Missoula Manor Homes 

To become a resident of Missoula Manor, simply print this form, fill it out and mail it to Missoula Manor Homes, 909 W. Central Ave., Missoula, MT 59801.

Application Form

I/We hereby apply for admission as a resident of Missoula Manor.  If admitted to the Manor, I/We promise to comply with the rules and regulations of the Manor.  I understand that Missoula Manor is a smoke free residence.  Smoking is not allowed anywhere inside the building.  This includes the apartments of Missoula Manor Homes.

Date of Application:                                                        , 20             

Name(s):                                                                  Phone:                                  

Current Address:                                                                                                              

Length of time at current address:                         

We require you furnish a list of all addresses where you have lived for the last ten years.  (If you need more space, please attach a list of these additional addresses.)

Previous Address (if less than 10 years at current address)                                                                                                              

Length of time at previous address:                       

Date of Birth:                                      Place of Birth:                                              

(Proof of Age and Citizenship must be provided.  Acceptable documents:  Birth Certificate, Valid Passport, Baptismal Certificate, Military Discharge Papers, Naturalization Certificate)

Race (optional – for statistical purposes only):                                                          

Present or Former Occupation:                                                                                

Social Security Number(s):                                                                                      

{Please furnish a copy of social security card(s)}

Have you ever been convicted of a felony?                                

Are you or a member of your household enrolled as either a part-time or full-time student at an institution of higher education for the purpose of obtaining a degree, certificate, or other program leading to a recognized educational credential?                 

Children:  Names, Addresses and Phone Numbers (if no children, other close relative)

Personal Physician:  Name, Address and Phone (permission to consult granted)

Permission is herby granted to Missoula Manor to consult my personal physician concerning my health history.  Further, my physician may be contacted when and if it appears that my condition warrants it.

(Applicant signature)                                      (Applicant signature)  

Personal Reference and address (no relatives please):

(1)                                                                                                                      

(2)                                                                                                                      

Landlord reference and address (no relatives please):

(1)                                                                                                                      

(2)                                                                                                                      

HUD requires Missoula Manor to verify all information that is used in determining an applicant’s eligibility.  Permission is herby granted to Missoula Manor to consult my references listed above. 

(Applicant signature)                                   (Applicant signature)

APARTMENT PREFERENCE:

Do you have a preference for a high or a low floor?                                                    

Do you have a preference as to the East or West side of the building?                          

If you smoke, are you aware that Missoula Manor is a smoke free residence?                           

How did you hear about Missoula Manor?                                                                 

FINANCIAL STATUS:  Since rent is based on income, this financial information is used to help us determined the rate you will pay.  This information must be up-dated and all income must be verified prior to moving into the Manor.

1) Social Security Payment                           3) Pension or retirement*                       

2) Interest/Dividend Income*                       4) Other Income*                                  

*Indicate whether amount is monthly or yearly.

It is specifically agreed, that on reasonable notice, prices may change to reflect changes in the cost of operation.  It is also understood that Missoula Manor is a retirement residence and is not permitted to provide physical care for residents.  Missoula Manor reserves the right to terminate the stay of any resident who violates the terms of the lease.

The applicant agrees to pay a damage deposit at the time of admission to Missoula Manor.  This deposit will be equal to one month's rent.  The applicant also agrees to pay the first month's charges upon moving into the apartment and agrees to pay each month's charges in advance.  The lease agreement may be terminated by either party upon giving thirty (30) days written notice to the other.

The damage deposit is required on each apartment to guarantee the condition of the apartment when the resident leaves.  Extra cleaning, cleaning of carpet or damage to carpet, blinds, walls or fixtures must be paid by the person occupying the apartment.

I/we have read the Tenant Selection Criteria.  In order to determine eligibilty, I understand that Missoula Manor Homes reviews sex offender registration sites on the internet and does criminal background checks through authorized law enforcement agencies.  In signing this form, I give my permission to Missoula Manor Homes to do the required criminal background check.  This information is gathered for the purpose of determining eligibility for admission to Missoula Manor Homes.

I hereby certify that I have carefully read this application and understand it, and that I have answered correctly, to the best of my knowledge, all of the questions herein contained.

Applicant’s Signature                                   Applicant’s Signature

PENALTIES FOR MISUSING THIS CONSENT:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.  HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information collected based on the consent form.  Use of the information collected based on this verification form is restricted to the purposes cited above.  Any person, who knowingly or willingly requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.  Any applicant or participant affected by negligent disclosure of information may bring action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use.  Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8).  Violation of these provisions is cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

Missoula Manor Homes does not discriminate on the basis of handicapped status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. 

The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the HUD regulations implementing Section 504 (24 CFR Part 8 dated June 2, 1988).

Name:        Conni Pfister

Address:      909 W. Central, Missoula, MT 59801

Voice:         (406) 728-3210

TDD:           1-800-253-4091