?*
Name of Household Member
Name of Employer
Monthly Gross $
Name of Household Member receiving Social Security
Monthly Gross Social Security $
Additional Household Member receiving Social Security
Monthly Gross Social Security $
Name of Household Member receiving Social Security Disability
Monthly Gross Social Security Disability $
Additional Household Member receiving Social Security Disability
Monthly Gross Social Security Disability $
Name of Household Member receiving Veterans Benefits
Monthly Gross Veterans Benefits $
Name of Household Member receiving Pension(s)
Source of Pension(s)
Monthly Gross Pension(s) Benefit $
Name of Household Member receiving Unemployment Compensation
Monthly Gross Unemployment Compensation $
Name of Household Member receiving AFDC (Aid to Families with Dependent Children)
Monthly Gross AFDC $
Name of Household Member receiving Alimony
Source of Alimony
Monthly Gross Alimony $
Name of Household Member receiving Child Support
Source of Child Support
Monthly Gross Child Support $
Do you anticipate any changes in this income in the next 12 months?*

YesNo
ASSETS
Do you have a Checking Account?*
Name of Bank*
Do you have any additional Checking Accounts at another bank?*
Name of Bank*
Do you have a Savings Account?*
Name of Bank*
Do you have any additional Savings Accounts at another bank?*
Name of Bank*
Do you have any Money Market Accounts?*
Name of Bank*
Do you have any Trust Accounts?*
Name of Bank*
Do you have any Certificates of Deposits?*
Name of Bank*
Do you have any IRAs?*
Name of Company*
Do you have any Savings Bonds?*
Cash Value $*
Do you have any Whole Life Insurance Policies?*
Cash Value $*
Do you own any property?*

YesNo
If Yes, state type of property*
Location of property*
Current Market Value of property owned*
Outstanding Mortgage Balance*
Have you sold/disposed of any business, property or other assets in the last 2 years?*

YesNo
If Yes, state type of business, property or asset*
Date of Sale/Disposition*
Market Value when sold/disposed of $*
Amount sold/disposed for $*
Do you have any other assets not listed above (example: recreational vehicle or mobile home; do not include personal property)?*

YesNo
If Yes, please list*
MEDICAL/HANDICAP ASSISTANCE EXPENSES
Is the head of household or spouse 62 or older, handicapped or disabled?*

YesNo
Medicare monthly premium amount $*
Medical Insurance Coverage Monthly Amount*
Name of Insurance Company*
Address of Insurance Company*
Anticipated Medical Expenses NOT covered by Insurance NOR reimbursed Monthly Amount $*
Medical bills or outstanding costs on which you are making monthly payments. Monthly Amount $*
Medical related travel costs monthly amount $*
Any other medical expenses: list type *
Monthly Amount?*
Are handicap assistance expenses needed to enable any family member to be employed?*

YesNo
Specialized Medical Attendant Care: Name of care giver*
Monthly cost for the care giver $*
Auxiliary Apparatus: List Type*
Cost $*
CHILD CARE EXPENSES
Is there household minors under the age of 13?*

YesNo
Name of 1st child being cared for*
Age of 1st child bring cared for*
Name(s) of additional children cared for
Age
Age
Age
Name of person/agency caring for children*
Address*
Telephone for person/agency caring for childen*
Weekly cost of child care due to employment*
Weekly cost of child care due to education*
PROGRAM INFORMATION
What size of unit are you requesting?*

1 Bedroom2 Bedroom3 Bedroom
Do you wish to claim a $400 deduction from your household income based on an "Elderly Household" status where the tenant or co-tenant is 62 or older, handicapped or disabled?*

YesNo
Do you wish to have priority for a handicapped accessible unit with special design features?*

YesNo
Do you have a Letter of Priority issued by USDA-Rural Development due to displacement from another property?*

YesNo
Have you ever been evicted from any type of housing?*

YesNo
Have you ever been convicted of a felony?*

YesNo
Are you currently a user of an illegal controlled substance?*

YesNo
Have you ever been convicted of a drug violation (use, attempted use, possession, manufacture, sale or distribution)?*

YesNo
Have you successfully completed a controlled substance abuse recovery program or presently enrolled in such a program?*

YesNo
Are you now or will you become a part time or full time student prior to move in?*

YesNo
How did you hear about this housing?*
OTHER INFORMATION

List all cars, trucks or other vehicles owned. (Parking will be provided for one vehicle. Arrangements with management will be necessary for more than one vehicle.)
Type of Vehicle
Year/Make
Color
License Plate No.
Registered To
Is there an additional vehicle?

YesNo
Type of Vehicle
Year/Make
Color
License Plate No.
Registered To
Do you own any pets?*

YesNo
If Yes, describe*
In case of emergency notify - Name*
Emergency Contact Address*
Emergency Contact Phone Number*
CERTIFICATION
I/We hereby certify that the unit applied for will be the household's permanent residence. I/We further certify that I/we do/will not maintain a separate subsidized rental unit in another location. I/We understand that I/we must pay a security deposit for this unit. I/We understand that my/our eligibility for housing will be based on USDA-Rural Development income limits and tenant selection criteria. I/We certify that all information in this Application is true to the best of my/our knowledge and understand that false statements or information are punishable by law and will lead to cancellation of this Application or termination of tenancy after occupancy.
SIGNATURES:
Tenant Signature*

Clear
Date*

MonthDayYear
Date
Co-Tenant Signature

Clear
Date

MonthDayYear
Date
AUTHORIZATION

I/We do hereby authorize GREATER MINNESOTA PROPERTY and its staff or authorized representative to contact any agencies, law enforcement offices, companies, groups or organizations to verify any information contained in this Application or to obtain and verify any additional information or materials which are deemed necessary to complete my/our Application for housing in programs administered by the United States Department of Agriculture
SIGNATURES:
Tenant Signature*

Clear
Date*

MonthDayYear
Date
Co-Tenant Signature

Clear
Date

MonthDayYear
Date
"In accordance with Federal Law and U.S. Department of Agricultural policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability (Not all prohibited bases apply to all programs

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington D.C. 20250-9410 or call (202)720-5964 (voice and TDD USDA is an equal opportunity provider and employer."

Please provide the following information so that Greater Minnesota Property will be in compliance with Title VI of the Civil Rights Act of 1964.

The following information is requested by the Federal Government in order to monitor compliance with the Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.
Applicant's Race (Select all that apply)*

WhiteAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific Islander
Applicant's Ethnicity (Select One)*

Not Hispanic or LatinoHispanic or Latino
Applicant's Gender (Select One)*

MaleFemale
"Please be aware that under federal laws, persons with disabilities have the right to request reasonable accommodations to rules and modifications to apartments at no cost to themselves"
Form 92006

This form is to be provided to each applicant for federally assisted housing Instructions:Optional Contact Person or Organization: You have the right by law to include as part of your application for housing, the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update, remove, or change the information you provide on this form at any time. You are not required to provide this contact information, but if you choose to do so, please include the relevant information on this form.
Applicant Name*
Applicant's Mailing Address, City, State & Zip Code*
Applicant's Phone Number*
Cell Phone No
Check YES if you choose NOT to provide the emergency contact information*

YesNo
Name of Additional Contact Person or Organization
Relationship to Applicant
Additional Contact's Address, City, State & Zip Code
Contacts Phone Number
Reason for Contact: (Check all that apply)

EmergencyAssist with Recertification ProcessUnable to contact youChange in lease termsTermination of rental assistanceChange in house rulesEviction from unitLate payment of rent
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
RHR RENTAL HISTORY REPORTS

General Consent Form - Each applicant 18 + over MUST complete a consent form
Last Name*
First*
Middle*
Maiden
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Sex*
Social Security Number*
Driver's License Number
Driver's License State
Applicant's Phone Number*
I/We authorize Rental History Reports (RHR) and/or the above named company to do a complete investigation of all information provided within my application for residency. I/We have personally filled in and/or reviewed all information contained within the application. I/We understand failure to complete these documents completely and truthfully may result in denial and/or forfeit of deposit. A complete investigation may include any or all of the following: Credit Report, Verification of Employment and Income, Criminal Record Search, Rental History References (including MPHA), UnlawfulDetainer/Eviction Investigation, Identity Trace, Sex Offender Search, Terrorism Search, Check Writing History, and Personal Interviews with all provided references. The source of the information may come from, but is not limited to: credit bureaus; banks and other depository criminal institutions; current and former employers; federal or state records including State Employment Security Agency records, county or state records,count agencies as it relates to the applicant's eligibility, non-eligibility and/or benefit amounts received by the tenant, or other sources as Itis understood that a photocopy or facsimile copy of this form will serve as authorization. I/We understand that I/We have a right to make required. writtenrequest within 30 days to receive information pertaining to this report if I/We are not accepted based upon information contained in the a report. I/We authorize RHR to produce to the credit granter Federal and State records of employment and income history, including State Employment Security Agency records. This authorization continues in effect for one (1) year unless limited by state law, in which case, the authorization continues in effect for the maximum period, not to exceed one (1) year.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Is there additional applicants over 18 years of age? If so they must also complete a background check RHR General Consent Form*

YesNo
RHR RENTAL HISTORY REPORTS

General Consent Form - Each applicant 18 + over MUST complete a consent form
Last Name*
First Name*
Middle Name*
Maiden
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Sex*
Social Security Number*
Driver's License Number
Driver's License State
Applicant's Phone Number*
I/WeauthorizeRental History Reports (RHR) and/or the above named company to do a complete investigation of all information provided within my application for residency. I/We have personally filled in and/or reviewed all information contained within the application. I/We understand failure to of complete these documents completely and truthfully may result in denial and/or forfeit of deposit. A complete investigation may includeanyorall the following: Credit Report, Verification of Employment and Income, Criminal Record Search, Rental History References (including MPHA), Unlawful Detainer/Eviction Investigation, Identity Trace, Sex Offender Search, Terrorism Search, Check Writing History, and Personal Interviews with all provided references. The source of the information may come from, but is not limited to: credit bureaus; banks and other depository criminal institutions; current and former employers; federal or state records including State Employment Security Agency records, county or state records,count agencies as it relates to the applicant's eligibility, non-eligibility and/or benefit amounts received by the tenant, or other sources as Itis understood that a photocopy or facsimile copy of this form will serve as authorization. I/We understand that I/We have a right to make required. writtenrequest within 30 days to receive information pertaining to this report if I/We are not accepted based upon information contained in the a report. I/We authorize RHR to produce to the credit granter Federal and State records of employment and income history, including State Employment Security Agency records. This authorization continues in effect for one (1) year unless limited by state law, in which case, the authorization continues in effect for the maximum period, not to exceed one (1) year.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Is there additional applicants over 18 years of age? If so they must also complete a background check RHR General Consent Form.*

YesNo
RHR RENTAL HISTORY REPORTS

General Consent Form - Each applicant 18 + over MUST complete a consent form
Last Name*
First*
Middle*
Maiden
Current Address*

Current Address

Street Address Line 2

CityState

Zip Code
Previous Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth*

MonthDayYear
Date
Sex*
Social Security Number*
Driver's License Number
Driver's License State
Phone Number*
I/WeauthorizeRental History Reports (RHR) and/or the above named company to do a complete investigation of all information provided within my application for residency. I/We have personally filled in and/or reviewed all information contained within the application. I/We understand failure to complete these documents completely and truthfully may result in denial and/or forfeit of deposit. A complete investigation may includeanyorallof the following: Credit Report, Verification of Employment and Income, Criminal Record Search, Rental History References (including MPHA), Unlawful Detainer/Eviction Investigation, Identity Trace, Sex Offender Search, Terrorism Search, Check Writing History, and Personal Interviews withall provided references. The source of the information may come from, but is not limited to: credit bureaus; banks and other depository institutions; current and former employers; federal or state records including State Employment Security Agency records, county or statecriminal records,count agencies as it relates to the applicant's eligibility, non-eligibility and/or benefit amounts received by the tenant, or other sources as required. It is understood that a photocopy or facsimile copy of this form will serve as authorization. I/We understand that I/We have a right to make a written request within 30 days to receive information pertaining to this report if I/We are not accepted based upon information contained in the report. I/We authorize RHR to produce to the credit granter Federal and State records of employment and income history, including State Employment Security Agency records. This authorization continues in effect for one (1) year unless limited by state law, in which case, the authorization continues in effect for the maximum period, not to exceed one (1) year.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
All Applicant's 18 years of age and over are required to pay a $35 application fee (per applicant) before the application process can begin. This fee is to run our Credit, Criminal and Rental History Backgrounds. If you would like us to set up an auto payment through your checking or savings account please complete the form below. If you do not have a checking or savings the application can not be processed until we receive your money order in our office.
Do you have a checking or savings account to set up for the application fee?*

YesNo
AUTHORIZATION FOR AUTOMATIC PAYMENT

I authorize Greater Minnesota Management and the bank named below to initiate debits from my checking/savings account. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the bank a reasonable opportunity to act on it. I can stop payment of any debit by notifying my bank
three (3) days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account up to fifteen (15) days following issuance of my bank statement or sixty (60) days after posting, whichever occurs first.
Name of Financial Institution*
Name on Checking/Savings Account *
Is this a Checking or Savings Account*

CheckingSavings
Routing Number (First 9 digits on bottom of check or deposit slip)*
Re-enter Routing Number *
Account Number*
Re-enter Account Number*
Signature*

Clear
On (date) Date* I authorize Greater Minnesota Management in Erskine, Minnesota to initiate electronic debit from my account and agree to the terms as detailed on the authorization. This authority will remain in effect until I cancel it in writing to the company
USDA
Rural Housing and Community Programs

Things You Should Know About USDA Rural Rental Housing

Don't risk losing your chances for federally assisted housing by providing false, incomplete, or inaccurate information on your application or recertification

Penalties for Committing Fraud You must provide information about your household sta- tus and income when you apply for assisted housing in apartments financed by the U.S. Department of Agriculture (USDA USDA places a high priority on pre- venting fraud. If you deliberately omit information or give false information to the management company on your application or recertification forms, you may be: Evicted from your apartment; Required to repay all the extra rental assistance you received based on faulty information; Fined; Put in prison and/or barred from receiving future

All Household Members. List the names of all the

Your State and local governments also may have laws that allow them to impose other penalties for fraud in addition to the ones listed here.

How To Complete Your Application

When you meet with the landlord to complete your application, you must provide information about: All Household Income. List all sources of money that you receive. If any other adults will be living with you in the apartment, you must also list all of their income. Sources of money include: -Wages, unemployment and disability compensation, welfare payments, alimony, Social Security benefits, pensions, etc.; -Any money you receive on behalf of your children, such as child support, children's Social Security, etc.; -Income from assets such as interest from a savings account, credit union, certificate of deposit, stock dividends, etc.; -Any income you expect to receive, such as a pay raise or bonus.

people, including adults and children, who will actual- ly live with you in the apartment, whether or not they are related to you. Ask for Help if You Need It If you are having problems understanding any part of the application, let the landlord know and ask for help with any questions you may have. The landlord is trained to help you with the application process. Before You Sign the Application Make sure that you read the entire application and understand everything it says; Check it carefully to ensure that all the questions have been answered completely and accurately; Don't sign it unless you are sure that there aren't any errors or missing information. By signing the application and certification forms, you are stating that they are complete to the best of your knowledge and belief. Signing a form when you know it contains misinformation is considered fraud.

The management company will verify your informa- tion. USDA may conduct computer matches with other Federal, State or private agencies to verify that the income you reported is correct; Ask for a copy of your signed application and keep a copy of it for your records. Tenant Recertification

Residents in USDA-financed assisted housing must provide updated information to the management com- pany at least once a year. Ask your landlord when you must recertify your income.

All Household Assets. List all assets that you have. If any other adults will be living with you, you must also list all of their assets. Assets include: -Bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc.; -Any business or asset you sold in the last 2 years for less than its full value, such as selling your home to your children.

You must immediately report: Any changes in income of $100 or more per month; Any changes in the number of household members.

For your annual recertification, you must report: All income changes, such as increases in pay or benefits, job change or job loss, loss of benefits, etc., for any adult household member;
Any household member who has moved in or out; All assets that you or your adult housemates own, or any assets that were sold in the last 2 years for less than their full value.

Prevent fraudulent schemes through these steps: Don't pay any money to file your application; Don't pay any money to move up on the waiting list; Don't pay for anything not covered by your lease; Get receipts for any money you do pay; Get a written explanation for any money you are required to pay besides rent, such as maintenance charges. Report Abuse: If you know anyone who has falsified an application, or who tries to persuade you to make false statements, report him or her to the manager. If you cannot report to your manager, call your local or state USDA office at 1 (800) 670-6553, or write: USDA, STOP 0782, 1400 Independence Ave., SW, Washington, DC 20250.

If the grievance is not resolved, the tenant must request a hearing within 10 days of receipt of the meet- ing findings. The parties will then select a hearing panel or hearing officer to govern the hearing. All parties are notified of the decision 10 days after the hearing. When a Grievance Is Legitimate The landlord must determine if a grievance is within the established rules for the program. For example, "I want to file a complaint because the manager doesn't speak to me" is not a legitimate complaint. However, "I want to file a complaint because the manager isn't maintaining the property according to USDA guidelines" is a legiti- mate complaint. Below are examples of cases in which tenants may and may not file a complaint.

A complaint may be filed A complaint may not be filed with the owner/management with the owner/management if: if: There is a modification of the USDA has authorized a pro- lease, or changes in the rules or posed rent change. rent that are not authorized by

If You Disagree With a Decision

Tenants may file a grievance in writing with the complex owner in response to the owner's actions, or failure to act, that result in a denial, significant reduction, or termi- nation of benefits. Grievances may also be filed when a tenant disputes the owner's notice of proposed adverse

The complex owner must notify tenants in writing about any proposed actions that may have adverse conse- quences, such as denial of occupancy and changes in the occupancy rules or lease. The written notice must give specific reasons for the proposed action, and must also advise tenants of the "right to respond to the notice within 10 calendar days after the date of the notice" and of "the right to a hearing." Housing complexes in areas with a concentration of non-English-speaking people must send notices in English and in the majority non- English language.

A tenant believes that he/sheThe owner or management fails to maintain the property in a has been discriminated against decent, safe, and sanitary man- because of race, color, religion, national origin, sex, age, familialner. status, or disability. Discrim- ination complaints should be filed with USDA and/or the Department of U.S. Housing and Urban Development (HUD), not with the owner/manage- ment. The complex has formed a ten-The owner violates a lease pro- vision or occupancy rule. ant's association and all parties have agreed to use the associa- tion to settle grievances. USDA has required a change in the complex. the rules and proper notices have been given. The tenant is in violation of the lease and the result is termina- tion of tenancy. There are disputes between tenants that do not involve the owner/management. Tenants are displaced or other adverse effects occur as a result of loan prepayment.

A tenant is denied admission to

USDA believes that the best way to resolve grievances is through an informal meeting between tenants and the landlord or owner. Once the owner learns about a tenant grievance, the process should begin with an informal meeting between the two parties. Owners must offer to meet with tenants to discuss the griev- ance within 10 calendar days of receipt of the com- plaint. USDA encourages owners and tenants to try to reach a mutually satisfactory resolution to the problem at the meeting.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all pro- grams Persons with disabilities who require alternative means for com- munication of program information (braille, large print, audiotape, etc should contact USDA's TARGET Center at (202) 720-2600 (voice and

To file a complaint of discrimination write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800)795-3272 (voice) or (202)720-6382 (TDD USDA is an equal opportunity provider and employer.
Should be Empty:

Nymore Evergreen Acres ~ Bemidji, MN

REFERENCE INFORMATION

HOUSEHOLD INCOME

ASSETS

MEDICAL/HANDICAP ASSISTANCE EXPENSES

CHILD CARE EXPENSES

PROGRAM INFORMATION

OTHER INFORMATION

CERTIFICATION

SIGNATURES:

AUTHORIZATION

SIGNATURES:

Form 92006

RHR RENTAL HISTORY REPORTS

RHR RENTAL HISTORY REPORTS

RHR RENTAL HISTORY REPORTS

USDA