Questionnaire First Name *Last Name *IN CONFORMANCE WITH SUBPART I OF 24 CFR PART 5, THIS ADDENDUM TO TENANT SELECTION PLAN SUPERSEDES AND AMENDS ANY OTHER LANGUAGE IN THE TENANT SELECTION PLAN WITH REGARD TO SCREENING APPLICANTS FOR CRIMINAL ACTIVITY AND DRUG/ALCOHOL ABUSE. IN IMPLEMENTING THIS ADDENDUM, ALL OWNER ACTIONS WILL BE IN COMPLIANCE WITH FAIR HOUSING AND EQUAL OPPORTUNITY PROVISIONS. 1. The owner MUST prohibit admission of applicants if any household member was evicted from federally-assisted housing for drug-related criminal activity.Have you or any member of the applicant family ever been evicted from federally-assisted housing for drug-related criminal activity?YesNoIf "Yes", the owner MAY admit such household if the family member has successfully completed an approved supervised drug rehabilitation program or the circumstances leading to the eviction no longer exist. Please explain:2. The owner MUST prohibit admission of applicants if any household member is engaged in the illegal use of drugs, or if the owner has reasonable cause to believe that a household member's illegal use of a drug or pattern of illegal use may interfere with health, safety and right to peaceful enjoyment of other residents.Are you or any member of your household currently engaged in the use of illegal drugs?YesNo3. The owner MUST prohibit the admission of persons subject to lifetime registration requirements under a State sex offender program.Are you or any member of your household subject to lifetime registration requirements under a State sex offender program?YesNoPlease list all addresses where you and other household members have previously resided since 18:4. An owner MUST prohibit admission if there is a reasonable cause to believe that a household member's abuse or pattern of abuse of alcohol interferes with the health, safety or peaceful enjoyment of the premises by other residents.Do you or any member of your household abuse alcohol?YesNo5. An owner MAY prohibit admission for 1. Drug-related criminal activity; 2. Violent criminal activity; 3. Other criminal activity that would threaten the health, safety or right to peaceful enjoyment of the premises by other residents; or, 4. Other criminal activity that would threaten the health, safety, or the owner or any employee, contractor,subcontractor,or agent of the owner who is involved in the housing operations. An owner MAY establish a set period of "reasonable time" in which the applicant must not have engaged in these activities before admission. The owner's criteria: Basis of Rejection (one or more of the following:) Crimes against persons: conviction within the past seven (7) years;Crimes against property: conviction within the past five (5) years;Drug-related criminal activity: conviction for the manufacture, sale, or distribution, or for possession with the intent to manufacture, sell, or distribute, a controlled substance within the past five (5) years;Illegal firearms: conviction for possession of an unregistered firearm or an illegal weapon within the past five (5) years; OR Pattern of criminal behavior: as evidenced by reports of repeated disturbances involving the police. Note: Drug-related criminal activity does not include the use or possession of a controlled substance if the applicant can demonstrate: Applicant has an addiction, a records of such an impairment, or is regarded as having such an impairment; ANDHas evidence of recovery via proof of completion of an accredited rehabilitation program;Has not used or possessed a controlled substance for at least one (1) year; AND,Does not currently use or possess a controlled substance.Do you or any member of your household have a record of criminal activity?YesNoIf so, please explain:6. An owner MAY admit an applicant who was previously denied admission for criminal activities but now has sufficient evidence that the household member was not involved in criminal activity for a reasonable length of time.Have you or any member of your household been previously denied admission for criminal activity that has ceased to continue?YesNoIf so, please explain:THE APPLICANT HEREBY CERTIFIES THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. THE OWNER HEREBY CERTIFIES THAT ALL SELECTION CRITERIA IS WITHIN THE FINAL RULE ON SCREENING AND EVICTION FOR DRUG ABUSE AND OTHER CRIMINAL ACTIVITY, AS FOUND IN 24 CFR PART 5, ET AL, PUBLISHED MAY 24, 2001, AND IS CONSISTENT WITH FAIR HOUSING AND EQUAL OPPORTUNITY PROVISIONS.DateOwner SignatureYour browser does not support e-Signature field.DateApplicant Digital SignatureYour browser does not support e-Signature field.DateApplicant Digital SignatureYour browser does not support e-Signature field.DateApplicant Digital SignatureYour browser does not support e-Signature field.DateApplicant Digital SignatureYour browser does not support e-Signature field. After you submit this form successfully. You will then be forwarded automatically to Step 2 of the application process.Submit Questionnaire