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201109462 Have you ever received rental assistance?Yes No_ If Yes,explain Has your rental assistance ever been terminated 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/N) Special living accommodations required? (Y/N) Please Explain(Attach additional pages as needed): 11. IN CASE OF EMERGENCY,NOTIFY: Name Address Phone I/We understand that the above information is being collected to determine my/our eligibility for residency. I/We authorize the owner/manager to verify information provided on this application and my signature is our consent to obtain such verification. I/We certify that I/we have revealed all assets currently 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 best of my/our knowledge and belief and are awarc that fal,°statements are punishable under 1�'ederal law. I/We understand that this applicarion and all related inquires will be used only for its relevance to screening and occupancy at this Property. SIGNATURE OF ALL PARTIES TO THIS APPLICATION,18 YEARS OR OLDER: Applicant Signature(HEAD) Date Applicant Printed Name(HEAD) Applicant Signature Date Applicant Printed Name Applicant Signature Date Applicant Printed Name (Updated 12/]0)