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La Salle Apartments
Pre-Application Cover Letter
For office use only
Date Application given ________
Mgr. Initials ______
___________________________________
Applicants Name
___________________________________
Applicants Phone #
___________________________________
Alternate Phone#
___________________________
Special requests/needs:
_________________________
Thank you for your interest in living in a Pike Place Market PDA owned and managed building, the La Salle Apartments.
This pre-application is a short form to enable us to preliminary assess if your household is eligible to be added to our waitlist. If
your household is eligible for our waitlist and your name became closer to the top of our waitlist, your household will be notified
and required to complete a full application packet with other attachments. Once you completed the full rental application packet
and all Department of Housing and Urban Development (HUD) required forms, we will then determine your full eligibility for a
HUD subsidized unit.
All interested individuals have the right to complete and submit an application. A background screening, which the PDA will pay
for, will be performed on all adult applicants as they get closer to the top of the waiting list. We perform a screening to
determine acceptable behavior through prior landlord rental history, criminal history, public records, and credit history (note that
poor credit history is not a major factor in application review). HUD also requires the PDA to ask and screen whether the
applicant, any member of the household, or any live-in-aid is subject to State Lifetime Sex Offender Registration in any state.
Filling out the application:
One pre-application is completed for the household. When completing the pre-application form, please allow yourself a few
minutes to read it over, then fill it out in its entirety. This should take about 5-15 minutes. Fill it out to the best of your
knowledge. Please do not leave any blank spaces and if you make a mistake, please cross-out and rather than using white out.
If a question does not apply to you, please write out the words "Not Applicable." Be sure to sign and date the pre-application.
Once you have completed and signed our pre-application form, you will need to bring or mail it to the Manager’s office.
We will advise you in writing on the status of your pre-application form within 10 days of receiving your completed preapplication.
If you need assistance in completing this form, we are happy to help you. If you have a disability and require a reasonable
accommodation related to the completion and return of the application, please feel free to request one. We will accommodate
persons with disabilities who, as a result of their disabilities, cannot read or understand our application documents or utilize our
preferred application process by providing alternative methods of taking applications. Please let us know if you need an
accommodation.
Who is Eligible to live at our Property?
La Salle Apartments requires that the head of household, co-head or spouse must be 62 years of age or older and/or with a
disability.
The occupancy and income limits for La Salle Apartments is posted at the property or you can call for information as it may vary
from year to year.
Our priority is to take the extremely low income households (below 30% median income) first in our fiscal year for up to
40% of our expected vacancies, then offer units to the applicants on our list that are either extremely very low or very
low income (below 50% median income) chronologically thereafter.
Rents at this property are HUD subsidized and are equal to 30% of your monthly adjusted income. Water, sewer,
garbage and electricity are included in your rent. There is a HUD Section 8 required minimum total tenant payment of
$25.00 per month, unless a verifiable qualifying hardship exists. Please contact the manager for details about the rent
structure at this property.
There are certain restrictions for non-citizen household members and students in HUD subsidized housing. If any of
your household members are ineligible non-citizens or students, the management will explain how this may affect you
receiving a HUD subsidy at this property. For example, if your household includes family members who do not declare
F-012015PDA - HUD Pre-application – 01/2015 – La Salle online
citizenship or non- citizenship status, or who sign a statement electing not to contend non-citizen status, your
application may be rejected. If you are denied based on our screening criteria, you will be notified in writing and given
the option to appeal the decision.
The Waiting List
We will choose applicants off of our waiting list in chronological order from the date and time they submit their
application within the income targeting and/or other criteria associated with the property and HUD. You are welcome to
request any reasonable accommodations or modifications to the units, site property policies, or procedures to
accommodate a disability. Please indicate in your application if you believe you qualify for an accommodation based
on a disability.
If you are placed on our waiting list, it is important that you update us with any changes in your household. It is very
important to tell us immediately if there are any changes in your present information such as change of address, phone
number, household size, members or income.
You will also need to contact us at least every six months to let us know that you are still interested in remaining in our
waitlist. If you do not contact us, we may send you a letter at your last known address asking for notification of your
continued interest in remaining on our waiting list. If we do not hear back from you, we may have to remove your name
from our waiting list, so please keep us informed of changes.
When an Apartment Comes Available
You will be contacted in chronological order from the top of the waiting list when a unit becomes available or 1
paperwork prior to a unit becoming available.
Once contacted by the manager, you will be required to come into the rental office to finalize your application process
within 10 days of notification. Additional information and paperwork will go with the final application packet regarding
our criteria, additional attachment, supplemental disclosure, income asset statement, documentation requirements and
others.
A final decision regarding your eligibility cannot be made until all the above information has been received, verified,
and reviewed. Once you have passed our final screening requirements and an apartment is available that meets your
needs and requirements, you will be notified to start the move-in process.
For full information about HUD Project eligibility requirements and resident criteria, you may request for a copy of our
Tenant Selection Plan (TSP) and Criteria for Residency from the Residential Manager.
If you have any questions regarding completing the property pre-application, HUD regulations and requirements,
please feel free to contact the manager.
We look forward to be of service to you.
Sincerely,
Kim Barreto
La Salle Residential Manager
Pike Place Market PDA/La Salle Apartments does not discriminate on the basis of age, race, religion, color, creed, ethnicity,
national origin, sex, familial status or individual handicaps. We also provide equal access to housing regardless of sexual
orientation and gender identity.
The Pike Place Market PDA/La Salle Apartments is an equal opportunity housing provider.
F-012015PDA - HUD Pre-application – 01/2015 – La Salle online
Pre-Application Form
for Subsidized Unit
La Salle Apartments
85 Pike St. #500, Seattle, WA 98101
Phone: (206) 774-5228 Fax: (206) 774-5295 TDD 711 (for hearing impaired)
Office Hours: Monday-Friday 9 a.m. - 3 p.m. Email: kimb@pikeplacemarket.org
Tenant and Spouse/Co-Tenant:
First Name
Last Name
Birth Date
Gender
Social Security Number
Head of Household Contact Information:
__________________________________ ___________________ _____________
___________
Mailing Address
City
State
Zip
Code
______________________________
___________________________
______________________________
Home Phone Number
Cell Phone Number
Message Number
___________________________________________________________________________
_____________
Alternate Contact Name or Case Manager
Phone Number
Primary Language Spoken at Home: ________________________________ Interpreter Needed: __ Yes__ No
Other Household Members (Full or part time)
First Name
Last Name
Current Landlord Name/address/phone number:
Name
Street Address
Birth Date
Gender
Social Security Number
City
State/Zip
Phone Number
All Income Sources (Last 12 months and projected) - See attached income/asset statement definitions
Income Source (Employer/Agency)
Phone#
Gross Monthly
Net Monthly
$
$
$
$
$
$
Questionnaire:
1. Have you, or anyone named on this application, ever been charged, arrested or convicted of any crime including a
F-012015PDA - HUD Pre-application – 01/2015 – La Salle online
drug-related crime or a crime involving violence against others?
YES
NO If yes, who? ______________________
where?__________________ (State) Explain (use additional pages if necessary) ________________________________
______________________________________________________________________________________________________________________
__
2. Have you, or anyone named on this application ever been cited, evicted or termination of tenancy proceedings started for criminal
activity (including drug related activity), fraud, non-payment of rent, non-compliance with lease/rule provisions or failure to
cooperate in recertification procedures?
Yes
No If yes, explain: ___________________________________________________________________________________
3. HUD prohibits admission to a household member who is subject to a State sex offender lifetime registration. Are you or anyone
YES
NO
named on this application a registered or non-registered sex offender?
(PDA will utilize the free national Dru Sjodin National Sex Offender database)
4. Do you or anyone named on this application have a history of using illegal drugs or abusing alcohol?
YES
NO
If yes, explain: _______________________________________________________________________________________________________
5. Do you or anyone named on this application currently use illegal drugs or abuse alcohol?
YES
NO
If yes, explain: _______________________________________________________________________________________________________
6. Is anyone named on this application a student (part or full-time) including a Student Enrolled in an Institute of Higher Education?
YES
NO If yes, who and where
If yes, indicate whom and further verification is required
attending____________________________________________________
7. HUD regulations require that all applicants disclose and provide acceptable PROOF of:
A. Valid Social Security Numbers for all family members (if applicable) - see Tenant Selection Plan (TSP) for exemption rule.
B. Eligibility and allowances for all family members (age, household membership, disability if applicable, etc)
C. Legal citizenship status – see TSP for more details
Are you able to meet these requirements on or before move-in?
YES
NO If not, why not?
_________________________________________________________________________________________________
8. You MUST list all the states in which you or anyone listed on this application have lived, taken out credit or have held licenses to
drive including DL#'s (use additional pages if necessary)
_____________________________________________________________________________________________
9. Have you or anyone named on this application ever been evicted in the last 3 years from federally assisted housing for drug
YES
NO If yes, explain:_________________________________________________________________
related activities?
10. Are you being involuntarily displaced due government action or presidentially declared disaster? (Preference applies only
for applicants of Section 236 or 221(d)4, 221(d)3 and BMIR properties)
YES
NO If yes, explain __________________________
11. Do you, or anyone named on this application request the features of a wheelchair accessible or adapted unit, downstairs vs.
YES
upstairs apartment (if available) or site or policy accommodation or modification based on a medical condition or disability?
NO If yes, what is requested?
_________________________________________________________________________________________________
12. Do you or anyone named on this application request protection under the VAWA (Violence Against Women) Act- protecting
YES
NO If Yes, further verification will be required. For Section 8
victims of domestic violence, dating violence or stalking?
and PRAC properties, this law provides special consideration of the rental application, screening or potential denial of tenancy, solely
based on their victim status, if the applicant otherwise qualifies for assistance or admission..
13. HUD requires the PDA to request information from applicants who were 62 or older as of January 31, 2010, who do not have SSN,
YES
if they are receiving HUD rental assistance at another location on January 31, 2010. Do you fall under this description?
NO
14. Please tell us your ethnic category
Hispanic or Latino
Not Hispanic or Latino
Chose not to disclose
15. Please tell us your racial category
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other
Chose not to disclose
How did you hear about our Property? _______________________________________________________
It is your responsibility to ensure that La Salle Apartments has your correct contact information and to notify La Salle management
about any change in contact information, household size, income, household members, or other relevant changes.
By signing below, I am certifying that I have completed this questionnaire and that the answers that I have given are true, correct
and complete to the best of my knowledge.
_______________________________________________
Applicant Signature
____________________
Date
_______________________________________________
Co-Head/Spouse Signature
____________________
Date
Attachment: HUD Form 92006 - Supplement to Application for Federally Assisted Housing
Pike Place Market PDA does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally
assisted programs and activities. The person (agency) named below has been designated to coordinate compliance with the nondiscrimination
requirements contained in the Department of Housing and Urban Development’s regulations implementing Section 504 (24 CFR, part 8 dated June 2,
1988). ELSIE N. JANSON 85 Pike Street Room 500, Seattle, WA 98101 (206) 774-5250 (TDD 711 for hearing impaired).. We do business in accordance
F-012015PDA - HUD Pre-application – 01/2015 – La Salle online
with the Federal Fair Housing Act and provide persons with disabilities reasonable accommodation upon request. Persons with language barriers may
request or arrange interpretation alternatives or services.
Managers Use: (OFFICE USE ONLY)
Date the Pre-Application was received: ______________
Time:___________ Received by (Sign/Initial) ___________________________
Comments:
_______________________________________________________________________________________________________________________________________________________
F-012015PDA - HUD Pre-application – 01/2015 – La Salle online
OMB Control # 2502-0581
Exp. (11/30/2015)
Optional and Supplemental Contact Information for HUD-Assisted Housing Applicants
SUPPLEMENT TO APPLICATION FOR FEDERALLY ASSISTED HOUSING
This form is to be provided to each applicant for federally assisted housing
Instructions: Optional Contact Person or Organization: You have the right by law to include as part of your application for housing,
the name, address, telephone number, and other relevant information of a family member, friend, or social, health, advocacy, or other
organization. This contact information is for the purpose of identifying a person or organization that may be able to help in resolving any
issues that may arise during your tenancy or to assist in providing any special care or services you may require. You may update,
remove, or change the information you provide on this form at any time. You are not required to provide this contact information,
but if you choose to do so, please include the relevant information on this form.
Check this box if you choose not to provide the contact information.
Applicant Name:
Mailing Address:
Telephone No:
Cell Phone No:
Name of Additional Contact Person or Organization:
Address:
Telephone No:
Cell Phone No:
E-Mail Address (if applicable):
Relationship to Applicant:
Reason for Contact: (Check all that apply)
Emergency
Unable
to contact you
Termination of rental assistance
Eviction from unit
Late payment of rent
Assist with Recertification Process
Change in lease terms
Change in house rules
Other: ______________________________
Commitment of Housing Authority or Owner: If you are approved for housing, this information will be kept as part of your tenant file. If issues
arise during your tenancy or if you require any services or special care, we may contact the person or organization you listed to assist in resolving the
issues or in providing any services or special care to you.
Confidentiality Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the
applicant or applicable law.
Legal Notification: Section 644 of the Housing and Community Development Act of 1992 (Public Law 102-550, approved October 28, 1992)
requires each applicant for federally assisted housing to be offered the option of providing information regarding an additional contact person or
organization. By accepting the applicant’s application, the housing provider agrees to comply with the non-discrimination and equal opportunity
requirements of 24 CFR section 5.105, including the prohibitions on discrimination in admission to or participation in federally assisted housing
programs on the basis of race, color, religion, national origin, sex, disability, and familial status under the Fair Housing Act, and the prohibition on
age discrimination under the Age Discrimination Act of 1975.
Signature of Applicant
Date
The information collection requirements contained in this form were submitted to the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520). The
public reporting burden is estimated at 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. Section 644 of the Housing and Community Development Act of 1992 (42 U.S.C. 13604) imposed on HUD the obligation to require housing providers
participating in HUD’s assisted housing programs to provide any individual or family applying for occupancy in HUD-assisted housing with the option to include in the application for occupancy the name,
address, telephone number, and other relevant information of a family member, friend, or person associated with a social, health, advocacy, or similar organization. The objective of providing such
information is to facilitate contact by the housing provider with the person or organization identified by the tenant to assist in providing any delivery of services or special care to the tenant and assist with
resolving any tenancy issues arising during the tenancy of such tenant. This supplemental application information is to be maintained by the housing provider and maintained as confidential information.
Providing the information is basic to the operations of the HUD Assisted-Housing Program and is voluntary. It supports statutory requirements and program and management controls that prevent fraud,
waste and mismanagement. In accordance with the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information, unless the
collection displays a currently valid OMB control number.
Privacy Statement: Public Law 102-550, authorizes the Department of Housing and Urban Development (HUD) to collect all the information (except the Social Security Number (SSN)) which will be
used by HUD to protect disbursement data from fraudulent actions.
Form HUD- 92006 (05/09)