Contact info

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

First Name:
Last Name:
Date of Birth:
Email Address:
Phone Number #:
Social Security Number (or equivalent ID):
Address:
City:
State:
Zip Code:
Do You Have a Driver's License or state issued ID?
Driver's License State:
Driver's License #:
Do you have a co-applicant applying with you?
Will there be addiitional household members living in the unit or apartment?
Enter the number of additional family members:

co-applicant information

First Name:
Last Name:
Date of Birth:
Email Address:
Phone Number #:
Social Security Number (or equivalent ID):
Address:
City:
State:
Zip Code:
Do You Have a Driver's License?
Driver's License State:
Driver's License #:

Additional Household Members

Name:
Relationship to You:
Date of Birth:
Social Security #:
Name:
Relationship to You:
Date of Birth:
Social Security #:
Name:
Relationship to You:
Date of Birth:
Social Security #:
Name:
Relationship to You:
Date of Birth:
Social Security #:

Employment Information Section

Applicant Employ Information

Employment Status:
Student Status:

Applicant Employer Information

Job Title:
Start Date:
Employer:
Supervisor Name:
Supervisor Email Address:
Employer Phone #:
Address:
City:
State:
Zip Code:
Salary Amount:
Paid Per:
Have You Worked Here Less Than 6 Months?

Applicant Previous Employer Information

Previous Employer:
Address:
City:
State:
Zip Code:

Co-Applicant Employ Information

Employment Status:
Student Status:

Co-Applicant Employer Information

Job Title:
Start Date:
Employer:
Supervisor Name:
Supervisor Email Address:
Employer Phone #:
Address:
City:
State:
Zip Code:
Salary Amount:
Paid Per:
Have You Worked Here Less Than 6 Months?

Co-Applicant Previous Employer Information

Previous Employer:
Address:
City:
State:
Zip Code:

Residential History Section

Do You Rent or own Your Current Residence?
Have You Lived Here less Than 3 Years?
When Did you Move Into Your Current Residence?:
Reason For Leaving:
Did You Own or Rent Your Previous Address?
Monthly Rent Amount:
Does Your Rent Include Utilities?
Monthly Utility Cost:

Landlord Contact Information

Landlord's Name:
Landlord's Phone Number #:
Landlord's Email Address:
Landlord's Address:

Previous Rental History

Reason For Leaving:
Monthly Rent Amount:
Did Your Rent Include Utilities?
Monthly Utility Cost:

Previous Landlord Contact Information

Landlord's Name:
Landlord's Phone Number #:
Landlord's Email Address:
Landlord's Address:
Have you lived anywhere else in the last 3 years?

Previous Rental History

Reason For Leaving:
Monthly Rent Amount:
Did Your Rent Include Utilities?
Monthly Utility Cost:

Previous Landlord Contact Information

Landlord's Name:
Landlord's Phone Number #:
Landlord's Email Address:
Landlord's Address:

Additional Rental Information

Have You Ever Been Evicted From Tenancy?:
Please Explain:
Have You Ever Willfully Or Intententionally Refused To Pay rent When Due?
Please Explain:
Are You Currently Receiving Rent Assistance?
Please specify type and source:
Has your rent assistance ever been terminated for fraud, non-payment of rent, or failure to certify?
Please Explain:

Income & asset section

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 by completing the section below:

Employment:
Amount Received:
Date Mailed:
Date Received:
Social Security / SSI:
Amount Received:
Date Mailed:
Date Received:
Disability:
Amount Received:
Date Mailed:
Date Received:
Unemployment:
Amount Received:
Date Mailed:
Date Received:
Child Support / Alimony / Family Maintenance:
Amount Received:
Date Mailed:
Date Received:
Pension / Annuities:
Amount Received:
Date Mailed:
Date Received:
Public Assistance/ TANF:
Amount Received:
Date Mailed:
Date Received:
Educational Grants / Scholarships:
Amount Received:
Date Mailed:
Date Received:
Severance Pay:
Amount Received:
Date Mailed:
Date Received:
Net Business Income:
Amount Received:
Date Mailed:
Date Received:
Military Compensation:
Amount Received:
Date Mailed:
Date Received:
From temporarily absent family members:
Amount Received:
Date Mailed:
Date Received:
From persons permanently confined to Nursing Home, ETC:
Amount Received:
Date Mailed:
Date Received:
Worker's Compensation:
Amount Received:
Date Mailed:
Date Received:
Recurring Gifts / Contributions:
Amount Received:
Date Mailed:
Date Received:
Periodic Lottery Payments:
Amount Received:
Date Mailed:
Date Received:
Rental Income:
Amount Received:
Date Mailed:
Date Received:
VA Benefits:
Amount Received:
Date Mailed:
Date Received:

Asset Information

Please list all assets held by household members (18 years of age or older) below:

Checking Account:
Value Amount:
Date Mailed:
Date Returned:
Savings Account:
Value Amount:
Date Mailed:
Date Returned:
Safe Deposit Box:
Value Amount:
Date Mailed:
Date Returned:
Cash Kept At Home:
Value Amount:
Date Mailed:
Date Returned:
Trust Account:
Value Amount:
Date Mailed:
Date Returned:
Land Contract:
Value Amount:
Date Mailed:
Date Returned:
Real Estate Property Assets:
Value Amount:
Date Mailed:
Date Returned:
Stocks / Bonds:
Value Amount:
Date Mailed:
Date Returned:
Treasury Bills:
Value Amount:
Date Mailed:
Date Returned:
CD / Money Markets:
Value Amount:
Date Mailed:
Date Returned:
IRA / Keough:
Value Amount:
Date Mailed:
Date Returned:
Assets disposed of in the past 2 years sold in excess of $1,000 less than Fair Market Value:
Value Amount:
Date Mailed:
Date Returned:
Pension / Annuities:
Value Amount:
Date Mailed:
Date Returned:
Personal Property held as an Investment:
Value Amount:
Date Mailed:
Date Returned:

REFERENCE SECTION

Credit References

Reference Name:
Address:
Phone #:
Reference Name:
Address:
Phone #:
Reference Name:
Address:
Phone #:

Personal References

Reference Name:
Address:
Phone #:
Years Known:
Reference Name:
Address:
Phone #:
Years Known:
Reference Name:
Address:
Phone #:
Years Known:

Additional Information Section

Number of Occupants: *
Pets: *
Vehicles: *
Additional Comments:

Consent and Declaration Section

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Call Us

(304) 436-6367
SHED Housing

69 Wyoming Street
Welch, WV 24801
(304) 436-6367
shedhousing.org

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