Application for Apartment

The following information will be required by the federal government to monitor this owner’s compliance with equal housing opportunity and fair housing laws. The law provides that an applicant may not be discriminated against on the basis of the information supplied below or whether or not the information is furnished.

EQUAL HOUSING OPPORTUNITY

This community does not discriminate on the basis of race, color, religion, sex, national origin, familial status (except as permitted under the Housing for Older Persons Act), disability, sexual orientation, gender identity or expression, marital status, age, ancestry, country of origin, or lawful source of income, as protected under the federal Fair Housing Act and the Rhode Island Fair Housing Practices Act (R.I. Gen. Laws § 34-37-1 et seq.).

John Clarke Senior Living

Thank you for your interest in John Clarke Senior Living. Please complete this application fully and legibly. Incomplete applications may delay processing. This community qualifies as "housing for older persons" under the federal Housing for Older Persons Act (HOPA), 42 U.S.C. § 3607(b), and requires that at least one occupant of each unit be 55 years of age or older. Reliable documentation of age (e.g., driver's license, birth certificate, passport, or government-issued ID) will be required at move-in for at least 80% of occupied units community-wide, consistent with HOPA verification procedures.

Property & Application Fee *

Property: John Clarke Senior Living, 600 Valley Road, Middletown RI 02842 (401) 864-0743 Application Fee: $150 (per applicant, non-refundable)

Date of Application: *

Application Fee: $150 (per applicant, non-refundable)

Desired Move-in Date: *

Your Email *

Full Legal Name *

First

Last

Date of Birth: *

Social Security Number: *

Age *

Phone Number: *

Present Address (street, city, state, zip) *

How did you hear about the apartment community?

Number of Bedrooms desired:

Driver's License #

State:

Do you own a vehicle?

Make, Model & Year

License Plate & State:

Do you have any pets?

John Clarke Senior Living maintains a no-pets policy. Pets of any kind are not permitted in units or common areas. Trained service animals and assistance/emotional support animals necessary for a person with a disability are not considered pets and are permitted as a reasonable accommodation

If yes, please describe (service/assistance animals only)

# Are you

Do you plan to keep it at the community?

Present Landlord:

Landlords Phone:

How long have you lived there?

Present Monthly Rent:

Emergency Contact (Name & Relationship)

Emergency Contact Email:

Emergency Contact Phone Number:

Current Employer:

Address:

Phone Number:

Length of employment with this company:

Gross Annual Wage:

Head of household gross monthly social security amount:

Souse/ other gross monthly social security amount?

SSI/ SSDI Gross Monthly Amount?

Pension amount (gross) per month / Name of Recipient

Pension Fund Name & Address

Are you a Veteran?

What adaptions, if any, will you need in your apartment for accessibility reasons?

please list all

Were you ever the subject of any eviction complaint?

YES or NO - if YES, please explain

Background, Credit & Criminal Records Check Consent (Initial & Date Below)

I authorize John Clarke Senior Living and its designated screening agents to request and obtain a consumer credit report about me from one or more consumer reporting agencies, for the sole purpose of evaluating this rental application, in accordance with the federal Fair Credit Reporting Act (15 U.S.C. § 1681 et seq.) and applicable Rhode Island law. I understand the report may include credit history, payment history, and public record information, and that I have the right to request the name and address of any consumer reporting agency used.

Consent to Obtain Criminal Background / CORI Records Check (Initial & Date Below)

I authorize John Clarke Senior Living and its designated screening agents, including the Rhode Island Attorney General's Bureau of Criminal Identification (BCI) or a private screening company, to conduct a criminal background records (CORI) check on me for the sole purpose of evaluating this rental application. I understand this check may include state and national criminal history records, sex offender registry records, and court records. I understand that a criminal record will not result in automatic denial: consistent with HUD guidance and Rhode Island law, John Clarke Senior Living will individually assess the nature and severity of any offense, the time elapsed, and its relevance to tenancy before making a decision, and I will have the opportunity to provide evidence of rehabilitation or dispute the accuracy of the record before a final denial. The following identifying information is required by BCI/CORI screening providers to accurately match criminal records to the correct individual. This information will be used only for the background check and will be handled under the confidentiality protections.

Privacy Statement — Social Security Number & Date of Birth

The Social Security Number and Date of Birth requested in this application are collected solely to: (1) verify applicant identity and eligibility for 55+ occupancy under HOPA; (2) obtain a consumer credit and background report; and (3) process lease and tenant-screening documentation. This information will be kept confidential, stored securely, shared only with authorized screening agencies, property ownership/management, and as required by law, and will not be used for any other purpose. Applicants may ask how their information will be used and may decline to provide it, understanding that doing so may prevent the community from processing this application.

Fair Housing & Applicant Certification (Name & Date)

I/We certify that the information provided in this application is true, complete, and accurate to the best of my/our knowledge. I/We understand that any false or misleading statement may be grounds for denial of this application or, if discovered after occupancy, for termination of tenancy. I/We acknowledge that this community operates as 55+ age-restricted housing under HOPA and that I/we meet, or my/our household includes a member who meets, the applicable age requirement. I/We acknowledge receipt of the community's Equal Housing Opportunity policy and understand that Rhode Island law prohibits discrimination based on race, color, religion, sex, sexual orientation, gender identity or expression, disability, age, marital status, familial status (subject to HOPA), country of origin, and lawful source of income, including housing choice vouchers.

Signature / Date