Lottery Application Form - The Langdon Affordable Rental Housing Program

THIS FORM MUST BE COMPLETED AND SIGNED BY
EACH OCCUPANT OVER THE AGE OF 18.

THIS FORM MUST BE RECEIVED By July 7, 2025

TO BE ELIGIBLE

FOR ENTRY INTO THE LOTTERY.

Total number of household members that will occupy the apartment:

	Two Bedroom 80% AMI	One Bedroom 80% AMI	Studio 80% AMI
Apartment size requested (Check all that apply):

APPLICANT

First Name

Last Name

Last Name Suffix (Jr., Sr., etc.

Former Last Name

BirthDate

Do you have a Social Security #?

YesNo

Social Security Number:

If no SSN, are you in the U.S. on a Visa?

Yes

Visa Number:

Exp. Date:

NOTE: Owner/Property Manager may require this information to complete their tenant screening.

Your Vehicle

Make:

Model:

Year:

Plate #:

Driver's License

Driver's License No.

Driver's License State:

Exp. Date:

Applicant Current Residence Information:

Current Street Address

Suite or Apt.

City

State

Zip Code

Country:

Phone

Email Verification

Retype Email

Type (Check one)

Rent

Own

Other

Name of Apartment Community:

Name of Mortgage Company:

Start Date of Current Residency:

Contact Name:

Contact Phone:

Monthly Payment:

Reason for Moving:

Please explain this household member's current living situation:

Applicant Employment Information:

Are you currently employed?

YesNo

Current Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Do you currently have a second employer?

YesNo

Second Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Do you currently have a third employer?

YesNo

Third Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Do you have other sources of income?

YesNo

Sources of Additional Income:

Monthly Amount of Additional Income $:

Will you be receiving a tenant-based Housing Choice Voucher (Section 8) or Certificate or other rental subsidy such as Veterans Affairs Supportive Housing Voucher (VASH)?

YesNo

ALL LAWFUL SOURCES OF INCOME WILL BE ACCEPTED EQUALLY.

Name of Housing Authority Agency issuing Housing Voucher

Applicant

ACKNOWLEDGEMENT

By signing this Lottery Application, you certify (1) that you have read, understand and agree to the Program Guidelines, (2) that all intended occupants over the age of 18 years of age have completed and signed this Lottery Application, and (3) that each such occupant of the Apartment will sign the Lease at the time required by 43-47 Broadway Realty, LLC, their affiliates, property managers, employees, or agents (the "Owner/Manager"), if you are deemed eligible; and (4) that LIHP is permitted to disclose any and all information contained in the undersigned's application for the Program to the Owner/Manager for review, processing or in connection with regulatory or administrative compliance purposes.

You authorize Owner/Manager, themselves or through its designated affiliates, agent or employees, to obtain a Consumer Report and (1) conduct a background search on you which will include, but not be limited to, a credit and criminal records check, and (2) obtain and verify all income, employment, credit, and related information, for the purpose of determining whether or not to lease the Apartment to you. You understand that should you enter into the Lease for the Apartment, Owner/Manager and their designated affiliates, agents and employees will have a continuing right to review your credit information, rental application, and related information, for account review purposes and for improving application methods.

By signing this Lottery Application, you certify that all information contained in this Lottery Application is true, correct and complete. You agree, and it is your intent, to sign this record/document by inserting/typing your name below and by electronically submitting this record/document. You understand that by signing and submitting this record/document in this fashion, you are affirming the truth of the statements contained therein and that it is the legal equivalent of having placed your handwritten signature on the submitted record/document and all parties may rely on same.

It is unlawful to discriminate against an applicant or tenant because of their race, color, national origin, source of income, religion, gender, familial status, disability, or any other basis that may be protected under applicable state or local law.

First Name

Last Name

I acknowledge the above.

FIRST ADDITIONAL HOUSEHOLD MEMBER

Is this household member under 18?

YesNo

First Name

Last Name

Social Security Number:

Birth Date

Relation to Applicant:

First Name

Last Name

Last Name Suffix (Jr., Sr., etc.

Former Last Name

Birth Date

Does this household member have a social security number?

YesNo

Social Security Number:

If no SSN, is this household member in the U.S. on a Visa?

Yes

Visa Number:

Exp. Date:

NOTE: Owner/Property Manager may require this information to complete their tenant screening.

Your Vehicle

Make:

Model:

Year:

Plate #:

Driver's License

Driver's License No.

Driver's License State:

Exp. Date:

Current Residence Information:

Current Street Address

Suite or Apt.

City

State

Zip Code

Country:

Phone

Type (Check one)

Rent

Own

Other

Name of Apartment Community:

Name of Mortgage Company:

Start Date of Current Residency:

Contact Name:

Contact Phone:

Monthly Payment:

Reason for Moving:

Please explain this household member's current living situation:

Employment Information:

Is this household member currently employed?

YesNo

Current Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by another employer?

YesNo

Second Employer (as of move-in date)

Industry:

Position:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by a third employer?

YesNo

Third Employer (as of move-in date)

Industry:

Position:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Does this household member have additional sources of income?

YesNo

Sources of Additional Income:

Amount of Additional Income $:

First Household Member

ACKNOWLEDGEMENT

First Name

Last Name

I acknowledge the above.

SECOND ADDITIONAL HOUSEHOLD MEMBER

Is this household member under 18?

YesNo

First Name

Last Name

Social Security Number:

Birth Date

Relation to Applicant:

First Name

Last Name

Last Name Suffix (Jr., Sr., etc.

Former Last Name

Birth Date

Does this household member have a social security number?

YesNo

Social Security Number:

If no SSN, is this household member in the U.S. on a Visa?

Yes

Visa Number:

Exp. Date:

NOTE: Owner/Property Manager may require this information to complete their tenant screening.

Your Vehicle

Make:

Model:

Year:

Plate #:

Driver's License

Driver's License No.

Driver's License State:

Exp. Date:

Current Residence Information:

Current Street Address

Suite or Apt.

City

State

Zip Code

Country:

Phone

Type (Check one)

Rent

Own

Other

Name of Apartment Community:

Name of Mortgage Company:

Start Date of Current Residency

Contact Name:

Contact Phone:

Monthly Payment:

Reason for Moving:

Please explain this household member's current living situation:

Employment Information:

Is this household member currently employed?

YesNo

Current Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by another employer?

YesNo

Second Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by third employer?

YesNo

Third Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Does this household member have additional sources of income?

YesNo

Sources of Additional Income:

Amount of Additional Income $:

Second Household Member

ACKNOWLEDGEMENT

First Name

Last Name

I acknowledge the above.

THIRD ADDITIONAL HOUSEHOLD MEMBER

Is this household member under 18?

YesNo

First Name

Last Name

Social Security Number:

Birth Date

Relation to Applicant:

First Name

Last Name

Last Name Suffix (Jr., Sr., etc.

Former Last Name

Birth Date

Does this household member have a social security number?

YesNo

Social Security Number:

If no SSN, is this household member in the U.S. on a Visa?

Yes

Visa Number:

Exp. Date:

NOTE: Owner/Property Manager may require this information to complete their tenant screening.

Your Vehicle

Make:

Model:

Year:

Plate #:

Driver's License

Driver's License No.

Driver's License State:

Exp. Date:

Current Residence Information:

Current Street Address

Suite or Apt.

City

State

Zip Code

Country:

Phone

Type (Check one)

Rent

Own

Other

Name of Apartment Community:

Name of Mortgage Company:

Start Date of Current Residency

Contact Name:

Contact Phone:

Monthly Payment:

Reason for Moving:

Please explain this household member's current living situation:

Employment Information:

Is this household member currently employed?

YesNo

Current Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by another employer?

YesNo

Second Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by a third employer?

YesNo

Third Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Does this household member have additional sources of income?

YesNo

Sources of Additional Income:

Amount of Additional Income $:

Third Household Member

ACKNOWLEDGEMENT

First Name

Last Name

I acknowledge the above.

FOURTH ADDITIONAL HOUSEHOLD MEMBER

Is this household member under 18?

YesNo

First Name

Last Name

Social Security Number:

Birth Date

Relation to Applicant:

First Name

Last Name

Last Name Suffix (Jr., Sr., etc.

Former Last Name

Birth Date

Does this household member have a social security number?

YesNo

Social Security Number:

If no SSN, is this household member in the U.S. on a Visa?

Yes

Visa Number:

Exp. Date:

NOTE: Owner/Property Manager may require this information to complete their tenant screening.

Your Vehicle

Make:

Model:

Year:

Plate #:

Driver's License

Driver's License No.

Driver's License State:

Exp. Date:

Current Residence Information:

Current Street Address

Suite or Apt.

City

State

Zip Code

Country:

Phone

Type (Check one)

Rent

Own

Other

Name of Apartment Community:

Name of Mortgage Company:

Start Date of Current Residency:

Contact Name:

Contact Phone:

Monthly Payment:

Reason for Moving:

Please explain this household member's current living situation:

Employment Information:

Is this household member currently employed?

YesNo

Current Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by another employer?

YesNo

Second Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by a third employer?

YesNo

Third Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Does this household member have any additional income sources?

YesNo

Sources of Additional Income:

Amount of Additional Income $:

Fourth Household Member

ACKNOWLEDGEMENT

First Name

Last Name

I acknowledge the above.

FIFTH ADDITIONAL HOUSEHOLD MEMBER

Is this household member under 18?

YesNo

First Name

Last Name

Social Security Number:

Birth Date

Relation to Applicant:

First Name

Last Name

Last Name Suffix (Jr., Sr., etc.

Former Last Name

Birth Date

Does this household member have a social security number?

YesNo

Social Security Number:

If no SSN, is this household member in the U.S. on a Visa?

Yes

Visa Number:

Exp. Date:

NOTE: Owner/Property Manager may require this information to complete their tenant screening.

Your Vehicle

Make:

Model:

Year:

Plate #:

Driver's License

Driver's License No.

Driver's License State:

Exp. Date:

Current Residence Information:

Current Street Address

Suite or Apt.

City

State

Zip Code

Country:

Phone

Type (Check one)

Rent

Own

Other

Name of Apartment Community:

Name of Mortgage Company:

From:

Contact Name:

Contact Phone:

Monthly Payment:

Reason for Moving:

Please explain this household member's current living situation:

Employment Information:

Is this household member currently employed?

YesNo

Current Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by another employer?

YesNo

Second Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Is this household member currently employed by a third employer?

YesNo

Third Employer (as of move-in date)

Position:

Industry:

Monthly Income:

Work Phone:

Street Address

City

State

Zip Code

Name of Supervisor:

Supervisor Phone:

Dates of Employment

From:

To:

Does this household member have additional sources of income?

YesNo

Sources of Additional Income:

Amount of Additional Income $:

Fifth Household Member

ACKNOWLEDGEMENT

First Name

Last Name

I acknowledge the above.

THIS FORM MUST BE RECEIVED BY
5 PM on JULY 7, 2025
TO BE ELIGIBLE FOR ENTRY INTO THE LOTTERY.

EACH OCCUPANT OVER 18 YEARS OF AGE MUST COMPLETE AND SIGN THIS FORM.