Electronic Application

Accessible Space, Inc.
HOUSING FOR PERSONS WITH DISABILITIES
NATIONWIDE HOUSING SITE LOCATIONS
This is a fillable PDF document. Please check the necessary boxes and/or move the dots as they apply to you. When
completed, please print and mail it to Accessible Space, Inc. 2550 University Ave. West Ste. 330N St. Paul, MN 55114.
Call 800-466-7722 with questions.
APARTMENT LIVING
Each resident rents his/her own accessible apartment. ASI supportive services are available in some
locations, and some locations offer services from other providers. Housing locations in bold print
indicate housing with ASI Services available. Please contact ASI’s Intake Specialist with service related
questions at (651) 645-7271 or (800) 466-7722, extension 224. TTY/TDD (800) 627-3529. Please note:
ASI services are available only to qualified applicants and residents, and rent payments do not include
the cost or provision of ASI supportive living services that may be available.
Alabama
□ Florence – Dogwood Terrace
□ Hoover – Patton Ridge Apts.
□ Mobile – Anderson Fischer Apts.
Arizona
□ Chandler – Arroyo Terrace
□ Mesa – R.J. Piltz Vista Bonita
California
□ Capitola – The Dakota
□ Davis – Becerra Plaza
□ Fullerton – Harbor View Terrace
□ South Lake Tahoe – Sky Forest Acres
Colorado
□ Fort Collins – Harmony Road Apts.
□ Greeley – Fox Run
□ Longmont – Casa Libertad
□ Greeley – Twin Rivers
Illinois
□ Carbondale – Heartland Apts.
Kansas
□ Kansas City – Mid America Commons
(1 BR only)
□ Topeka – Melissa Anne Hanger Apts.
□ Kansas City – Blackbird Apts.
7/23/2014
Missouri
□ Springfield – Tim O’Brien Apts.
Montana
□ Billings – Grandview Apts.
□ Bozeman – Spring Run Apts.
□ Great Falls – Meadow Lark Apts.
□ Great Falls – Southwinds Estates
□ Helena – Queen City Estates
□ Missoula – Bruce Blattner Apts.
□ Missoula – Eagle Watch Estates
North Dakota
□ Fargo – Northland Apts.
□ Grand Forks – Linden Place (1 BR only)
□ Jamestown – Dewey Apts.
□ Minot – Accessible Space Apts.
Nevada
□ Carson City (89701) – Frost Yasmer Estates
□ Henderson (89009) – Major Avenue Apts.
□ Henderson (89015) – George & Lois Brown
Estates
□ Las Vegas (89110) – Sandy Robinson Apts.
□ Las Vegas (89115) – John Chambers Apts.
□ Las Vegas (89119) – Bob Hogan Apts.
□ Las Vegas (89122) – Carol Haynes Apts.
□ Las Vegas (89122) – Dina Titus Estates
□ Las Vegas (89123) – Shelbourne Avenue Apts.
□ Las Vegas (89146) – Ray Rawson Villa
□ Las Vegas (89156) – Bledsoe Lane Apts.
□ Las Vegas (89156) – Park Apts.
Accessible Space, Inc.
HOUSING FOR PERSONS WITH DISABILITIES
NATIONWIDE HOUSING SITE LOCATIONS (PAGE TWO)
□ Las Vegas (89104) – Mojave Cedar Apts.
□ Reno (89502) – John Butterworth Estates
□ Reno (89502) – William J. Raggio Apts.
APARTMENT LIVING (CONTINUED) *See Minnesota Properties on Next Page
New Mexico
□ Santa Fe – Homeward Bound Apts.
Oklahoma
□ Rock Ridge Apartments- McAlester
South Dakota
□ Rapid City – Galaxy Apts.
□ Sioux Falls – Crocus Meadow Apts.
□ Watertown – Eastwood Apts.
Tennessee
□ Memphis – McCullough Place
□ Memphis – Welsh Manor
□ Nashville – Hagy Commons
Texas
□ Austin – Pecan Hills
□ Baytown – Rollingbrook Apts.
□ Clear Lake – Paul Chase Commons
□ Corpus Christi – Henry Harbour
□ Pasadena – Vista Villa (1 BR only)
□ San Antonio – Oak Forest Heights
□ The Woodlands – Windvale Pines Apts.
□ Universal City – Wagon Crossing Apts.
Virginia
□ Chesapeake – The Sanderling
□ Exmore – AP’s Freedom Apts. (1 BR only)
□ Norfolk – The Anchorage
Washington
□ Spokane – Eagle Crest Estates
Wisconsin
□ Hudson – Tribute Commons
**Please note that the LIHTC & HOME income
can increase to 140% AMI which is appropriate
for LIHTC, however for HOME units the income
can only increase to 80% AMI before rent must
be adjusted to be 30% of the tenants income
7/23/2014
Accessible Space, Inc.
DISABILITIES
HOUSING FOR PERSONS WITH
MINNESOTA HOUSING SITE LOCATIONS
***PLEASE LIMIT YOUR SELECTIONS TO A TOTAL OF FIVE (5) HOUSING LOCATIONS***
Housing locations in bold print indicate housing with ASI Services available. Please contact ASI’s
Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722, extension 224.
TTY/TDD (800) 627-3529. Please note: ASI services are available only to qualified
applicants/residents, and resident rent payments do not include the cost or provision of ASI supportive
living services that may be available.
APARTMENT LIVING
Each resident rents his/her own accessible
apartment. ASI Assisted Living Services are
available in some locations, and some locations
offer services from other providers.
□ Alexandria – Nordic Meadow Apts.
□ Austin – Prairie Sky Apts.
□ Bloomington – Henry Courts I (1 BR only)
□ Brainerd – Northern Lights Apts.
□ Burnsville – Leah’s Apts.
□ Burnsville – West Apts.
□ Duluth – Burke Apts.
□ Duluth – Pine Grove Apts.
□ Duluth – Redruth Valley Apts. (1 BR only)
□ Duluth – Superior View Apts.
□ Hibbing – Winston Court Apts.
□ Marshall – River Winds Apts.
□ Owatonna – Kay Knutson Apts.
□ Rochester – Bostrom Terrace (1 BR only)
□ Rogers – Meadow Trail Apts.
□ Roseville – Roselawn Village
□ Sartell – Hope Village Apts.
□ Shakopee – River Bluff Apts.
□ St. Cloud – Quarry Heights
□ St. Paul – Henry Courts II (1 BR only)
□ Stillwater – Hillcrest Apts.
□ Willmar – Becker Avenue Apts.
HOMES WITH ASSISTED LIVING SERVICES
Each resident has a private bedroom and shares
common areas with other residents in an
accessible home. ASI offers/provides 24/7, onsite Assisted Living services to Medicaid
eligible residents.
□ Grand Rapids – Moses
□ Minneapolis – 28th Street
□ Minneapolis – Camden
□ Minneapolis – Chicago
ADULT LICENSED FOSTER CARE HOMES
Each resident has a private bedroom and shares
common areas with other residents in an
accessible home. ASI offers/provides 24/7, onsite Adult Licensed Foster Care services to
Medicaid eligible residents.
□ Blaine – Van Buren Home
□ Coon Rapids – Flintwood Home
□ Coon Rapids – Magnolia Home
□ Falcon Heights – Snelling Home
□ St. Anthony – Silver Lake Home
□ White Bear Lake – Cedar Home
HOMES WITHOUT ASI SERVICES
Each resident has a private bedroom and shares
common areas with other residents in an
accessible home. Residents who need
supportive services can arrange with the provider
of their choice.
□ Golden Valley – Pesch Place
□ St. Paul – Iglehart Home
□ St. Paul – Selby Home
Accessible Space, Inc.
HOUSING FOR SENIORS AGE 62 & BETTER
NATION WIDE HOUSING SITE LOCATIONS
***PLEASE LIMIT YOUR SELECTIONS TO A TOTAL OF FIVE (5) HOUSING LOCATIONS***
APARTMENT LIVING (1 BR)
Each resident rents his/her own apartment. Accessible apartments are available. ASI supportive services are available in some
locations, and some locations offer services from other providers. Housing locations in bold print indicate housing with ASI
Services available. Please contact ASI’s Intake Specialist with service related questions at (651) 645-7271 or (800) 466-7722,
extension 224. TTY/TDD (800) 627-3529. Please note: ASI services are available only to qualified applicants and residents,
and rent payments do not include the cost or provision of ASI supportive living services that may be available.
Some locations offer information and referral services at no charge to residents. Meal programs are available at some
locations from other providers for a suggested donation.
Minnesota
□ Albert Lea – Washington Avenue Apts.
□ Owatonna – Maple Trail Apts.
□ Rochester – Kenosha Drive Apts.
□ Rogers – Autumn Trails
□ Sartell – David F. Day
□ St. Paul – Arlington Gardens
□ Worthington – Buffalo Ridge Apts.
Montana
□ Bozeman – Summer Wood Apts.
□ Great Falls – The Portage
□ Helena – Aspen Village
□ Kalispell – Van Ee Apts.
Nevada
□ Las Vegas – Tonopah Lamb Apartments.
North Dakota
□ Dickinson – Frontier Apts.
South Dakota
□ Brookings – Pheasant Run Apts.
□ Sioux Falls – Pasque Meadow Apts.
Texas
□ The Woodlands – Tangle Brush Villa
Wisconsin
□ Hudson –Heirloom Court Apts.
**Please note that the LIHTC & HOME income
can increase to 140% AMI which is appropriate
for LIHTC, however for HOME units the income
can only increase to 80% AMI before rent must
be adjusted to be 30% of the tenants income
5/7/2013
Wyoming
□ Cheyenne – Heritage Court Apts.
**FOR OFFICE USE ONLY DO NOT WRITE IN THIS BOX**
1 BR _____ 2 BR _____
Date Rcv’d_____________________
Location #1_____________ Location#2_______________
Location #3________________ Location#4__________________
Location #5 ________________
Interest List(s) __________________________________________
APPLICATION FOR HOUSING ADMISSION AND RENTAL ASSISTANCE
APPLICANT NAME _____________________________________________________________________________________________
CO-APPLICANT NAME __________________________________________________________________________________________
CURRENT MAILING ADDRESS___________________________________________________________________________________
CITY, STATE, ZIP CODE_________________________________________________________________________________________
HOME PHONE (________) ______________________________
WORK PHONE (_________) _______________________________
E-MAIL ADDRESS:___________________________________________CELL PHONE(______)_______________________________
If I cannot be reached at above number(s), please contact:
PERSON TO CONTACT_________________________________________
PHONE (_________) ________________________________ RELATIONSHIP_____________________________________________
In case of an EMERGENCY please contact:
PHONE (
PERSON TO CONTACT ____________________________________________________
)
RELATIONSHIP___________________________________________
**ALL CO-APPLICANTS AGE 18 OR OLDER, OTHER THAN SPOUSE ARE REQUIRED TO COMPLETE A SEPARATE
APPLICATION
Any applicant, who purposefully falsifies, misrepresents or withholds any information related to program eligibility or submits
inaccurate and/or incomplete information on this application will not be considered for housing nor placed on the waiting list.
HOUSEHOLD COMPOSITION AND CHARACTERISTICS
1. List the Head of Household and all other members who will be living in the unit. Give the relations of each family member to the head.
Member #
Member’s Full Name
Relationship
1
2.
Birth Date
Age
Sex
Social Security Number
Head
Is Head of Household or spouse/Co-Head handicapped or disabled?
______ Yes
(For program and unit eligibility purposes only)
______ No
01/11 FORM # HUD-1
2550 University Ave West, Suite 330N
Saint Paul, Minnesota 55114
651-645-7271 (800-466-7722) Fax: 651-209-6623
TTD/Voice: 800-627-3529
1
Equal Opportunity Employer
Equal Housing Opportunity
The Department of Housing and Urban Development requires that, for statistical purposes only, we report the race and ethnicity of the Head
of Household for applicants. You are not required to answer, nor does your answer affect your position on our waiting list or your eligibility
for housing
3. Race of Head of Household: (Select all that apply)
______ White
_______ Black or African American
______ American Indian or Alaskan Native
______Asian
_______ Native Hawaiian or Other Pacific Islander
4.
Ethnicity of Head of Household: (Select One)
______ Hispanic
______ Non-Hispanic
5.
Will you be the only person to occupy the unit? ______ Yes
6.
Do you expect a change in your household composition? ______ Yes
________ Other
______ No
______ No
If yes, please explain: __________________
____________________________________________________________________________________________________________
7.
Please identify any special housing needs your household has: ___________________________________________________________
____________________________________________________________________________________________________________
RENTAL HISTORY
CURRENT HOUSING
✔ Own Home
____
_____ Apartment
____ Parent’s Home
_____ Nursing Home
_____ Rehab Center
Other:
Name and Address of Your Current Landlord:
____________________________________________________
Landlord Phone___________________________________________
____________________________________________________
How Long Have You Lived There? __________________________
____________________________________________________
Reason for Leaving? ______________________________________
Is this a subsidized unit? _____ Yes
_____ No
Has your housing assistance ever been terminated for fraud, non-payment of rent or utilities, failure to cooperate with recertification
procedures or for any other reason? _____ Yes _____ No If yes, please explain ____________________________________________
Name and Address of your Former Landlord:
____________________________________________________
Landlord Phone___________________________________________
____________________________________________________
How Long Did You Live There?_____________________________
Reason for Leaving?______________________________________
2
HOUSEHOLD INCOME INFORMATION (All information will be verified by a third party)
Please answer each of the following questions. List current and anticipated income for the next twelve months, (including full time, part time
or seasonal income). If a household member has more than one source of income, use a separate line for each source.
MONTHLY
DOES ANY MEMBER OF YOUR HOUSEHOLD:
YES
NO
AMOUNT
1. Work full-time, part-time or seasonally?
______
______
____________
2.
Work for someone who pays them cash?
______
______
____________
3.
Expect to work for any period during the next year?
______
______
____________
4.
Expect a leave of absence from work due to lay-off, medical, maternity
or military leave?
______
______
____________
5.
Now receive or expect to receive unemployment benefits or severance pay?
______
______
____________
6.
Now receive or expect to receive child support?
______
______
____________
7.
Entitled to child support that he/she is not now receiving?
______
______
____________
8.
Now receive or expect to receive alimony?
______
______
____________
9.
Have an entitlement to receive alimony that is not currently being received?
______
______
____________
10. Now receive or expect to receive public assistance or welfare?
______
______
____________
11. Now receive or expect to receive Social Security or disability benefits?
______
______
____________
12. Now receive or expect to receive income from a pension or annuity?
______
______
____________
13. Now receive or expect to receive regular contributions from organizations
or from individuals not living in the unit?
______
______
____________
14. Other (list) : ________________________________________________
______
______
____________
HOUSEHOLD ASSETS (All information will be verified by a third party)
DO YOU HAVE MONEY HELD IN:
1. Checking Accounts?
2. Savings Accounts?
3. Stocks?
4. Capital Investments?
5. Bonds?
6. Trust?
7. Securities?
8. IRA/KEOGH Accounts?
9. Certificates of Deposit?
10. Pension/Retirement Funds?
YES
______
______
______
______
______
______
______
______
______
______
3
NO
______
______
______
______
______
______
______
______
______
______
CURRENT
BALANCE
__________
__________
__________
__________
__________
__________
__________
__________
__________
__________
HOUSEHOLD ASSETS (All information will be verified by a third party) continued
11. Money Market Funds?
12. Treasury Bills?
13. Other (list)? __________________________________________
______
______
______
______
______
______
__________
__________
__________
YES
NO
BALANCE
Do you currently hold a contract for deed?
______
______
__________
Do you currently own real estate?
______
______
__________
If yes, please list the location(s), number of acres owned, any expenses incurred (i.e., taxes, insurance) and any income received:
________________________________________________________________________________________________________________
Do you have any coin collections, antique cars, gems/jewelry, stamps or any other items held for investment purposes (do not consider
wedding rings and personal jewelry)?
______
______
__________
Are any assets held jointly with another person?
______
______
__________
If yes, list person’s name and the asset(s) held jointly: __________________________________________________________
I/We hereby certify that I/We Have _____ have not _____ sold or disposed of any assets for less than fair market value during the two year
(24 month) period preceding the date of this application. Any assets sold or disposed of for less than fair market value is subject to
identification and verification.
HOUSEHOLD ALLOWANCE INFORMATION (All information will be verified by a third party)
All or part of your household’s expenses may be allowable as a deduction from your annual income. Eligible expenses include child care
costs, payments on outstanding medical insurance premiums, cost of assistive devices, cost of attendant care, and any other medical and dental
costs NOT covered by an outside source: e.g. insurance, Medicare, state agency, or charitable organizations.
MONTHLY
DO YOU EXPECT TO INCUR ANY OF THE FOLLOWING EXPENSES:
YES
NO
AMOUNT
1. Child care which enables you or another household member to work, go to
school or seek employment?
______
______
____________
2. Attendant care for a handicapped or disabled household member, so that an adult
household member can work, seek employment or go to school?
______
______
____________
3. Medicare premiums?
______
______
____________
4. Other medical insurance premiums?
______
______
____________
Name of Company _________________________________________
5. Outstanding medical bills on which you are currently paying?
______
______
____________
6. Cost of assistive devices for a handicapped or disabled household member?
______
______
____________
7. Do you receive medical assistance through the County or State?
______
______
____________
8. Do expect to have any additional medical expenses during the next twelve months? ______
______
____________
If yes, please explain: __________________________________________________________________________________________
4
MISCELLANEOUS
1.
Are you attending college?
_____ Yes
_____ No
_____ Full Time
_____ Part Time
2. Have you or any members of your household ever been convicted of a felony or misdemeanor other than a traffic violation?
_____ Yes
_____ No
3. Drug related criminal activity _____ Yes
_____ No
4. Are you or any household member a registered sex offender? ______ Yes ______ No
If answered yes for questions 2, 3 and/or 4 please explain and list the states of conviction and/or registration:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Please list all of the states you and all household members have resided in:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
SIGNATURES
I/We understand the information in this application will be used to determine eligibility for housing assistance and that this information will be
verified. I/We understand that any false information may make me/us ineligible for a unit.
I/We certify that all information given in this application is true, complete and accurate. I/We understand that if any of this information is
false, misleading or incomplete, management may decline our application or, if move-in has occurred, terminate our lease agreement.
I/We authorize management to make any and all inquiries to verify this information, directly or through information exchanged now or later
with rental and credit screening services, and to contact previous and current landlords or other sources for credit and verification information
which may be released to appropriate federal, state or local agencies.
If my/our application is approved and move-in occurs, I/we certify that only those persons listed in this application will occupy the unit, that it
will be my/our only residence, and that there are no other persons for whom I/we have, or expect to have, responsibility to provide housing.
I/We agree to notify management in writing regarding any changes in household address, telephone numbers, income and household
composition.
Applicant’s Signature _________________________________________________
Date__________________________
Co Applicant Signature ____________________________________________________
Date _________________________
INCOMPLETE APPLICATIONS WILL BE RETURNED AND NOT PROCESSED
DO YOU HAVE A LEGAL GUARDIAN, CONSERVATOR OR POWER OF ATTORNEY?
_____ Yes
_____ No
IF YES, ATTACH A COPY OF LEGAL DOCUMENTATION.
5

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