Rental Application: Louise C. Stokes Scholar House

Page 1

Are you currently a full-time student at an accredited Ohio Institute of learning?

Which Institution?

Are you a high school graduate attending college this semester for the first time?

Are you the head of household with at least one minor child dependent and attending school fulltime?

Please list the age of your dependents here

Do you have at least one year of remaining coursework required before graduation?

Do you currently have a GPA of 2.0 or higher?

Page 2

First Name

Last Name

Birthdate

Social Security Number

Current Street Address

Current City

Current State

Current Zip code

Email Address

Mobile Phone

Alternative Phone

Length of residency at your current address

If less than 2 years, do you have two years of verifiable residency history?

Page 3

How many additional adults live in the household

Additional Adult Household Members

Please list the name(s) of all additional adults, as well as their birthdates. Please click "Add additional household member" for each entry needed.

First Name

Last Name

Birthdate

Total number of Household Members (Children and Adults)

Does your household need an ADA Home?

How much is the gross combined (before tax) monthly income of all adults that will be on the lease?

Do you receive any type of Rental Assistance

What type of assistance did you receive?

Do you owe CMHA or CHN any past due errors?

Have you or anyone in your household been evicted within the last 2 years?

Have you or anyone in your household been convicted of a felony within the last five years?

Is anyone in the household a registered sex offender?

Have you had to file for bankruptcy within the past two years?

Are you are any family member, now, or previously during the last 12 months an employee, agent, consultant, officer, elected, or appointed official of the City of Cleveland, Community Development Department, of the CHN Housing Partners (CHN), or any CHN member organization or any contractor doing business with CHN? Definitions: A "family member" is defined as the employee's spouse and everyone who is related to the employee or employee's spouse in the following ways: parents, children, grandparents, grandchildren, brothers, sisters, aunts, uncles, nieces, nephews, step relatives and half relatives.

How did you hear about us?

I hearby certify that the information stated above is true, correct and complete to the best of my knowledge. I further understand and agree that if any of the information I have provided in this pre-application is found to be incomplete, incorrect or false, it will be grounds for denial of this pre-application or termination of my tenancy. I further understand that this pre-application does not guarantee housing or a position on a waiting list. I further understand that my signature below provides CHN Housing Partners the ability to communicate with me via text messaging or email via the information provided on this form. To sign, please type your name below and then select the "Signed Date" Signature

Signed Date

We are unable to submit this application because you are not a full time student or do not have at least one minor child dependent

Contact Information