Application for Occupancy
Asher Haus

Welcome to Assumption Community! We ask that you fill out this application for occupancy, sign and date as
requested and return to Asher Haus.

Date of preferred move in, if accepted for occupancy:

APPLICANT INFORMATION:

CONTACT INFORMATION (if different from applicant):

Senior LinkAge Line Long-term Options Counseling Verification Number:

(You may contact the Senior Linkage Line at 1-800-333-2433)

POTENTIAL TENANT INFORMATION:

Assumption Community is a Tobacco-Free Community.  Tobacco use of any kind is prohibited in all areas of the building and grounds.  I verify that by initialing in the space provided that I understand this policy of Assumption Community and agree if accepted for occupancy that I will comply.

Assumption Health Services provides a required nursing assessment by a Registered Nurse.  This is completed prior to the date in which you sign a contract with Asher Haus or prior to move in whichever is earlier.

Does the potential tenant have a diagnosis of Alzheimer's Disease or another form of dementia?

Symptoms related to dementia diagnosis/behavioral concerns related to care needs and safety:

Have you ever been evicted from a rental dwelling?

Have you ever been convicted of a felony offense?

Are you currently subject to a registration requirement as a predatory offender?

Do you currently use illegal drugs or abuse alcohol?

Do you now, or have you ever used aliases?

REASONABLE ACCOMIDATION REQUEST:

If you are disabled, please request any reasonable accommodations you wish to be made that may help you access or use Asher Haus's housing programs or services.

CERTIFICATION/RELEASE OF INFORMATION:

I certify that all information contained in this application is true and accurate to the best of my knowledge.  I authorize release of any and all information in this application to Asher Haus and/or its designee.

This is a preliminary application and is not binding.  You will be notified as soon as possible about the availability of an apartment.  You will need to attend a personal interview and provide verification of identity and age.  Reference checks are made and Assumption Community reserves the right to reject applicants solely on negative references.  Telephone, Cable TV, Heat, Water, and Trash are included in the rent.  Health Services costs are separate charges payable with rent each month.  Assumption Community is proud to be a tobacco-free campus.