ASSUMPTION COURT APPLICATION | Assumption Community

Our mission:

As a Catholic, Benedictine healthcare service, the mission of Assumption Community is to provide a continuum of exceptional quality care that honors the dignity of local community members entrusted to us.

Application for Occupancy

Assumption Court

615 First Street North

Cold Spring, MN 56320

PH: 320.348.2350 FAX: 320.685.3401 TTY/TTD Users Dial: 711

Applicant Information:

Senior LinkAge Line Long-term Options Counseling Verification Number

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

FAMILY COMPOSITION: Please list all household members who will live in the unit.

Relationship to head of household

Sex

Birthdate

Social Security #

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 offers a complimentary nursing assessment provide by a Registered Nurse. This is completed prior to the date in which you sign a contract with Assumption Court or prior to move in whichever is earlier. Would you like to receive this complimentary nursing assessment to determine potential health service needs and cost of service?

Yes

Background:

1. Please list the following information on dwellings you have rented during the past five years.

2. Have you ever been evicted from a rental dwelling?

Yes

3. Have you ever been convicted of a misdemeanor or felony offense?

Yes

4. Are you currently subject to a registration requirement as a sex offender?

Yes

5. Do you currently use illegal drugs or abuse alcohol?

Yes

6. Do you now, or have you ever used any aliases?

Yes

7. List any Counties and States you have resided in during the past 10 years

8. List the name and address of two credit references:

Reasonable Accommodation Request:

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

Responsible Party Agreement:

I, am the Responsible Party for (applicant).

By agreeing to serve in this capacity, I understand that I have the following responsibilities
1.) Make payment for rent and fees to Assumption Court on or before the first day of each month. 2.) Make advance arrangements, with the Landlord, if there is to be any delay in making payment. I understand that if the tenant becomes unable to fulfill the requirements of tenancy as set forth in the lease agreement of Assumption Court, I will make arrangements to either secure professional services for the tenant so that he or she can comply with the requirements of tenancy or arrange for an appropriate transfer to other housing within the time frame stated in the lease. If the tenant’s condition constitutes an emergency, I will make these arrangements within 24 hours.

Responsible Party Signature

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 Assumption Court Apartments and/or it’s designee.

Your Signature

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, and Electricity are not included in the rent. Meal program and Health Services costs are separate charges payable with the rent each month. Assumption Community is proud to be a tobacco-free campus.

Name: (FIRST, MI, LAST)