RENTAL APPLICATION

AFFORDABLE COMMUNITIES

The Lofts @Clifford Brown Walk

1320 Clifford Brown Walk
19801Wilmington, DE
PH: (302)656-5599

The Lofts @ Clifford Brown Walk This community does not discriminate based on race, color,
creed, religion, sex, national origin, ancestry, age, handicap or disability of any person, familial
status, the use of a guide or support animal because of the physical handicap of the user or
because the user is a handler or trainer of support or guide animals or because of the handicap or
disability of an individual with whom the person is known to have a relationship or association.
_Lofts@ Clifford Brown Walk strictly adheres to these anti-discrimination laws and the Owner
agrees that this property will be listed, shown, leased and managed in accordance with these laws.

INSTRUCTIONS FOR THE HEAD OF HOUSEHOLD

1. Please do the following while completing this application:
• Complete all sections in ink ( please print)
• Please do not leave any section blank ( including sections that do not apply to you. If a
section asks for information you do not have currently available, you may write N/A for:
not applicable or not available.
• When making corrections (1) put one line through incorrect information (2) write the
correct information (3) initial the change
2. As head of household, you will complete this rental application form on behalf of your entire
household. However, each Additional adult household member 18 years-of-age or old who is
expected to live in the apartment must sign this rental Application.
3. False, incomplete or misleading information will cause your household’s application to be
declined.
4. As long as your active application is on file with us, it is your responsibility to contact us whenever
your address, telephone number, or income situation changes and whenever you need to add a
person to your application or remove a person from your application.

APPLICATION PROCESSING

1. All applications will be processed in accordance with the procedures outlined the Community
Resident Selection Criteria. A copy of the Resident Selection Criteria is available upon request;
otherwise a copy is available for viewing in the management office.

2. A preliminary determination of your household’s eligibility will be established after your application
is Accepted. If your household meets the preliminary eligibility requirements, your application will
be placed on Our Community Waiting List. However, this does no guarantee that your household
will be offered an apartment.

3. In the event you fail to respond to an application update request within the specified time frame,
your application will be removed from the Community Waiting List and determined inactive. The
reactivation of applications may be granted if the household meets the exceptions outlined in the
Community Resident Selection Criteria.

4. When management anticipates an expected vacancy, applicants with active applications on file
will be contacted in order of date and time for an in person eligibility interview. All adult members
 of your household are required to attend the eligibility interview. In the event your household does
not meet the final eligibility requirements your application will be declined.
*There is a $25.00 screening fee at the time of application, payable to “Lofts @ Clifford
Brown Walk” by MONEY ORDER ONLY. CASH IS NOT ACCEPTED
Date: ____________________
02/28/2024 RENTAL
Time: ____________a.m./p.m.
1;09 APPLICATION
Received by: ______________ AFFORDABLE
COMMUNITIES
CONTACT INFORMATION (CURRENT)
CELL
PHONE
FIRST NAME HEAD OF LAST NAME HEAD OF MI HOME PHONE WORK/ MESSAGE
NUMBER
HOUSEHOLD HOUSEHOLD NUMBER NUMBER
Traya. Pipkin N 3026880756
CURRENT STREET ADDRESS CITY STATE ZIP CODE
3105 West Second St Wilmington DE 19805
MI CELL
PHONE
FIRST NAME CO-HEAD LAST NAME CO-HEAD HOME PHONE WORK/ MESSAGE
NUMBER
NUMBER NUMBER
CURRENT STREET ADDRESS CITY STATE ZIP CODE
Text
Household Composition
List all persons, including yourself, who are expected to reside in the unit. NOTE: The number to left indicates the “Family
Member Number” and is the number requested in the remaining sections of this application. * Enter “E” for elderly or “D”
for disabled.
Full Name Relation- Gender Elderly/ AGE DOB Social Occupation Student
ship Disabled Security Status
Number Y N
M/F/
Prefer
not to
disclose
Head of
Traya Pipkin Household F. 22 08/18/2001.
222-94-3356 warehouse
1. worker. n
Amari Coleman. daughter. f. 2 11/19/21 878-86-9492
2.
3.
4.
Is any member of your household a member of the Armed Forces or Reserves? [ ] Yes [ ] No
Is any member of your household in the process of enlisting into the Armed Forces or Reserves? ] No
Is there anyone not listed on your rental application living in your unit or residing in your household [ ] No on
a temporary basis?
If not, do you expect anyone to move-in on a regular or temporary basis in the future? [ ] No
Is anyone member of your household fleeing from domestic violence? [ ] No
PROGRAM ELIGIBILITY
[ ] Yes [ ] No
o [ ] Yes [ ] No
[ X ] No owner preference applicable at the community

Is your household displaced? [ ] Yes [ ] No

Definition:

Displaced Family A family in which each member, or whose sole member, is a person displaced by governmental
action, or a person whose dwelling has been extensively damaged or destroyed as a result of a
disaster declared or otherwise formally recognized pursuant to federal disaster relief laws
[24 CFR 5.403]
Displaced Person A person displaced by governmental action, or a person whose dwelling has been extensively damaged
or destroyed as a result of a disaster declared or otherwise formally recognized pursuant to federal relief
laws. [24CFR 5.403]
SOCIAL SECURITY NUMBER

Information from applicants who were age 62 or older as of January 31, 2010, and who do not have a SSN, if they were
receiving HUD rental assistance at another location on January 31, 2010. This information is needed in order for the owner
to verify whether the applicant qualifies for the exemption from disclosing and providing verification of SSN. Does this apply
to you? [ ] Yes [ ] No
MISCELLANEOUS
Do you own a pet? [ ] Yes [ ] No If yes: Cat___ Dog____ Other_____________
If this property has a NO PETS POLICY, would you be willing to give up your pets(s) in order to reside here?
[ ] Yes [ ] No

How did you hear about our apartment community? [ ] newspaper; [ ] Internet search [ ] friend/family [ ]
[ ] Other—specify ____________________________________________

EMERGENCY CONTACT
NAME RELATIONSHIP ADDRESS PHONE NUMBER
 STUDENT STATUS
Under Section 8 of the U.S. Housing Act of 1937 certain households with students are ineligible for occupancy at our community. We

therefore require all applicants and residents upon certification/ re-certification, to answer the following questions regarding student status.

Exemption #1 —The HUD student rule is only applicable to applicants applying to communities for which they are requesting
Section 8 ( subsidy) assistance.

Exemption #2—Students with disabilities that were receiving Section 8 (subsidy) assistance as of November 30, 2005 are exempt
from the Student Status requirements under Section 8. However, students with disabilities receiving assista nce as of December
1, 2005 are subject to the following Student Status requirements under the Section 8 program.

Answer questions below for all adult household members 18 years of age and older

1. How long have you and/or any other adult household members established a household separate from your/their parents or legal

guardian? ____________________

2. Are you or any other adult household member a Full -time or Part-time student? [ ] Yes [ ] No
3. Are you or any other adult household member under the age of 24? [ ] Yes [ ] No
4. Are you or any other adult household memb er currently a student of an institution
of higher education? [ ] Yes [ ]
No

5. Are you or any other adult household member a veteran? [ ] Yes [ ] No

6. Are you or any other adult household member married? [ ] Yes [ ] No
7. Do you or any other adult household member have a dependent child(ren)? [ ] Yes [ ] No
8. Is one or both of your parents, or any other adult household member’s parent(s)

currently receiving Section 8 assistance? STUDENT STATUS [ ] Yes

[ ] No
9. Are you or any other adult household member claimed as a dependent by your/their
Parent(s) or legal guardian pursuant to IRS regulations? [ ] Yes [ ] No

If yes:
Mother/Guardian Name ______________________________________

Address____________________________________________________Phone___________________
Father/Guardian Name_______________________________________

Address___ _________________________________________________Phone___________________

10. Please provide the name and address of the educational institution or agency that can confirm your current Student

status:

__________________________________________________________ _________________________________

Name of college/university Address Phone

RENTAL HISTORY
List landlord rental history for the past 2 years. History must include all places where you and/or any adult household member
18 years and older lives, lived, and places where you, and /or where other adult household members lived but did not appear
on the lease. Also include places where you or other adult household members used a different name.
NOTE: Use the family member numbers from the HOUSEHOLD COMPOSITION TABLE. If you need more space,
please use a blank sheet of paper.
• If any household member has used a different name during residency of a current or prior landlord list
names used:
_______________________________ ____________________________

_______________________________ ____________________________

FAMILY CURRENT/ ADDRESS PHONE RENT REASON Dates

MEMBER PREVIOUS LANDLORD NUMBER FOR
number
Of
LEAVING Residency
From To

Out-of-state rental history:

List all out-of-state landlords and addresses where you, and/or any other adult (18 years of age or older) have resided
or currently reside and places where you and/or other adult members did not appear on the lease. Also include
places where your or other adult household members used a different name. NOTE: Indicate family member number
from your household composition. If you need more space please use a blank sheet of paper.
FAMILY CURRENT/PREVIOUS LANDLORD FAMILIES PHONE MONTHLY REASON DATES
MEMBER & ADDRESS PREVIOUS # RENT FOR OF
NUMBER ADDRESS LEAVING RESIDENCY
FROM TO
INCOME:

EMPLOYMENT ONLY: List all full-time, part-time and/or seasonal employment for ALL household members including
self-employed earnings. If you have income from “other sources” see next section.

Family Place Of Employment Employer's Supervisor Annual

Member Employment Address Phone income
# Number (Yearly
total)

INCOME FROM OTHER SOURCES:

List ALL income from sources other than employment for ALL household members. This includes but is not limited
to public assistance, Social Security, SSI Disability Compensation, Unemployment Compensation, alimony, child
support, educational grants or scholarships etc.

Family Source of income Address of source of income /Contact Person Estimate

member # and phone # Of annual
income

ASSETS:

CHECKING/SAVINGS ACCOUNTS
 Family Indicate Account Bank Name Bank Address Current Current
Member Type number Balance Rate Of
# Of account interest
Checking/
Savings etc.

CASH ON HAND:

Current Amount
Cash on hand

$_____________
Please indicate the amount of cash your household currently has on hand

ASSETS CONTINUED; STOCKS, BONDS, CREDIT UNION SHARES, CD’S, LIFE INSURANCE POLICIES SURRENDER
VALUES ETC.
FAMILY DESCRIPTION OF ASSET/ACCOUNT # ( i.e. C.D. #0045609) Current Annual
MEMBER Value of Income from
# Asset asset

*If more space is needed, please list on separate sheet of paper and attach to this application

ASSETS CONTINUED:
Do you have any life insurance policies that have a surrender value: [ ] Yes [ ] No If
so, what is the total surrender value of the policies? $______________

REAL ESTATE:

Do you now own real estate? [ ] Yes [ ] No

If yes, are you receiving any income from this property? [ ] Yes [ ] No If
yes, complete the following:

LOCATION OF PROPERTY (IES) ANNUAL INCOME FROM PROPERTY (IES)

___________________________________________ $______________________
___________________________________________ $______________________

Have you or any member of your household sold or given away any real estate property or any other assets in the
past 2 years?
If yes, explain
_________________________________________________________________________________________

AUTOMOBILES AND OTHER VEHICLES:

List all motor vehicles, including motorcycles owned or registered to household members

Family Make & Model # Year License tag number State Color of vehicle
Member
#

MEDICAL EXPENSES:

MEDICAL EXPENSES APPLY ONLY FOR HOUSEHOLD WHERE THE HEAD OF HOUSEHOLD, SPOUSE, OR CO-HEAD
IS 62 YEARS OR OLDER, OR DISABLED.
List all applicable medical expenses including outstanding insurance premiums, prescriptions, co-payments, dental
cost (not covered by insurance), payments to a provider for adult disability care, etc. (If more space is needed please
list on a separate sheet and attach to this application.
Family Description of expense Paid to Address Cost per
Member month
Number

MEDICAL EXPENSES CONTINUED:

ONLY ELDERLY AND/OR HOUSEHOLDS WITH PERSONS WITH DISABILITIES ONLY ( HEAD, SPOUSE, OR CO-HEAD)

Please answer the following questions about yourself and all members of your household who will occupy unit.

1. Do you have Medicare? [ ] Yes [ ] No

If yes, what is your monthly payment? $____________ If yes, what Medicare do you have? ______________________

If yes, what is your annual deductible? $___________

2. Do you have any other kind of medical insurance? If yes, provide the following information:

Policy #_________ Company name_________________________ Agents name__________________________

Premium amount: $__________ per [ ] week [ ] month [ ] Other________________

3. Do you receive medical assistance through the Public Assistance Program? [ ] Yes [ ] No

Do you have any outstanding medical bills on which you are currently paying? [ ] Yes [ ] No

4. Do you expect to have any medical expenses during the next 12 months? [ ] Yes [ ] No

If yes, state the type and amounts of these medical expenses anticipated:

_________________ $________ ___________________ $__________

_________________ $________ ___________________ $__________

CHILD CARE/ ATTENDENT CARE EXPENSES

List all household members that require child or attendant care. Indicate out of pocket cost per month.
[HOURS PER DAY]
FAMILY AGE PROVIDER'S ADDRESS & PHONE NUMBER COST
MEMBER PER
NUMBER MONTH
SUN MON TUES WED THU FRI SAT

$
Is the child or attendant care paid by an agency or individual other than an adult household member? [ ] Yes [ ] No

Is the child/attendant care paid out of pocket on a weekly basis or monthly basis? Circle one: Weekly Monthly
CRIMINAL SCREENING:
A CRIMINAL BACKGROUND CHECK WILL BE COMPLETED ON ALL ADULT MEMBERS OF THE APPLICANT'S FAMILY
(18 YEARS AND OLDER). THE RESULTS OF THIS CHECK WILL BE THE BASIS FOR REJECTION IF ANY OF THE
FOLLOWING IS FOUND:
Any household containing a member(s) who was evicted in the last 3 years from Federally Assisted Housing for drug-related criminal activity.
There are 2 exceptions for this provision: (1) The evicted household member has successfully completed an approved, supervised drug
rehabilitation program or (2) The circumstances leading to the eviction no longer exist ( e.g. the household member no longer resides with the
applicant's household). These questions apply to all household members:
CRIMINAL SCREENING QUESTIONS YES NO
 (1) Are you or any members of your household currently using an illegal controlled substance?

(2) Have you or any member of your household ever been convicted of a violent crime? If
yes, please explain

(3) Have you or any member of your household ever been convicted of possession usage, or distribution
of a controlled illegal substance? If yes, please explain:

(4) Have you or any member of your household ever been convicted of possession of an unregistered
firearm or possession of an illegal weapon that can cause physical harm or emotional suffering by
intimidation?
If yes, please explain:

(5) Have you or any other adult members ever used a name(s) or Social Security number(s) other than
the one you are currently using? If yes, please explain:

(6) Have you or any member of your household ever committed any fraud in a Federally-assisted housing
program or been evicted from any Federally assisted housing development for drug related criminal
activity? If yes, explain:

(7) Have you or any member of your household ever been convicted of or pleaded guilty to a felony?

(8) Have you or any member of your household ever been convicted of or pleaded guilty to a sexual
offense AND/OR are you or any member subject to a lifetime registration requirement under a state sex
offender registration program?

(9) Do you or any member of your household abuse alcohol, or have a pattern of abuse of alcohol that
would interfere with the health, safety, and/or right to peaceful enjoyment of the premises by the other
residents?

(10) If the answer to question 9 above is yes, is the household member currently enrolled in or has
completed an approved supervised alcohol rehabilitation program?

(11) Are you or any member of your household currently engaged in any form of criminal activity
(including drug related criminal activity) that would threaten the health, safety or right to peaceful
enjoyment of the premises by other residents and their guests?

(12) Have you or any member of your household ever engaged in criminal activity that would threaten the
health or safety of other residents, the owner or any employee, contractor, subcontractor or agent of the
owner who is involved in the housing operations?

(13) Have you or any member of your household ever lived in any other state? If yes, which members
and which states did you or other members reside in?

(14) Have you or any member of your household ever been convicted or plead guilty to “no
contest” to any felony? If yes to any of the above questions, please explain providing location,
date and nature of the offense:
Location Date Nature of offense

__________ ____ ____________________________________________________

__________ ____ ____________________________________________________

WARNING: 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 and any owner (or any employee of HUD or the owner) may be subject to penalties
for unauthorized disclosures or improper use 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 willingly 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number
are contained in the Social Security Act at 42 U.S.C. 208(f) (g) and (h). Violation of these provisions are cited as violations of 42 U.S.C. 408 (f) (g) and (h).

STATEMENTS BY ALL ADULT HOUSEHOLD MEMBERS

(1) We certify that all information given in this application and any addenda thereto is true, complete and accurate. 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
rental agreement.

(2) We authorize Lofts @ Clifford Brown Walk to make any and all inquiries to verify this information either directly or through
information exchanged now or later with rental, credit screening services or criminal screening services and to contact previous and current
landlords or other sources for credit and verification confirmation which may be released to appropriate Federal, State or local agencies.

(3) If our application is approved and move-in occurs we certify that only those persons listed in this application will occupy the
apartment , that they will maintain no other place of residence and that there are no other persons for whom we have or expect to have
responsibility to provide housing.

(4) We agree to notify management in writing immediately regarding any changes in household address, telephone numbers, income
and household composition.

(5) We have read and understand the information in this application, in particular, the information contained in the Instructions for Head
of Household; and we agree to comply with such information.

(6) We have been notified that the Resident Selection Criteria which summarizes the procedures for processing applications are posted
in the management office.

(7) We understand that if this application is placed on a waiting list, we may request sample copies of the Rental Agreement and House
Rules. If this application is approved, and move-in occurs, we certify that we will accept and comply with all conditions of occupancy as set
forth therein including specifically all conditions regarding pets, damages, and security deposits.

(8) We authorize management to obtain one or more “consumer reports” as defined in the Fair Credit Reporting Act, 15 U.S. C. Section
1681a (d); seeking information on our credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics
or mode of living.

FAIR CREDIT REPORTING ACT

THIS IS TO INFORM YOU THAT AS PART OF OUR PROCEDURE FOR PROCESSING YOUR APPLICATION, AN INVESTIGATIVE
REPORT MAY BE MADE WHEREBY INFORMATION IS OBTAINED THROUGH PERSONAL INTERVIEWS WITH THIRD PARTIES—
SUCH AS FAMILY MEMBERS, BUSINESS ASSOCIATES, FINANCIAL SOURCES, FRIENDS, NEIGHBORS OR OTHERS WHO ARE
ACQUAINTED WITH YOU. THIS INQUIREY INCLUDES INFORMATION AS TO YOUR CHARACTER, GENERAL REPUTATION,
PERSONAL CHARACTERISTICS, MODE OF LIVING, INCOME AND CREDIT BACKGROUND AS WELL AS POLICE RECORDS. ALL
INFORMATION YOU OR OTHERS GIVES US WILL BE HELD IN STRICT CONFIDENCE.

WE DO NOT DISCRIMINATE ON THE BASIS OF RACE, RELIGION, NATIONAL ORIGIN, COLOR, CREED, AGE, SEX, HANDICAP, OR
FAMLIAL STATUS.

BY SIGNING THIS APPLICATION, YOU DECLARE THAT ALL OF YOUR RESPONSES ARE TRUE AND COMPLETE AND AUTHORIZE
THE OWNER/MANAGER TO VERIFY THIS INFORMATION THROUGH ANY SOURCE DEEMED APPROPRIATE. ANY FALSE
STATEMENTS ON THIS APPLICATION WILL BE GROUNDS FOR REJECTIONS OF YOUR APPLICATION.
I/WE HAVE READ AND UNDERSTAND THE ABOVE:

__________ ________________________________ ________________________________________

DATE APPLICANT'S NAME (PRINT) APPLICANT'S SIGNATURE

__________ ________________________________ ________________________________________ DATE

APPLICANT'S NAME (PRINT) APPLICANT'S SIGNATURE

__________ ________________________________ ________________________________________ DATE

APPLICANT'S NAME (PRINT) APPLICANT'S SIGNATURE

_________ ________________________________ ________________________________________ DATE

APPLICANT'S NAME (PRINT) APPLICANT'S SIGNATURE

HOUSEHOLD COMPOSITION CONTINUED:

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 & residents. You are not required to
answer the questions below, nor does your answer affect your position on our waiting list or your
eligibility for housing. As this time we are requesting this information for the head of household only.
However, at the time of the eligibility interview (if applicable) this information will be requested for each
household member.

Ethnic Categories Select

(Head of Household only) One

Hispanic or Latino

Non-Hispanic or Latino

Racial Categories Select all

that apply

American Indian or Alaska Native

Asian

Black or African American

White
 Other

IMMIGRATION STATUS
CHECK THE STATUS THAT APPLIES FOR EACH FAMILY MEMBER
FAMILY FAMILY MEMBER NAME Check Check here Check here if the family member has other
MEMBER
NUMBER here If a if a form of status and explain:
citizen or noncitizen
national with eligible
of the U.S. immigration
status

HOH ___ ___ ___

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