KARTAY APARTMENT MANAGEMENT
USDA Application Form

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Please fill in all of the information and click 'Submit' at the bottom. If you have any questions, Contact Us.


If you'd prefer to print out the application and deliver it to us at 302 1st Street East, in Independence, Click Here.

NOTE: Before filling out the form, you must read the USDA Rural Rental Housing and Community Programs information.

You must fill in all information that applies to you.

Town Preference:

List all persons who will occupy the apartment:
Last Name: First Name: M.I. Social Security Number: Date of Birth: Age:
1.
2.
3.
4.

Present Address:
How Long: Home Phone Number:
Landlord's Name:Phone Number:
Landlord's Address:

List all sources of income to the household:
Applicant's Income Source(s):
Estimated Annual Income: $
Co-Applicant's Income Source(s):
Estimated Annual Income: $

Income from assets: $
(Please complete asset statement further down below)
Total Gross Income: $
Deductions-Child Care Expenses: $/year. Medical Expenses After Insurance: $/year

Have you ever been convicted of a felony or any drug charges?
Yes
No
If so, explain below:


Are you a smoker?
Yes
No

I / We certify this apartment will be my / our permanent residence.
I / We do not maintain a separate subsidized rental unit in a different location.
I / We posess capacity to enter into a legal contract.
I / We certify that the above information is true and complete to the best of my / our knowledge.
I / We authorize inquiries to be made to verify the statements above.


Date: Electronic Signature (Your name):
Date: Electronic Signature (Your name):

If you are less then 62 years old, are you eligible for occupancy based on your status as an individual with handicaps or disabilities?
Yes
No

Do you wish to have priority for an apartment with special design features for persons with diabilities (if available at this complex)?
Yes
No

Do you wish to claim a $400.00 deduction from your income based on a disabling condition?
Yes
No

ln accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA's TARGET Center at (202) 720- 2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint filing cust. html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (l) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for civil Rights, 1400 Independence Ave. SW, Washington, D.C. 20250-9410: (2) fax: (202) 690-7442: or (3) email: program.intake@usda.gov. "This institution is an equal opportunity provider".

Ethnicity: Race: Gender:
Hispanic or Latino White Male
Not Hispanic or Latino Black or African American Female
Am. Indian/Alaska Native
Asian
Native Hawaiian or Other Pac. Islander

IF THIS SECTION IS NOT COMPLETED, THE APPLICATION WILL NOT BE REVIEWED
Current Landlord:
Name:
Address: City:
Home Phone: Work Phone:

Previous Landlord:
Name:
Address: City:
Home Phone: Work Phone:

Personal Non-Related References:
Name:
Address: City:
Home Phone: Work Phone:

Name:
Address: City:
Home Phone: Work Phone:

ASSETS STATEMENT

Assets
A.
Net Case Value
B.
Annual Income
1. Real Estate Owned:

Description-house, farm, # of acres, etc.
  A. Gross value minus selling cost
  B. Actual verified income
$ $
2. Contract Held or other notes receivable:
  A. Unpaid Balance
  B. Interest portion of payments
$ $
3. Bonds:
  A. Actual cash value today
  B. Interest earned each year
$ $
4. Stocks:
  A. Cash Value
  B. Actual verified income including dividends
$ $
5. IRA's and other retirement accounts
  A. Current balance
  B. Interest earned each year
$ $
6. Money Market Accounts & CD's
  A. Current Balance
  B. Actual interest earnings
$
$
$
$
7. Cash on hand
  A. Amount currently on hand
  B. Value
$ $
8. Checking account
  A. Current balance
  B. Interest earnings
$
$
$
$
9. Savings account
  A. Current balance
  B. Interest earnings
$ $
10. Cash value life insurance
  A. Current balance
  B. Actual verified income including dividends
$ $
11. Revocable trusts
  A. Current balance/value
  B. Actual verified income
$ $
12. Business assets where tenant is NOT
actively engaged in business:
  A. Gross value minus selling costs - debts or expenses
  B. Actual verified income
$ $
13. Business or houshold assets disposed of in the past two (2) years:
  A. Market value - Sales price expenses
$
14. All other: $ $
ADD TOGETHER ONLY POSITIVE NET VALUES FOR TOTAL
(Negative amount = zero)
$ $
TOTAL ACTUAL VERIFIED INCOME FROM ASSETS $ $

I / We certify that all assets, income producing or otherwise, except for necessary items of personal property such as furniture and automobiles, are listed above. I / We understand that this informaiton is necessary for computing our income.

Tenant's Electronic Signature
(Your Name)
Co-Tenant's Electronic Signature
(Co-Tenant's Name)
Date

*Assets are valued at "NET Cash Value" to impute income. Therefore, you are allowed to deduct selling expenses, etc., even if you do not plan to sell in order to arrive at a cash basis.


I / we understand that KarTay Apartment Management must verify all information prior to housing and that its staff may contact any agencies, offices, groups, or organizations to obtain any information or materials which it deems necessary to complete my / our application.

Electronic signature of applicant(s):
Date:
Email Address: