Johnson County Housing Coalition, Inc
403 A W Poplar Street
Olathe, KS 66061
Phone: (913) 390-0413 * Fax (913) 390-0358
director@jocohousingcoalition.com
Rental Application
Name: Last First Middle
Date of Birth Social Security Number DL # ______________
Current point of contact:
Phone:
Phone:
Please provide a point of contact in order for us to contact you when a unit is available. Inform us if there are any changes to
the contact information.
Previous Address, Landlords Name and Phone Number:
List name(s) of all persons living with you: Relationship___ Ages Social Security Number
Name Birth date Relationship Social Security Number US Citizen
___________________ _________ ___________ ___________________ Y / N
___________________ _________ ___________ ___________________ Y / N
___________________ _________ ___________ ___________________ Y / N
___________________ _________ ___________ ___________________ Y / N
___________________ _________ ___________ ___________________ Y / N
___________________ _________ ___________ ___________________ Y / N
___________________ _________ ___________ ___________________ Y / N
Do you anticipate any other individual to be living with you within the next 12 months?
___________________ _________ ___________ ___________________ Y / N
__________________ _________ ___________ ___________________ Y / N
Notice: Persons not listed on this application will not reside with the applicant unless approved in writing by the
manager
Have any children been tested for elevated blood lead levels? YES NO
Have you recently lived in a house built before 1978? YES NO
Please identify any special needs for the household? (e.g.. hearing impaired, handicapped accessibility, vision impaired, etc.)
Have you or any members of your household ever plead guilty, been convicted or placed on probation for a crime? YES
NO______ If so, what was it for, year it occurred and where it took place? Are you now waiting on any pending court
decision or presently on probation? If yes, explain: ________________________________________________
__ ___
_ _____
______
Monthly Household Income:
Name Source Phone Amount Office use only
Total Household income:
Does the household have assets, (checking or savings accounts, certificates of deposit, stocks or bonds, IRA or other
retirement funds, Mutual Funds, Trust accounts, whole life or universal life insurance, personal property held as an investment,
real estate for sale or rent, cash in excess of $5,000, investments, pensions, annuities), or other sources of income not
included above? If so please specify in the table below
Account Name and Account Number Type or SourceDescription Value Office use only
Total Household assets:
Have you disposed of assets for LESS THAN FAIR MARKET VALUE within the past 12 months? Yes ______ No
______. If yes explain: ____________________________________.
Is the household currently receiving or does any member expect to receive any financial assistance in the next 12 months?
(Specify)
SSI Section 8 ____ Disability ____ VA Child support ___ Unemployment _____ Other _____
Has the household applied for housing assistance? YES NO
Does any member of the household that is currently unemployed expect to find employment within the next 12 months? Yes /
No
Preferences: House Duplex Apartment No preference
Proof of identification is required. (Two forms of identification are required, at least one photo ID and proof of
social security number for adults and birth certificates and proof of social security number for minors.) This
information must be provided prior to signing any lease agreement.
The Johnson County Housing Coalition is an equal opportunity housing provider. If you feel you have been unfairly treated or
been the subject of discrimination contact the HUD Fair Housing Office at 1-800-669-9777. You may also call the Executive
Director at (913) 390-0413 or the Johnson County Housing Authority at (913) 432-2174. If you have legal concerns about
this application or other landlord-tenant issues please call Kansas Legal Services (913) 621-0200 or 1-800-479-6520.
The Johnson County Housing Coalition seeks to keep its properties crime free. The Crime Free lease addendum
is available for your review prior to signing any lease agreement. I have received a copy of the Crime Free
Addendum. .
I / We understand that in accordance with HUD HOME program regulations regarding recertification, I/We will
be required to complete an annual certification within the next 12 months and each 12 months thereafter.
Providing false information on this application may be cause for termination of any lease agreement and may be cause for
eviction.
I attest that the information included in this application is true and accurate.
Name Date
Name Date