Section I: Applicant Information

How long have you lived at this address?

Section II: Household Information

Names, relationships, etc. of ALL persons who will be occupying the unit

Other Income

Note: Applicants must complete this section in order to determine qualification for residency within the Federal LIHTC / Tax bond rental Program. Although this information is voluntary under the Federal Fair Housing Act, failure to provide such information may result in non-qualification for residency for any rental unit in these Affordable Housing Programs. Other Income Includes: Alimony, child support, welfare, unemployment, aid to dependent children, social security, annuities insurance policies, retirement benefits, pensions and other regular periodic payments. Please consult the leasing personnel for a complete list of other income.

List below from all members of the household all income derived from all sources and who receives the income.

NOTE: List all sources of income from all members of the household NOT previously listed above.

Assets Include: Cash (wherever held), trust corpus, equity in real estate or capital investment, notes receivable, stocks, bonds, money market accounts. IRAs, retirement and pension funds, and luxury personal property (gems, jewelry, art, coin collections, antique non- daily use items, etc.)

Assets Do Not Include: Necessary personal property such as clothing, jewelry, furniture, daily-use autos, tools, dishes, etc. Also excluded is any special equipment for use by the handicapped, cash value of life insurance policies, and assets of a business.

List below all assets held by each member of the applicant's household.

Section V: Other Information

It is my understanding that any and all information pertinent to my payment record and housekeeping habits during my tenancy at this address may be made available to other apartment communities or landlords to which I might apply in the future. Management reserves the right to reject applicant if false or incomplete information is given or may also terminate the lease agreement if information is found to be false or incomplete at a later date. The information collected on this form may be released to appropriate federal, state, and local agencies when relevant to civil, criminal or regulatory proceedings. Section 1001 of Title 18, United States Code, provides, "Whoever, in any matter within the jurisdiction of any department agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a material fact, or makes any fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement of entry shall be fined not more than $10,000 or imprisoned not more than five years, or both."

ONLY THOSE PERSONS LISTED IN THIS APPLICATION MAY LIVE IN THE APARTMENT WITHOUT THE WRITTEN PERMISSION OF THE LANDLORD OR AGENT.

A holding/security deposit is required for all apartments to consider an apartment "held" for an applicant upon completion of the certification process. Upon receipt of the security deposit, the applicant has 72 hours to cancel this agreement and receive a refund; after 72 hours the security deposit will be forfeited in order to cover the cost of holding the apartment off the market.

A written 60-day notice of intent to vacate is required before you can vacate your apartment. Your security deposit will be refunded if the proper written 60-day notice has been given and the premises are left in the condition of initial occupancy. The deposit shall be retained by Owner, if it is determined that you have provided false information on this application. In the event this application is disapproved, or the lease agreement is not consummated for any reason for which the Owner is responsible, the deposit will be returned to applicant within thirty (30) days from date of receipt of such by address provided on this application or address otherwise given to Agent by applicant in writing. Applicant hereby deposits $as security deposit. Applicant hereby waives any claim to damages by reason of non-acceptance. At the end of my lease term I understand that any security deposit refund will be made payable to all parties listed as tenant on the lease and the said check will be mailed to one (1) address provided by tenant in writing. Any variation from this policy must be requested in writing by tenant(s).

I understand the $ 35.00 application fee is non-refundable. This application is made with the understanding that it is subject To acceptance by Owner and subject to execution by an officer of said company and delivery of a lease covering said premises. (Application processing time will vary depending on the quantity of third party verifications required I agree that if my application Should I fail is approved, the scheduled date for my occupancy of Apartment #, will be (date) to move-in on the scheduled date indicated, I understand that I will be required to begin paying rent on the apartment, as if I had taken possession. I understand that I am applying for a lease term of 1 year commencing on the above mentioned move in date at a monthly rental of $ excluding options. It is the policy of this company to require a written application from all perspective residents prior to signing a lease. We require a fully executed lease on all apartments prior to move-in. The answers to the questions on this application, along with the results of the investigation conducted helps determine the selection of our residents. This application must be completed in its entirety before it will be processed to be placed on a waiting list. If you need assistance in completing this application, please inform the Site Representative of the type of assistance you need.

I understand that eligibility for residency will be based on Low-Income Housing Income Limits and regulations (please read thedesignated section checked above) as well as JDC Management, LLC Resident Qualification Standards for Keswick I Apartments. Iunderstand that the Qualification Standards are posted in the Site Office for review. I certify that all information in this application istrue, complete and correct to the best of my knowledge and I understand that false statements or information are punishable by lawand will lead to cancellation of this application or termination of tenancy after occupancy. I have read and understand all statementscontained within this entire rental application.

I hereby authorize the release of any information necessary to process my application. I further understand that it may be necessary to obtain a criminal background report and or a credit report.

I, {name}, has applied for residency at Ashleigh Place Senior Apartments. The undersigned hereby authorize all persons or companies in the categories listed below without liability. Depending on program policies and requirements, previous or current information regarding me may be needed. Verifications and inquires that may be requested include but are not limited to:

• Credit and Criminal Activity
• Identity and Marital Status
• Student Status
• Residences and Rental Activity
• Income(including employment if applicable) and Assets
• Social Security Numbers
• Family Composition
• Federal/State/Tribal/Local Benefits
• Medical Allowances

The groups or individuals, including any governmental organization, may be asked to release and/or verify the above information (depending on program requirements) including but not limited to:

• Courts and Post Offices
• Past and Present Employers
• Present Landlord
• Law Enforcement Agencies
• State Unemployment Agencies
• Credit Providers and Bureaus
• Veterans Administration
• Welfare Agencies
• Retirement Systems
• Social Security Administration
• Utility Companies
• Banks and Other Financial Institutions
• Previous Landlords (Including Public Housing Agencies)
• Education Institutes
• Support and Alimony Providers
• Health Care Providers
• Life Insurance Agent

PENALTIES: 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, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosure or improper uses 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 willfully 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, the PHA or the owner responsible for the unauthorized disclosure or improper use.