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20080927( 20\'(()JD;8 Have you cver received rental assistance? Yes _ No _ If Yes, explain Has your rental assistance ever been tenninated for fraud, non-payment of rent or failure to recertify? Yes No If Yes, explain 10. SPECIAL NEEDS: Does anyone in your household have special needs? (Y IN) _ Special living accommodations required? (Y IN) _ Please Explain (Attach additional pages as needed): II. IN CASE OF EMERGENCY, NOTIFY: Name Address Phonc I/We understand that the above information is being collected to determine my/our cllglbility for residency. I/We authorize the owner/manager to verify information provided on this application and my signature is our consent to obtain such vcrlfication. I/We certify that I/we have revealed all assets currcntly held or previously disposed of and that I/we have no other assets than those listed on this form (other than personal property). I/We further certify that the statements made in this application are true and complete to the bcst of my/our knowledge and belief and arc aware that false statements are punishable under Federal law. I/We understand that this application and all relatcd inquires will be used only for its relevance to screcning and occupancy at this Property. SIGNA TURE OF ALL PARTIES TO THIS APPLICATION, 18 YEARS OR OLDER: Applicant Signature (HEAD) Date Applicant Printed Name (HEAD) Applicant Sik'llature Date Applicant Printed Name Applicant Signature Date Applicant Printed Name (Updated 11107)