Senior Apartment Application Brothers of Mercy Senior Apartment ApplicationName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Apartment Number*Phone*Email* Head of HouseholdName* First Last Social Security Number*Date of Birth* MM slash DD slash YYYY Co - Head of HouseholdName* First Last Social Security Number*Date of Birth* MM slash DD slash YYYY Apartment SizeSelect one or two sizes. Household must meet applicable occupancy standards.Apartment Size* 1 bedroom Suite (individual) 1 bedroom (1-2 persons) Special Requirements* i.e., immediate occupancy, 1st floor only, near the elevator, etc.Copies of proof of income (social security award letter, paystub, pension award letter, annuity monthly statement, alimony statement, and/or any other income sources) MUST be included with application.Monthly Wages: $* Monthly Social Security: $* Monthly Pension: $* Monthly Annuities: $* Copies of Proof of Income.Max. file size: 64 MB.Veterans Admission Preference:Attach DD-214 to qualify for admission preference.* Veterans Admission Preference In recognition of their service, Veterans' applications are given priority review for placement on our wait list. If head or co-head of household is an honorably discharged veteran or surviving spouse (not ex-spouse) of an honorably discharged veteran in the US Armed Services, please check boxPlease attach DD-214Max. file size: 64 MB.Referral Source:* How did you hear about us?Certification:The above information is correct to the best of my knowledge. I have no objection to inquiries of credit, criminal and sexual offender registries and I agree to furnish all required documentation at the time I am offered an apartment. I understand the at the time, a $20 fee for a credit and background check must be submitted, unless I can provide Brothers of Mercy Senior Apartments with a copy of a completed background and credit check conducted within 30 days prior of the request.Completed Background CheckMax. file size: 64 MB.Has applicant contracted with a placement agency?* Yes No If yes, please list name of agency & contact information*(*Please note that Brothers of Mercy is not contracted with any third party referral agencies. Under no circumstances will any Brothers of Mercy facility pay a referral fee for placement of any resident at any Brothers of Mercy facility.)Housing Company Use Only*Application Date (date original application stamped received):Housing Company Use Only* Monthly IncomeI ATTEST* Yes no I hereby declare that all statements made herein are true according to the best of my knowledge and belief. In witness whereof. I have hereunto set my hand to this application.