AFFORDABLE HOUSING MODERATE INCOME APPLICATION

Affordable Housing Moderate Income Application ATTACHED

The following table shows the maximum rent and income levels for fiscal year 2014-2015 for MODERATE INCOME inclusionary housing units. A landlord may increase the rent each year up to 75% of the Cost of Living as set by the City Council .

The following table shows the maximum income level before moving in for fiscal year 2014-2015 for MODERATE INCOME inclusionary housing units. Once residing in an inclusionary apartment unit, the tenant’s rent may increase and that is allowable. There is a schedule that is adjusted for the cost-of-living each year.

MAXIMUM INCOME Number of Persons

Very Low-Income Low-Income Moderate-Income

1 Up to $28,847 $28,848-$46,154 $46,155-$57,693 2 Up to $31,154 $31,155-$49,847 $49,848-$62,308 3 Up to $33,462 $33,463-$53,539 $53,540-$66,924 4 Up to $35,770 $35,771-$57,231 $57,232-$71,539 5 Up to $38,077 $38,078-$60,924 $60,925-$76,155

Completed applications should be mailed to: The John Stewart Company c/o Monica Solorzano – Waiting List Manager 888 S. Figueroa Street, #700 Los Angeles, CA 90017

For more information about the City’s waiting list please contact the John Stewart Company at (213) 787-2735.

MAXIMUM RENT Income Category Single One Bedroom Two Bedroom Very Low-Income $417 $476 $632

Low-Income $605 $690 $1,010 Moderate-Income $835 $956 $1,261

City of West Hollywood 8300 Santa Monica Boulevard West Hollywood, CA 90069 www.weho.org (323) 848-6400

G:\Rent Stabilization Division\FORMS & FACSHEETS 2012\PDF Format\Moderate Income Application (89).pdf Form 89 2014 -15

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CITY OF WEST HOLLYWOOD AFFORDABLE HOUSING PROGRAM

2014 - 2015 MODERATE-INCOME APPLICATION

This application is for the moderate-income waiting list only. Moderate-Income Households: Maximum Monthly Rents: 1 person household earning between $46,155 and $57,693 2 person household earning between $49,848 and $62,308 0 BR $835 3 person household earning between $53,540 and $66,924 1 BR $956 4 person household earning between $57,232 and $71,539 2 BR $1,261 5 person household earning between $60,925 and $76,155

SECTION 1: APPLICANT INFORMATION Name of applicant:_______________________________________________________________

Present address:_________________________________________________________________ street city zip Phone numbers: (____)_______________ (____)_________________ (____)_______________ home work cellular If applicable, please provide English-speaking person’s name and Tel #:_____________________________________________________

Name of manager:____________________________ Manager’s phone: (____)______________

Current Rent: $_________ + Average Utility Cost: $_________ = Rent & Utility: $ _________

SECTION 2: INCOME Please check all sources of income and list total amount received per month for everyone in the household:

$___________Wages, salaries, overtime pay, commissions, fees, tips, bonuses and/or other compensation per month $___________Social Security retirement income per month $___________Unemployment insurance per month $___________Supplemental Security Income (SSI) or state supplementary payments, per month $___________Social Security Disability Income (SSDI) per month $___________Veteran’s administration, GI bill, national guard and/or military benefits per month $___________Workers compensation per month $___________Public assistance income (CalWorks, TANF, general relief, etc) per month $___________Child support, alimony and/or spousal support received per month $___________Payments from trusts, annuities, inheritance per month $___________Payments from pension funds per month $___________Income from real or personal property per month $___________Income from stocks, bonds annuities, other investment instruments per month $___________Other sources of income. Explain: __________________________________________

SECTION 3: REAL PROPERTY, OTHER ASSETS AND DEFERRED INCOME Does anyone in household own property or an interest in property anywhere in the United States? Yes No Does anyone in the household contribute to a 457, 401K, Roth or other pension plan annually? Yes No

If yes, how much is the contribution annually? _______________________

Do you own an automobile? Yes No

If yes, Make ______________ Model __________ Year_____ Estimated value ________________

Do you own other assets (including cash & securities) over $50,000 in fair market value in total? Yes No

If yes, describe and itemize the value

____________________ _________________

______________________________________________________________________________________

G:\Rent Stabilization Division\FORMS & FACSHEETS 2012\PDF Format\Moderate Income Application (89).pdf Form 89 08/2014

SECTION 4: EMPLOYMENT Please provide the following employment information for all proposed occupants. You may attach additional sheets if necessary: (Note: The total of all salaries listed below should equal the amount listed under section 2 for wages, salaries, etc) Name:_______________________________________________________________________________ Employer:____________________________________________________________________________ Business Address:______________________________________________________________________ Street City Zip Supervisor:_____________________________ Title:________________________ Phone:(____)________ Length of employment:__________ year(s) __________ month(s) Salary: $_______________ per year Employment information continued (Add additional sheets, if needed) Name: ___________________________________________________________________________ Employer:________________________________________________________________________ Business Address: __________________________________________________________________ Street City Zip Supervisor: _________________________ Title: ____________________ Phone: (____)____________ Length of employment: __________ year(s) __________ month(s) Salary: $___________per year SECTION 5: HOUSEHOLD INFORMATION Proposed Occupants (List all persons to live in the unit) Name Social Security # Birth date Relation

1. _______________________________ ______-_____-________ _______ Yourself 2. _______________________________ ______-_____-________ _______ ___________ 3. _______________________________ ______-_____-________ _______ ___________ 4. _______________________________ ______-_____-________ _______ ___________ 5. _______________________________ ______-_____-________ _______ ___________

Number of occupants in your current household?

Number of bedrooms in current residence?

Do you have a Section 8 Voucher or Certificate? Yes No

If yes, Voucher or Certificate number: ___________________ Date Issued: __________________

Are you a Full-Time Student? Yes No

Is the head or co-head of your household a senior citizen (over 62 years) Yes No

Is any household member recognized by the state as disabled? Yes No

Number of bedrooms requested? (You may check more than one but there must be a minimum of one person per bedroom in your household.) Single 1 Bedroom 2 Bedroom Under penalties of perjury, I certify that the information presented on this forms is true and accurate to the best of my/our knowledge. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information will result in the denial of application or termination of the lease agreement

Signature:___________________________________ Date: ______________________ Mail completed application to: The John Stewart Company c/o Monica Solorzano – Waiting List Manager 888 S. Figueroa Street, #700 Los Angeles, CA 90017

G:\Rent Stabilization Division\FORMS & FACSHEETS 2012\Moderate Income Application (89).doc Form 89 08/2014