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Medina Creative Housing

232 North Court St. Medina, Ohio 44256

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Medina Creative Housing

224 North Court St. Suite 200 Medina, Ohio 44256

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Application for Medina Creative Living IV

Application for Medina Creative Living II

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Medina Creative Living IV

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RENTAL APPLICATION

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Please complete this rental application in its entirety. Upon receipt of your completed application and related documents, we will make a preliminary determination whether you meet the eligibility requirements to live at Medina Creative Living.

How were you referred to Medina Creative Living?

Head of Household:

Current Street Address:

City:

State:

Zip:

Email Address:

Date of Birth:

Age:

Source of Disability:

Are you board eligible to receive services through the Medina County Board of Developmental Disabilities?

Yes

No

Race / Ethnicity:

Current Telephone Number:

Do you have a SSA case manager?

Yes

No

If yes, their name / telephone number:

May we contact your case manager if we are unable to reach you?

Yes

No

May we contact your case manager if determining eligibility for residency?

Yes

No

HOUSEHOLD COMPOSTION:

Who will be residing with you?

Preference of the size of unit you are interested in:

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Bedroom size Medina Creative Living IV has 2 – one bedroom units and 2 – two bedroom units. In the two bedroom units, you must be willing to share the unit

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RENTAL INFORMATION:

Most recent landlord:

Address:

Telephone Number:

How long have you resided at your current residence?

Are you currently receiving rental assistance from any agency?

If so, with what agency?

Are you currently on a waiting list for rental assistance?

If so, with what agency?

Are you currently in a pay-back plan with HUD?

How much do you owe?

For what reason?

Why do you want to move to Medina Creative Living?

Who is your current landlord?

Rent Amount:

Security Deposit Amount:

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Personal Information:

Have you or any member of your household been arrested and / or convicted of a felony?

Yes

No

If yes, what was the crime convicted of?

Have you ever been convicted of a lifetime sexual offender offense?

Yes

No

When was your conviction?

Do you own any firearms?

Yes

No

If yes, are they registered?

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Income:

What is your monthly gross income?

From where?

Are you employed?

Yes

No

Where:

Income Source

Amount Received

Telephone Number

Fax Number

Income Source

Amount Received

Telephone Number

Fax Number

Income Source

Amount Received

Telephone Number

Fax Number

Asset Source

Monthly Amount Received

Fax Number

Telephone Number

Asset Source

Telephone Number

Monthly Amount Received

Fax Number

Asset Source

Telephone Number

Monthly Amount Received

Fax Number

Applicant Signature:

Date:

I would like to receive communications from Medina Creative Housing:

Yes

No

Thank you for submitting your application.

We will get back to you as soon as possible.

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Please try again later.

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Home
About Us
Housing
Services & Programs
Community Assets
Events
Careers

CONTACT INFORMATION

Address: 232 North Court St. Medina, Ohio 44256

Phone: 330.591.4434

Fax: 330.723.7415

Email: info@medinacreativehousing.com

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