ONE APPLICATION PER HOUSEHOLD

Terrace Gardens Senior Housing
186 Beresford Ct.
Milpitas, CA 95035
(408) 946-9034

Application For Admission

Terrace gardens will comply with the provisions of any federal, state or local law prohibiting discrimination in housing on the basis of race, color, creed, ancestry, national origin, sex, sexual orientation, familial status, source of income, age, disability, AIDS, or AIDS relation condition.

TDD Telephone device for the deaf only California Relay Services (1-800-735-2929).

To the applicant: Please fill out this form completely. All references will be checked and if any information is found to be false or incomplete, the application may be rejected.

Secure Form: This web form is protected by SSL encryption technology and will securely send your information to our database.

PLEASE NOTE: THIS FORM WILL NOT SAVE! We strongly advise the applicant (and all co-applicants, if applicable) to be present while completing this form. Please be ready to fill out all information as required while completing your housing application.

Section I: Applicant Information

Applicant's Name*

Prefix First Last

Applicant's Social Security #:

Applicant's Age:*

Applicant's Date of Birth:*

Co-Applicant's Name

Prefix First Last

Co-Applicant's Social Security #:

Co-Applicant's Age:

Co-Applicant's Date of Birth:

Section II: Applicant Contact Information

Photo ID Required - Evidence of Residency

Home Phone:

Cell Phone:*

Email Address:*

Current Address:*

Street Address City State / Province / Region ZIP / Postal Code

Section III: Income Information

Please list all income sources for the applicant and co-applicant.

Applicant's Income Sources and Amounts (List All):*

Applicant's Total Annual Income:*

Co-Applicant Income Sources and Amounts (List All):

Co-Applicant's Total Annual Income:

Section IV: Asset Information

Asset Sources and Values (List All):*

Total Asset Value:*

Section V: References

Current Landlord

Current Landlord's Name:*

Current Landlord's Phone:*

Current Landlord's Street Address:*

Current Landlord's City and State:*

Current Landlord's Zip Code:*

Former Landlord

Former Landlord's Name:

Former Landlord's Phone:

Former Landlord's Street Address:*

Former Landlord's City and State:*

Former Landlord's Zip Code:*

Bank Information

Branch Name:*

Branch Street Address:*

Branch City, State and Zip Code:*

Account Number:*

Section VI: Mobility and Family

Do you require an altered or designed apartment for the mobility impaired? (Select one.)

Yes
No

Do you have children that live in Milpitas? (Select one.)

Yes
No

Name(s) / Address(es):

Section VII: Application Consent and Submission

By submitting this application, I understand and consent that further inquires may be made the verify the information herein and that any misrepresentations will disqualify this application. I understand that Management's acceptance of this application and that providing this information does not establish my eligibility for residency at Terrace Gardens.

Applicant's Name:*

Applicant's Signature:*

Date*

Co-Applicant's Name:*

Co-Applicant's Signature:*