SCOVIL APARTMENTS
PO BOX 220
BLAINE, MAINE 04734
Phone: 207-425-3192 Fax: 207-429-8520
www.scovilapartments.com
APPLICATION FOR ADMISSION TO HOUSING
DATE:
NAME:
ADDRESS:
PHONE #:
NUMBER OF BEDROOMS NEEDED:
WHAT TOWN \ CITY DO YOU NEED HOUSING? CIRCLE CHOICE(S)
PRESQUE ISLE  MARS HILL FORT FAIRFIELD BRIDGEWATER
ARE YOU LOOKING FOR SUBSIDIZED RENT?
PRESENT MONTHLY RENT: $
THIS PART FOR OFFICE USE ONLY
DATE RECEIVED:
PLACED ON WAITING LIST:
TENANT INTERVIEWED:
TENANT SELECTED/REJECTED:
TENANT NOTIFIED:
COMPLETED:
For Rural Development Properties:� In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.� (Not all prohibited bases apply to all programs).� To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W. Washington D.C. 20250-9410 or call (800) 795-3272 (Voice) or (202) 720-6382 (TDD).
Equal Housing Opportunity
TENANT #1
NAME:       SOC. SEC. #    
AGE:       BIRTH DATE:    
AUTOMOBILE:     PLATE NUMBER:    
DRIVER'S LICENSE NUMBER:        
PRESENT ADDRESS:          
PHONE #:    
PRESENT LANDLORD NAME:        
ADDRESS:            
TELEPHONE #:     PRESENT RENT:� $  
ARE UTILITIES INCLUDED:   HOW LONG A RESIDENT:  
PREVIOUS ADDRESS:       FROM:                           TO:
PREVIOUS LANDLORD NAME:   PHONE #:  
ADDRESS:            
EMPLOYMENT
CURRENT EMPLOYER:     LENGTH OF SERVICE:
POSITION WITH COMPANY:     WEEKLY WAGES:  
COMPANY ADDRESS:       PHONE #:
PREVIOUS EMPLOYER:     LENGTH OF SERVICE:
POSITION WITH COMPANY:       PHONE #:
COMPANY ADDRESS:          
REASON FOR LEAVING:          
               
CREDIT REFERENCE
#1 COMPANY NAME:          
ADDRESS       ACCOUNT #:  
#2 COMPANY NAME:          
ADDRESS       ACCOUNT #:  
LIST CHILDREN AND DEPENDENTS THAT WILL BE LIVING WITH YOU
SEX: NAME:     SSN:     DOB:
SEX: NAME:     SSN:     DOB:
SEX: NAME:     SSN:     DOB:
LIST CHILD CARE EXPENSES:        
LIST MEDICAL EXPENSES:          
               
TENANT #2
NAME:       SOC. SEC. #    
AGE:       BIRTH DATE:    
AUTOMOBILE:     PLATE NUMBER:    
DRIVER'S LICENSE NUMBER:        
PRESENT ADDRESS:          
PHONE #:    
PRESENT LANDLORD NAME:        
ADDRESS:            
TELEPHONE #:     PRESENT RENT:� $  
ARE UTILITIES INCLUDED:   HOW LONG A RESIDENT:  
PREVIOUS ADDRESS:       FROM:                         TO:
PREVIOUS LANDLORD NAME:   PHONE #:  
ADDRESS:            
EMPLOYMENT
CURRENT EMPLOYER:     LENGTH OF SERVICE:
POSITION WITH COMPANY:     WEEKLY WAGES:  
COMPANY ADDRESS:       PHONE #:
PREVIOUS EMPLOYER:     LENGTH OF SERVICE:
POSITION WITH COMPANY:       PHONE #:
COMPANY ADDRESS:          
REASON FOR LEAVING:          
               
CREDIT REFERENCE
#1 COMPANY NAME:          
ADDRESS       ACCOUNT #:  
#2 COMPANY NAME:          
ADDRESS       ACCOUNT #:  
LIST CHILDREN AND DEPENDENTS THAT WILL BE LIVING WITH YOU IF DIFFERENT FROM TENANT ONE
NAME:       BIRTH DATE:   SEX:
NAME:       BIRTH DATE:   SEX:
NAME:       BIRTH DATE:   SEX:
LIST CHILD CARE EXPENSES:        
LIST MEDICAL EXPENSES:          
               
EMERGENCY CONTACT TENANT #1
NAME:       PHONE #:    
ADDRESS:            
EMERGENCY CONTACT TENANT #2
NAME:       PHONE #:    
ADDRESS:            
PERSONAL REFERENCES TENANT #1 AND TENANT #2 (NON RELATED)
NAME:   ADDRESS:     PHONE #:
1              
2              
3              
4              
SOURCE OF INCOME AND AMOUNT
AMOUNT TENANT #1 AMOUNT TENANT #2
SOCIAL SECURITY: $     $    
PENSIONS: $     $    
UNEMPLOYMENT: $     $    
INTEREST: $     $    
EMPLOYMENT: $     $    
WELFARE: $     $    
ALIMONY/CHILD SUPPORT: $     $    
DIVIDENDS: $     $    
OTHER:   $     $    
ALL OTHER ASSETS
AMOUNT OF SAVINGS IN BANK: $     $    
AMOUNT OF CHECKING IN BANK: $     $    
NAME OF BANK:   ACCOUNT #:        
VALUE OF STOCKS, BONDS, CERTIFICATES: $     $    
VALUE OF REAL ESTATE OWNED: $     $    
VALUE OF OTHER ASSETS: $     $    
APPLICANTS/TENANTS MUST ALSO DISCLOSE ANY ASSETS DISPOSED OF FOR LESS THEN
MARKET VALUE IN THE TWO YEARS PRECEDING THE EFFECTIVE DATE OF THE CERTIFICATION
OR RECERTIFICATION OF INCOME.� HAVE YOU SOLD ANY ASSETS IN THE LAST TWO YEARS
NOT LISTED ABOVE?� IF YOU HAVE, PLEASE PROVIDE THE FOLLOWING INFORMATION:
DESCRIPTION: MARKET VALUE: AMOUNT RECEIVED: DATE SOLD:
1   $   $      
2   $   $      
3   $   $      
ANY ASSETS LISTED AS SOLD FOR LESS THEN ACTUAL CASH VALUE IN THE TWO YEARS
PRECEDING THE EFFECTIVE DATE OF THE CERTIFICATION OR RECERTIFICATION OF INCOME
WILL BE COUNTED AS ASSETS IF THE DIFFERENCE BETWEEN THE VALUE AND THE AMOUNT
RECEIVED EXCEEDS $1,000.00.
PLEASE ANSWER YES OR NO TO THE FOLLOWING QUESTIONS

1. DO YOU OR ANY OTHER HOUSEHOLD MEMBER REQUIRE A SPECIALLY DESIGNED UNIT?

 

        

2. DO YOU OR ANY  OTHER HOUSEHOLD MEMBER REQUEST  AN ELDERLY HANDICAP OR DISABILITY ADJUSTMENT?

 

 

 

 

 

 

3. DO YOU HAVE ANY PETS?        
4. ARE YOU OR A FAMILY MEMBER A CURRENT USER OF AN ILLEGAL CONTROLLED SUBSTANCE?        
5. HAVE YOU OR FAMILY MEMBER HAD A PREVIOUS CONVICTION FOR THE USE OF AN ILLEGAL CONTROLLED SUBSTANCE?  
6. HAVE YOU OR A FAMILY MEMBER EVER BEEN CONVICTED OF THE MANUFACTURE OR DISTRIBUTION OF AN ILLEGAL CONTROLLED SUBSTANCE?  
 
IF YOU ANSERED QUESTIONS NUMBER 4 OR 5 WITH A "YES", HAVE YOU OR A FAMILY MEMBER INVOLVED, SUCCESSFULLY COMPLETED A CONTROLLED SUBSTANCE ABUSE RECOVERY PROGRAM OR ARE YOU OR THE FAMILY MEMBER PRESENTLY ENROLLED IN SUCH A PROGRAM?  
DATE APARTMENT WANTED:        
NUMBER OF BEDROOMS NEEDED:        
REASON FOR MOVING:          
I CERTIFY THAT THE UNIT APPLIED FOR WILL BE MY HOUSEHOLD'S PERMANENT RESIDENCE AND I WILL NOT
MAINTAIN A SEPARATE SUBSIDIZED RENTAL UNIT IN A DIFFERENT LOCATION.
IN ORDER THAT I MAY BE CONSIDERED ELIGIBLE FOR OCCUPANCY IN AN APARTMENT FINANCED AND
SUBSIDIZED BY (RHS) RURAL HOUSING SERVICE I HERE BY STATE THE PRECEDING INFORMATION IS A TRUE
AND COMPLETE STATEMENT OF ALL EXPECTED INCOME AND ASSETS OF ALL RESIDING IN MY HOUSEHOLD
DURING THE NEXT 12 MONTH PERIOD.� I AUTHORIZE INQUIRIES TO BE MADE TO VERIFY THE STATEMENTS
ABOVE.� BY DISREGARDING THIS RULE I RISK POSSIBLE EVICTION.
TENANT #1:            
TENANT #2:            
THIS IS ONLY AN APPLICATION, NOT A LEASE. BEFORE OCCUPANCY, ALL TENANTS MUST SIGN A LEASE.
A LEASE SIGNED BY TENANTS IS NOT VALID UNLESS ALSO SIGNED BY THE OWNER.� ANY FALSE
STATEMENTS GIVEN ON THIS APPLICATION, OR IN CONNECTION THEREWITH CAN RESULT IN THE
CANCELLATION OF A LEASE GIVEN AFTER IT HAS BEEN MADE VALID BY THE SIGNATURE OF THE OWNER.
RENT IS DUE ON THE 1ST OF EACH MONTH. IF RENT HAS NOT BEEN PAID BY THE 15TH OF THE MONTH IN WHICH
DUE, THERE WILL BE A 4% LATE FEE.� IF NOT RECEIVED AFTER THE 15TH A "NOTICE TO QUIT" WILL BE SENT.
THE INFORMATION REGARDING RACE, NATIONAL ORIGIN, AND SEX DESIGNATION SOLICITED ON THIS
APPLICATION IS REQUESTED IN ORDER TO ASSURE THE FEDERAL GOVERNMENT, ACTING THROUGH THE
(RHS) RURAL HOUSING SERVICE, THAT FEDERAL LAWS PROHIBITING DISCRIMINATION AGAINST TENANT
APPLICANTS ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, RELIGION, SEX, AND HANDICAP ARE
COMPLIED WITH.
YOU ARE NOT REQUIRED TO FURNISH THIS INFORMATION, BUT ARE ENCOURAGED TO DO SO.� THIS
INFORMATION WILL NOT BE USED IN EVALUATING YOUR APPLICATION OR TO DISCRIMINATE AGAINST YOU IN
ANY WAY.� HOWEVER, IF YOU CHOOSE NOT TO FURNISH IT, THE OWNER IS REQUIRED TO NOTE THE RACE,
NATIONAL ORIGIN, AND SEX OF THE INDIVIDUAL APPLICANTS ON THE BASIS OF VISUAL OBSERVATION OR
SURNAME.
APPLICANTS SIGNATURE:        
NATIONAL ORIGIN:   RACE:   SEX:  
CO-APPLICANTS SIGNATURE:        
NATIONAL ORIGIN:   RACE:   SEX:  
A COPY OF THE Social Security Card and Birth Certificate of every member of the household
must be enclosed when you return this application in order for the application to be processed.
MOUNTAIN VIEW APARTMENTS AND/OR SCOVIL APARTMENTS
PO BOX 220
BLAINE, MAINE 04734
Phone: 207-425-3192          Fax: 207-429-8520
This paper is an authorization for release of information, so that we may use this information and the
information obtained with it, to administer and enforce (RHS) RURAL HOUSING SERVICE rental program
rules and policies.� May also be used for non-subsidized rental applications.
I DO HERE BY AUTHORIZE
The above named organization to obtain information about me or my family that is pertinent to eligibility for or
participation under any of the following programs:� RHS Rental Assistance (RA), Assisted Housing
Programs, or to obtain information on wages or unemployment compensation from State
Employment Securities Agencies.
INFORMATION COVERED INQUIRIES MAY BE MADE ABOUT
Child Care Expenses, Family Composition, Credit History, Employment, Income, Pensions, Assets,
Criminal Activity, Federal Benefits, State Benefies, Tribal Benefits, Local Benefits, Handicapped Assistance
Expenses, Residences and Rental History, Medical Expenses, Identity and Marital Status, Social Security
Numbers.
THE RELEASE OF INFORMATION MAY BE MADE BY ORGANIZATIONS AND INDIVIDUALS
Any Government Organization, Private Organization, or Individual may be asked to release information.
Examples are:� Prior Landlords, Prior Employers, Banks and Financial Institutions, Credit Bureaus, Courts
and Law Enforcement Agencies, U.S. Social Security Administration, U.S. Department of Veterans Affairs,
Pensions and Annuities, Handicapped Assistance, Medical Care, Credit, Child Care, Child Support, Alimony,
Utility Companies, Welfare Agencies, Schools and Colleges.
I agree to the condition that photocopies of this Authorization may be used for the purposes stated above.
If I do not sign this Authorization I also understand that my housing assistance may be denied or terminated.
   
PRINTED NAME OF HEAD OF HOUSEHOLD  
   
SIGNATURE AND DATE  
   
PRINTED NAME OF SPOUSE OR OTHER ADULT MEMBER OF HOUSEHOLD        
   
SIGNATURE AND DATE