Apply online: Pioneer Park | Grand Management Services

Part 1 of 17

Before you start

This is the application for Pioneer Park, every question of it, to fill out here instead of on paper. It takes about 30 to 45 minutes.

Each adult member must fill out a separate application

Have these ready

Names, dates of birth and Social Security numbers for everyone who will live in the apartment.
Income each person expects in the next 12 months, and every bank account and other asset with its balance.
Your landlords for the last five years, or at least three, with their phone numbers.
Three personal references who are not family and not a landlord you list.
Photo ID for each household member over 18 and Social Security cards for each member, as photos or scans. Or bring copies to the office.

Who signs, and how

Each adult in the household signs, in ink: the program for Pioneer Park asks for signatures on paper. After you send the application, print the signature pages, have each adult sign them, and bring or mail them to 375 Park Ave, Suite 1, Coos Bay, OR 97420.

Everything you enter is encrypted on this device before it is sent, and only the office can open it. Nothing is saved on this device, so if you leave before you send it, your answers are gone.

Read before you apply

VAWA: Violence Against Women Act

That an applicant is or has been a victim of domestic violence, dating violence, sexual assault, or stalking is not an appropriate basis for denial of program assistance or for denial of admission, if the applicant otherwise qualifies for admission.

In determining eligibility for housing in cases where the Agent, acting on behalf of the Project Owners, has become aware that the household includes a victim of domestic violence, dating violence, sexual assault, or stalking, and when screening reveals negative and potentially disqualifying information, such as poor credit history, previous damage to an apartment, or a prior arrest, inquiries will be made regarding the circumstances contributing to this negative history, to ascertain whether these past events were the consequence of domestic violence, dating violence, sexual assault, or stalking against a member of the applicant household.

All denial of housing letters will notify applicants of VAWA’s protections and that they may seek an informal review if they believe that the denial of assistance was related to acts of domestic violence, dating violence, sexual assault, or stalking committed against the applicant.

If because of safety concerns a victim of domestic violence, dating violence, sexual assault, or stalking is unwilling or unable to provide information or identification ordinarily required to confirm eligibility, efforts will be made to otherwise establish eligibility and alternative sources and methods of verification will be accepted.

If you would like more information about your rights under the Violence Against Women act, please see the attachment to the Resident Selection Criteria.

Rather do it on paper? Download the application (PDF), or call 541-269-5561 (TTY 711) and the office will help or mail you one.

Part 2 of 17

The apartment

I wish to apply for (please identify the specific apartment name and location of rental that you are interested in):

Pioneer Park, Veneta

What size apartment are you applying for?

For example, 1 bedroom or 2 bedrooms.

Would you take a smaller size unit if available?

YesNo

Each adult member must fill out a separate application

If another adult in your household has already sent an application, the reference number on it

It starts with GMS. This lets the office keep your household together.

Part 3 of 17

Household composition

Household Composition. Please complete the following table, identifying all individuals who will be occupying the apartment. Please list the head of household as the first name in the table.

Part 4 of 17

Disability and unit features

Handicap/Disability. Do you have a disability which requires a unit with special features or auxiliary aid?

YesNo

If yes, what features do you require?

Part 5 of 17

Income

Income Summary. PLEASE LIST THE TYPE, SOURCE AND AMOUNT OF INCOME THAT CAN BE EXPECTED DURING THE NEXT 12 MONTHS FOR EACH HOUSEHOLD MEMBER.

Examples of types of income are: wages, self-employment, cash or other assistance from someone outside of the household. Social Security, child support, alimony, financial aid, retirement funds, etc.

Part 6 of 17

Assets

LIST ALL ASSETS OF EACH HOUSEHOLD MEMBER (CHECKING, SAVINGS, RETIREMENT ACCTS., CASH ON HAND, BENEFIT DEBIT CARDS)

Asset Details. Please answer the following questions.

a.) Does any household member own real estate or any assets in which you receive income?

YesNo

b.) Please list any assets disposed of for less than their fair market value during the past two years and provide the fair market value of the asset at the time of disposal:

c.) Has any household member ever declared bankruptcy or does any member plan to declare bankruptcy within the next year?

YesNo

Part 7 of 17

Adjustments to income

This part is optional.

Adjustments to income

ADJUSTMENTS TO INCOME. You may be eligible to claim some or all of the following adjustments to income. We will verify your eligibility for any of the adjustments you want to be considered for. Please review the following and provide your estimated cost for any that you want to be considered for. Completion is optional:

Child Care: The reasonable cost of child care for children age 12 or younger paid to non-household members when it allows another household member to be employed or attend school provided no other adult household member is capable of providing care.

Estimated monthly cost of child care, not reimbursed or paid by another agency or individual:

Medical Expenses. If the head or co-head of household is 62 years or older, or an individual with a disability, then medical expenses not reimbursed by insurance or another source may be considered for all household members. Typical medical expenses include: services of physicians, medical insurance premiums; prescription medicine, dental expenses, eyeglasses and eye exams, medical apparatus or aids, live-in or periodic medical care, and on-going payments on accumulated medical bills.

ESTIMATE ANNUAL MEDICAL EXPENSES TOTAL

Elderly Family Deduction. If the head or co-head of household is 62 years or older, or an individual with a disability, then you are eligible for an annual deduction of $400. Would you like to be considered for this deduction?

YesNo

Disability Assistance Expense. Costs associated with the care or support of a disabled household member that allows that Person or another household member to be employed may be considered. The cost must be reasonable and is limited to no more than the wages earned by the employed household member.

Estimated monthly disability assistance expense not reimbursed by another person or agency:

Part 8 of 17

Rental history

Rental History. Provide at least three (3) landlord references, or five years of the most current rental history, including your current residence in lieu of a mortgage. If you are related to your landlord by blood, marriage, or other close ties, you must provide additional rental history and/or additional personal and credit reference

Current Residence

Apartment Complex Name and Complete Address:

Manager Name

Manager Phone

Length of Residency from (month/year)

to (month/year)

Amount of rent paid: /mo.

Reason for moving

Was this Manager/Landlord a friend or relative?

Prior Residence

Apartment Complex Name and Complete Address:

Manager Name

Manager Phone

Length of Residency from (month/year)

to (month/year)

Amount of rent paid: /mo.

Reason for moving

Was this Manager/Landlord a friend or relative?

Prior Residence

Apartment Complex Name and Complete Address:

Manager Name

Manager Phone

Length of Residency from (month/year)

to (month/year)

Amount of rent paid: /mo.

Reason for moving

Was this Manager/Landlord a friend or relative?

Part 9 of 17

Personal references

Personal References. Please list individuals who could provide personal references for you when asked questions about your history of financial obligations, your history of adhering to rental agreements, and other questions related to our processing of your rental application to determine if you meet our residency standards. Please do not include family members or a landlord previously listed.

Please list the States that all members have lived in:

Part 10 of 17

Applicant questions

Part 11 of 17

Pets, vehicles and a contact

Please identify any pets or assistance animal that you own.

Please provide information regarding your automobiles, recreational vehicles, boats, equipment.

If attempts to contact you are not successful, is there someone else we can contact in order to reach you? If so, please list their name below:

Part 12 of 17

Housing history and preferences

Part 13 of 17

How can we reach you?

Mailing Address

City

State

Zip

Email Address

Your confirmation comes here if you ask for one when you send.

Home Phone

Work Phone

Message Phone

Part 14 of 17

Race, ethnicity and sex

This part is optional.

Part 15 of 17

Photo ID and Social Security cards

Photo ID for each Household member over 18 and Social Security Cards for each member of the household member.

Add photos or scans here, or bring copies to the office. Your application is complete once the office has them.

Photo ID for each household member over 18

Add photos or scans

Photos or PDF files, up to 10.

Social Security card for each household member

Add photos or scans

Photos or PDF files, up to 12.

Part 16 of 17

Review your answers

Check each part. Change takes you back to it; your other answers stay.

Part 17 of 17

Sign and send

Signature Clause

I/We hereby certify that this apartment will be my/our permanent residence and I/we will not maintain a Separate subsidized rental unit in a different location. I/We agree to the landlord’s representative the authority to investigate and obtain my/our credit rating, current and previous rental history, personal references, criminal background, current/past utility records, income verifications, and any other information necessary to determine my/our eligibility for this housing. My/our signature below certifies that the statements made on this application are true and correct and gives management consent to verify the information provided in this application. I/we understand that if it is determined that I/we have provided false information, I/we may be denied occupancy or may be evicted after occupancy. I/we understand that due to changes in circumstances, additional information may be requested at a later date to complete the processing of this application.

Authorization for Release of Information

Consent. I authorize and direct any federal, state, or local agency, or any organization, business, or individual to release to Grand Management Services any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under one of the following programs:

USDA Rural Housing Services RRH, RCH, LH programs Section 515 Assistance Programs
Section 221 (d)(3) BMIR
Rent Supplement
Section 8 Housing Assistance
All Section 8 Housing Assistance Payment Programs Rent Assistance Payments (RAP)
Section 236
Oregon Housing and Community Services programs
LIHTC programs

I give my consent for the releases also for the minor children in my care, who live with me. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Oregon Housing and Community Services (OHCS) agency or the U.S. Department of Housing and Urban Development (HUD) or USDA Rural Development in administering and enforcing program rules and policies.

Information covered. I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquires that may be released, include but are not limited to:

Identity
Employment
Credit History
Social Security #’s
Medical Expenses
Income sources
Criminal background
Utility Consumption data
Child Care Expenses
Income Amounts
Residences and Rental Activity
Assets

Groups or individuals that may be asked. The groups or individuals that may be asked to release the above information (depending on program requirements) include but are not limited to:

Previous Landlords
Welfare Agencies
Medical Providers
Retirement Systems
Post Offices
State Unemployment Agencies
Support and Alimony Providers
Child Care Providers
Banks & Other Financial Institutions
Credit Providers and Credit Bureaus
Schools and Colleges
Utility Companies
Past & Present Employers
Veteran’s Administration
Public Housing Agencies
Social Security Admin

Computer matching notice and consent. I understand and agree that OHCS or HUD or RD or a Public Housing Authority (PHA) may conduct computer matching programs to verify the information supplied for my certification or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. OHCS or HUD or the PHA may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies.

Conditions. I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with the management office and will stay in effect for a year and one month from the date signed. I understand I have a right to review my file and correct any information that I can prove is incorrect.

Equal opportunity and civil rights

In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.)

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, and American Sign Language) should contact the responsible State or local Agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339.

Grand Management Services 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. or use of Agency facilities who believes he or she is being discriminated against because of age, race, color, religion, sex, familial status, disability, or national origin may file a civil rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form (PDF), found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. This institute is an equal opportunity provider.

“This Institute is an Equal Opportunity Provider”

I have read the Signature Clause and the Authorization for Release of Information, and the statements on this application are true and correct.

How you sign

The program for Pioneer Park asks for signatures in ink. Send your application now; on the next screen you can print the signature pages for each adult to sign. Bring or mail them to 375 Park Ave, Suite 1, Coos Bay, OR 97420. Your application is complete once the office has them.

Email me a confirmation

Apply for Pioneer Park

Before you start

Have these ready

Who signs, and how

Read before you apply

The apartment

Household composition

Disability and unit features

Income

Assets

Adjustments to income

Rental history

Personal references

Applicant questions

Pets, vehicles and a contact

Housing history and preferences

How can we reach you?

Race, ethnicity and sex

Photo ID and Social Security cards

Review your answers

Sign and send

Signature Clause

How you sign

Signature pages

Signature Clause

Authorization for Release of Information