APPLICATION CHECKLIST FOR

LEGACY HILL / CHESTNUT GLEN

REQUIRED DOCUMENT

REQUIRED DOCUMENTS (Applications will NOT be accepted without these

documents.)

Forms with blanks will NOT be processed and will result in your application being withdrawn

Fully-completed Rental Application (all questions MUST be answered)

Fully-completed Certification Questionnaire (all questions MUST be answered)

Fully-completed Racial and Ethnic Certification (all questions MUST be answered)

Current Picture I.D. for Adults (18 years & older) - provide a clear copy of each

Birth Certificate for all family members - provide a clear copy of each

Social Security Card for all family members - provide a clear copy of each

Proof of income for all family members including the most current check stubs for a minimum of two

(2) months and/or a letter from Social Security Administration that is less than 60 days old

2017 tax return or tax transcript

Daycare verification on letterhead that is less than 60 days old – if applicable

Child Support verification print out that is less than 60 days old – if applicable

Food Stamps benefit letter that is less than 60 days old – if applicable

Bank Statements for the last six (6) months

Fully-completed Tenant Release and Consent Form(s) for All Adults (18 years & older)

Under $5000 Asset Self Certification (if applicable)

Student Verification Form

Child Support Verification Form (if applicable)

NOTE: The documents listed above are required in order for North Alabama Signature Properties to accept your

application submission.

If you submit an application without ALL the documents listed above, it will not be processed and will be

discarded, and you will have to REAPPLY.

NOTE: THERE IS A WORKING FAMILY PREFERENCE FOR THESE

APARTMENTS.

THE HEAD OF HOUSEHOLD MUST BE WORKING AT LEAST 30 HOURS PER WEEK (FOR 12

CONSECUTIVE MONTHS) OR BE ELDERLY AND/OR DISABLED IN ORDER FOR THE

APPLICATION TO BE ACCEPTED.

Name (First & Last) Date of Birth Social Security #

Drivers License or ID

State of Issue and # (e.g.,

GA 123456)

Relationship

to Head of

Household

2. -

3. -

4. --

5. --

6. --

A SEPARATE FORM MUST BE COMPLETED FOR EACH ADULT UNLESS MARRIED

Application for: Legacy Hill Chestnut Glen Both Legacy Hill AND Chestnut Glen

210 Winchester Road 6835 Research Park Blvd.

OCCUPANTS SECTION 1 – HOUSEHOLD

Head of Household __________________________________ Birth Date: _____/_____/_____ Social Security #: _____-____-_____

Home #:(_______)___________________ Cell #:(_______)___________________ E-Mail: _____________________________

List a spouse or any children that will be residing with you in this unit (Does not include other adults or children completing their own applications)

SECTION 2 – RENTAL HISTORY

1. Current Address

(Street) (Apt #) (City, State, Zip) (Dates of Residency – From/To) (Name of Current Landlord/Mortgage

Company) (Phone #) (E-mail) (Rent per Month)

List previous address if dates of residency at current address is less than one year:

(Street) (Apt.#) (City, State, Zip) (Name of Landlord & Phone #) (Resident Dates From / To)

SECTION 3 – BACKGROUND

A. Yes No | Have you or any members of your household including children under 18, been involved in, arrested for, charged

with, or convicted of any criminal activity? If Yes, List the Household Member(s) _________________________________

B. Yes No | Are you required to register with a sex offender registry?

If you answered "Yes," to either of the above questions, please list the criminal charges or activity and explain the circumstances of the

involvement, arrest, charge or conviction. If additional space is needed, please write on the back of this page or attach additional

sheets.______________________________________________________________________________________________________________________

______________________________________________________________

Page 1 of 2 Application for Rental – Affordable (2016-03-29).docx

RENTAL APPLICATION – LEGACY HILL / CHESTNUT GLEN

IT IS THE POLICY OF THIS COMMUNITY TO RENT TO QUALIFIED PERSONS REGARDLESS OF RACE, COLOR, RELIGION, SEX,

NATIONAL ORIGIN, HANDICAP, OR FAMILIAL STATUS, AND IN COMPLIANCE OF ALL FEDERAL, STATE, AND LOCAL LAWS.

SECTION 4 – ACCESSIBILITY

Fully accessible units were designed for residents with mobility – related disabilities or who may use a wheelchair or scooter. These units

offer features such as wider doors, lowered controls, light switches, counter, cabinets, roll under sinks etc. Applicants may apply for this

type of unit anytime during their application process. Upon request an eligible household may be offered a fully accessible unit based on

availability. Applicants may also request that special features be added to units where the household does not require full accessibility.

Yes No |A. Does any household member require a fully accessible unit?

Yes No | B. Does any household member require a unit with special features or a program modification due to a disability?

If Yes, please describe the special feature needed to accommodate the household member’s disability or handicap and complete a “Request for Reasonable Accommodation” form so that we may review your request(s): __________

______________________________________________________________________________________________

______________________________________________________________________________________________

SECTION 5 – EMERGENCY CONTACT / SIGNATURES

Emergency Contact – You must list Full Name, Full Address, Phone Number & Relationship to Applicant

( ) (Name) (Street Address / City / State / Zip) (Phone Number) (Relationship to Applicant)

Automobiles/Trucks/Motorcycles/Other: Make:______________ Model:_____________ Year:________ Color:_________ Tag#:_____________ State: _______Expiration date ____________ Make:______________ Model:_____________ Year:________ Color:_________ Tag#:_____________ State: _______Expiration date ___________

PET/SERVICE ANIMAL Yes No Breed: _________________Color: ____________Weight: _________lbs Size: Sm Med Lg Deposit Amount: $____________ [Approval __________ CM/PM] (If approved, must attach Picture and Current Shot Records. Required annually)

I/We certify there is no other source of income, the above information is true, complete, and correct to the best of my/our knowledge

and belief, and is made in good faith. I understand that a knowing and willful false statement on this application is ground for

rejection by the community manager. WE UNDERSTAND THAT LEGACY HILL / CHESTNUT GLEN ARE 100% SMOKE-

FREE COMMUNITIES.

Applicant Signature:_______________________ _________ Applicant Signature:___________________________ ________

Date Date

Applicant Signature:______________________ _________ Applicant Signature:____________________________ _______

Date Date

Management Signature:________________________________________ Date___________________________

Office Use Only: Application Taken By: ____________________________________________ Date:________________________________

Unit Size Requested: ______________________________ Floor preference: _______________________ Unit assigned: ________________________________

Comments from consultant (if applicable): _____________________________________________________________________________________________________

Page 2 of 2 Application for Rental – Affordable (2016-03-29).docx

SECTION 1 - OCCUPANCY

List yourself on Line 1. List all dependents under 18 years of age in the household and under your custody, and Live-In Aides on Lines 2-8.

Name (First & Last) Date of Birth

Relationship to

Person #1 Employed?

Full-Time Student 5+

months of year

1. SELF Yes No Yes No

Marital Status: Never Been Married Married Separated Divorced Widowed 2. Yes No Yes No

3. Yes No Yes No

4. Yes No Yes No

5. Yes No Yes No

6. Yes No Yes No

1. Yes No | Do you expect any occupancy changes to your household within the next 12 months? (i.e., unborn child, marriage, etc.)

If Yes, please explain ______________________________________________________________________

___________________________________________________________(Additional documentation may be required)

2. Ye 2. Yes No | Are any of the household members listed above a live-in aide? A live-in aide is an essential caretaker. If yes, the applicant

must provide verification of need from a Certified Health Care Professional

SECTION 2 – INCOME FROM EMPLOYMENT & BENEFITS

Please check ALL Household Members that anticipate receiving NO INCOME for the next 12 months, excluding income from assets:

□ Occupant #1 □ Occupant #2 □ Occupant #3 □ Occupant #4 □ Occupant #5 □ Occupant #6

PLEASE LIST ALL EMPLOYMENT FOR THE PREVIOUS TWELVE (12) MONTHS Present Employer for (Household Member’s Name)__________________________________________________

(Company Name)

(Street Address/City/State/Zip) (Phone # and Fax #)

(Position/Title) (Yearly Gross Income) (Supervisor’s Name) (Employment Dates From / To)

Present OR Previous Employer for (Household Member’s Name)_____________________________________

(Company Name)

(Street Address/City/State/Zip) (Phone # and Fax #)

(Position/Title) (Yearly Gross Income) (Supervisor’s Name) (Employment Dates From / To)

Present or Previous Employer for (Household Member’s Name)______________________________________

(Company Name)

(Street Address/City/State/Zip) (Phone # and Fax #)

(Position/Title) (Yearly Gross Income) (Supervisor’s Name) (Employment Dates From / To)

DO NOT leave a question unanswered or blank. An application with blanks will not be accepted. Indicate NONE if a question does not pertain to you. If an error is

made, please mark a single line through the error, correct, initial and date. PLEASE PRINT -WHITE OUT IS NOT ALLOWED!

Page 1 of 3

Does any person listed in Section 1 receive or expect to receive income from the following sources? “Yes” or “No” must be indicated for each source. An income amount is required for all “Yes” responses. List the Applicant’s Name and income information in the space provided.

Does any person

receive? Received by Annual Gross Income

Social Security Yes No $

SSI / Disability Benefits Yes No $

VA / Military Income Yes No $

Unemployment Benefits Yes No $

Child Support Yes No $

Alimony / Spousal Support Yes No $

Recurring Cash Gift Yes No $

TANF/General. Asst. / Cash Benefit (Does Not include Food Stamps)

Yes No $

Workers Comp. / Severance Pay Yes No $

Regular recurring payments from an

Annuity or Retirement Account Yes No $

Other Income (Scholarships, Grants, etc.) Yes No $

SECTION 3 –INCOME FROM ASSETS

Does any person listed in Section 1 receive or expect to receive income from the following sources? “Yes” or “No” must be indicated for each source.

An income amount is required for all “Yes” responses. List the Applicant’s Name and income information in the space provided.

Page 2 of 3

Personal Property held as an

investment

Yes No

$

Other Yes No $ Disposed Assets: Has any household

member sold or given away assets for less than fair market value during the

past two (2) years?

Yes No

$

SECTION 4 – ADJUSTED INCOME ALLOWANCES (Applies to HOME & AA Programs Only)

(For children under 13 years of age)

Yes No Child Care $_______________/mo (Verification of child care expense amount needed in order to include the amount in the

calculation of adjusted income)

Yes No Unreimbursed Medical Expenses $____________/mo (i.e., costs associated with pharmacy expenses. Verification of expenses needed in order to

include amount for the calculation of adjusted income) For applicants with elderly and or

disabled head of household)

Yes No Medical Insurance Deduction $_________/mo (i.e., medical deduction on Social Security benefit statement) For applicants with elderly

and or disabled head of household)

Yes No Care Assistance Services $_____________/mo (Costs

associated with payments made for services. Verification of expenses needed in order to

include amount for the calculation of adjusted income For applicants with elderly and or

disabled head of household)

I certify there is no other source of income, the above information is true, complete, and correct to the best of my knowledge and

belief, and is made in good faith. I understand that a knowing and willful false statement on this application is ground for rejection

or eviction by the management.

1. Applicant Printed Name:_________________________________________

Applicant Signature:_____________________________________________ Date___________________________

2. Applicant Printed Name:_________________________________________

Applicant Signature:_____________________________________________ Date___________________________

3. Applicant Printed Name:_________________________________________

Applicant Signature:__________________________________________ Date___________________________

Management Signature:__________________________________________ Date___________________________

WARNING: 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 partic ipant 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)

Page 3 of 3

The collection of race and ethnic data by 360 Properties Huntsville, LP, state housing finance agencies and the U.S. Department of Housing and Urban Development (HUD)

is authorized by the U.S. Housing Act of 1937 as amended, the Housing and Urban Rural Recovery Act of 1983 and Housing and Co mmunity Development Technical

Amendments of 1984. This information is needed to be in compliance with data reporting requirements to HUD.

Owners/agents must offer the opportunity to the head and co-head of each household to “self certify’ during the application interview or lease signing. Paren ts or guardians

are to complete the self-certification for children under the age of 18.

RACE -The five racial categories to choose from are defined below: You should check as many as apply to you.

(1) American Indian or Alaska Native. A person having origins in any of the original peoples of North and South America (including Central America), and

who maintains tribal affiliation or community attachment.

(2) Asian. A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example,

Cambodia,

China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

(3) Black or African American. A person having origins in any of the black racial groups of Africa. Terms such as “Haitian” or “Negro” can be used in

addition to “Black” or “African American.”

(4) Native Hawaiian or Other Pacific Islander. A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

(5) White. A person having origins in any of the original peoples of Europe, the Middle East or North Africa.

ETHNICITY -The two ethnic categories you should choose from are defined below. You should check one of the two categories.

(1) Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term “Spanish

origin” can be used in addition to “Hispanic” or “Latino.”

(2) Not Hispanic or Latino. A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Household Member Names

1.

2.

3.

4.

5.

6.

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any matter within the jurisdiction of a federal agency.

RACE (CHOOSE ALL

THAT APPLY)

American Indian or Alaskan Native

Asian Black or African-American

Native Hawaiian or Other Pacific

Islander

White Other Decline to Report

ETHNICITY (CHOOSE

ONE)

Hispanic or Latino

Non-Hispanic or Latino

Decline to Report

ALL ADULTS MUST SIGN

__________________________ _________ __________________________ _________ Signature

Date Signature Date

__________________________ _________ __________________________ _________ Signature

Date Signature Date

__________________________ _________ __________________________ _________ Signature Date Signature Date

I______________________________________(Applicant/Resident), the undersigned hereby authorize all persons or companies in the

categories listed below to release without liability, information regarding employment, income, and/or assets to North Alabama Signature

Properties (the “Owner” or “Agent”) for purposes of verifying information on my apartment rental application.

INFORMATION COVERED

I understand that previous or current information regarding me may be needed. Verifications and inquiries that may be requested include,

but are not limited to: personal identity; employment, income, and assets; medical or child care allowances; credit history; and criminal

background. I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for

and continued participation as a Qualified Tenant.

The groups or individuals that may be asked to release the above information include, but are not limited to:

CONDITIONS

I understand that the Owner/Agent is required to protect the income information it obtains in accordance with any applicable State privacy

law. After receiving the information covered by this notice of consent, the Owner/Agent may inform me that my eligibility for, or level of,

assistance is uncertain and needs to be verified and nothing else. Employees of the Owner/Agent may be subject to penalties for

unauthorized disclosures or improper uses of the information that is obtained based on the consent form.

I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will

stay in effect for a year and one month from the date signed. I understand I have a right to review this file and correct any information that

is incorrect.

SIGNATURE

__________________________________________ _________________________ ________________

Applicant/Resident (Print Name) Date WARNING: 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).

UNDER $5,000 ASSET CERTIFICATION

For households whose combined net assets do not exceed $5,000.

Complete only one form per household; include assets of children.

Household Name:

Complete all that apply for 1 through 4:

1. My/our assets include:

(A)

Cash

Value*

(B)

Int.

Rate

(A*B)

Annual

Income Source

(A)

Cash

Value*

(B)

Int.

Rate

(A*B)

Annual

Income Source

$ $ Savings Account $ $ Checking Account

$

$ Cash on Hand

$

$ Safety Deposit Box

$

$ Certificates of Deposit

$

$ Money market funds

$

$ Stocks

$

$ Bonds

$

$ IRA Accounts

$

$ 401K Accounts

$

$ Keogh Accounts

$

$ Trust Funds

$

$ Equity in real estate

$

$ Land Contracts

$

$ Lump Sum Receipts

$

$ Capital investments

$

$ Life Insurance Policies (excluding Term)

$

$ Other Retirement/Pension Funds not named above:

$

$ Personal property held as an investment** :

$

$ Other (list):

PLEASE NOTE: Certain funds (e.g., Retirement, Pension, Trust) may or may not be (fully) accessible to you. Include only those amounts which are.

*Cash value is defined as market value minus the cost of converting the asset to cash, such as broker's fees, settlement costs, outstanding loans, early withdrawal

penalties, etc. **Personal property held as an investment may include, but is not limited to, gem or coin collections, art, antique cars, etc. Do not include necessary personal

property such as, but not necessarily limited to, household furniture, daily-use autos, clothing, assets of an active business, or special equipment for use by the

disabled.

2. Within the past two (2) years, I/we have sold or given away assets (including cash, real estate, etc.) for more than $1,000 below

their fair market value (FMV). Those amounts* are included above and are equal to a total of: $

(*the difference between FMV and the amount received, for each asset on which this occurred).

3. I/we have not sold or given away assets (including cash, real estate, etc.) for less than fair market value during the past two (2)

years.

4. I/we do not have any assets at this time.

The net family assets (as defined in 24 CFR 813.102) above do not exceed $5,000 and the annual income from the net family assets is

$ . This amount is included in total gross annual income.

Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge.

The undersigned further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading or incomplete

information may result in the termination of a lease agreement.

_________________________________ ______________ ______________________________ _____________

Applicant/Resident Signature Date Applicant/Resident Signature Date

_________________________________ ______________ ______________________________ _____________

Applicant/Resident Signature Date Applicant/Resident Signature Date