Elizabeth Drewry Apartment Application

Contact info

69 Wyoming Street, Welch, WV 24801 +304-436-6367 info@shedhousing.org Office Hours: 8AM - 5PM Monday-Friday

Elizabeth Drewry Apartment Application

Applicant and Family Information

Name

Relationship

Birthdate

Social Security Number

Name

Relationship

Birthdate

Social Security Number

Name

Relationship

Birthdate

Social Security Number

Name

Relationship

Birthdate

Social Security Number

Name

Relationship

Birthdate

Social Security Number

Will a live-in attendant be a household member?

Yes No

Applicant Employment Information

Please select YOUR current employment status (Check all that apply):

Employer:

Address:

City:

State:

Zip Code

***If employed by current employer less than (six) 6 months, give name and address of previous employer.

Previous Employer:

Previous Employer Address:

Previous Employer City:

Previous Employer State:

Previous Employer Zip Code

Co-Applicant Employment Information

Please select YOUR current employment status (Check all that apply):

Co-Applicant Employer:

Co-Applicant Employer Address

Co-Applicant Employer City:

Co-Applicant Employer State:

Co-Applicant Employer Zip Code:

***If employed by current employer less than (six) 6 months, give name and address of previous employer.

Co-Applicant Previous Employer:

Co-Applicant Employer Address

Co-Applicant Previous Employer City:

Co-Applicant Pevious Employer State:

Co-Applicant Previous Employer Zip Code:

Income Information

***Please indicate each source of income that any member of your household (18 years of age or older) receives or anticipates receiving in the next twelve (12) months as specified below:

Employment

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Social Security/SSI

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Disability

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Unemployment

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Child Support/Alimony/Family Maintenance

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Pension/Annuities

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Public Assistance/TANF

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Educational Grants/Scholarships

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Severance Pay

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Net Business Income

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Military Compensation

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Income from Temporarily Absent Family Members

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Income from Persons Permanently Confined to Nursing Home, etc

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Worker's Compensation

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Recurring Gifts/Contributions

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Lottery Payments (Periodic)

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Rental Income

Household Member

Yes No

Amount Received

Date Mailed

Date Received

VA Benefits

Household Member

Yes No

Amount Received

Date Mailed

Date Received

Asset Information

***Please list all assets held by household members (18 years or older):

-----Checking Account -----

Household Member

$ Value

Date Mailed

Date Returned

-----Savings Account -----

Household Member

$ Value

Date Mailed

Date Returned

-----Safe Deposit Box -----

Household Member

$ Value

Date Mailed

Date Returned

-----Cash Kept at Home -----

Household Member

$ Value

Date Mailed

Date Returned

-----Trust Account -----

Household Member

$ Value

Date Mailed

Date Returned

-----Land Contract -----

Household Member

$ Value

Date Mailed

Date Returned

-----Real Estate Property Assets -----

Household Member

$ Value

Date Mailed

Date Returned

-----Stocks/Bonds -----

Household Member

$ Value

Date Mailed

Date Returned

-----Treasury Bills -----

Household Member

$ Value

Date Mailed

Date Returned

-----CD/Money Markets -----

Household Member

$ Value

Date Mailed

Date Returned

-----IRA/Keough -----

Household Member

$ Value

Date Mailed

Date Returned

-----Assets disposed of in the past 2 years sold for in excess of $1000 less than Fair Market Value -----

Household Member

$ Value

Date Mailed

Date Returned

-----Pension Annuities -----

Household Member

$ Value

Date Mailed

Date Returned

-----Personal Property held as an Investment -----

Household Member

$ Value

Date Mailed

Date Returned

References

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