Covina Gardens

200 W. Rowland Street, Covina, CA 91723

Phone: (626) 967-4796 TTY: (800) 855-7100

APPLICATION INSTRUCTIONS
Dear Applicant:

Thank you for your interest in Covina Gardens, a 90-unit, age-restricted, affordable housing
community for households 55 years and older, located in Covina, California.

The general waiting list is currently open.

This packet provides important information about the property and how to apply. Please read this
information carefully.

Please complete the attached application in its entirety. Please do not submit copies of SS cards,
personal ID, licenses, or any financial or personal documents at this time. Upon request, application
materials will be made available in a format that meets the needs of an applicant with disabilities.

Be sure to check your application for accuracy. You will not be able to change your application
information (except for contact information) after the application is submitted. If your contact
information changes (e.g., address, phone number, email, etc.), please notify us by mailing the
updated information to the above address using your name as it appears on your previously
submitted application.

Completing the Application

 Use BLACK INK to complete the application.
 Complete all the information – no blanks. Incomplete applications will be returned for additional
information.
 Do not use white out. White out corrections are not accepted. To make corrections, make one
(1) line through any mistakes and initial any changes.

If you pick up or download an application, please fill out the application and then submit your
completed application in person or by mail to:

In Person Covina Gardens

or By Mail: 200 W. Rowland St., Attn: Manager’s Office
Covina, CA 91723

Applications that meet the preliminary screening requirements will be entered into our waiting list.
Applications will be processed on a first come first served basis and in the order they are received.

We hope that you will have the opportunity to make Covina Gardens your home. If you have any
questions or concerns, please contact the management office at (626) 967-4796.

Sincerely,

Covina Gardens Management

Rental Application
Covina Gardens
200 W. Rowland St. , Covina, CA 91723
Phone: (626) 967-4796 TTY: (800) 855-7100
Email: [email protected]
INSTRUCTIONS
Please complete ALL sections of this application. Please do not leave any questions blank or use White Out. ALL adult
household members (18 and over) must sign the application. Screening criteria available upon request. Please do not
submit multiple applications.
OCCUPANCY LIMITS
To qualify for each of the unit sizes, please note the minimum and maximum persons required. See the Tenant Selection
Plan for additional information regarding occupancy guidelines.
Age-Restricted: 55+
Minimum Maximum
1 Bedroom 1 person 2 people
HOUSEHOLD INFORMATION
List ALL household members that are applying to live in the apartment beginning with the Head of Household (HOH).
Include any household member that is under the age of 18 and will reside in the household 50% of the time or more. Be
sure to include your own name. Failure to provide accurate and complete contact information may result in application
denial.
Relationship Optional Birthdate
Last Name First Name MI to HOH M/F SSN MM/DD/YYYY
1. Self
2.
3.
CURRENT CONTACT INFORMATION (Required)
What is your preferred method of being contacted? ☐ Mail ☐ E-Mail ☐ Other_______________
Current Address:

Mobile phone: Other Phone:

Email Address: Other Contact:
REASONABLE ACCOMMODATION INFORMATION
Covina Gardens has accessible units and/or units with accessible features. Applicants may inquire about features of these
units by contacting the management office (626) 967-4796 or TTY (800) 855-7100.
1. Do you require that your apartment be designed for the disabled/mobility impaired? ☐ Yes ☐ No
‐ Please check if applies: ☐ Mobility ☐ Vision ☐ Hearing
‐ Please explain the required modification needed:
A person with a disability may ask for:
 A change in rules (reasonable accommodation)
 A physical change to their apartment or shared areas in the building (reasonable modification)
 An accessible apartment
 Aids and services to help them communicate with us

If you or anyone in your household has a disability and needs any of these things to live at Covina Gardens and use our
services, please contact the management staff to fill out a ‘Reasonable Accommodation or Modification Form.’

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Covina Gardens
EFFECTIVE COMMUNICATION
Please notify the management office if you need application assistance such as large type font, information by audio tape,
computer disk, Braille and/or a language other than English. Best efforts will be made to accommodate such requests.
☐ (Arabic) ‫ﻋﺭﺑﻰ‬ ☐ (Cantonese) 广东话 ☐ (Mandarin) 普通话
Primary
☐ (Russian) русский ☐ (Spanish) Español ☐ (Tagalog) Tagalog
Language:
☐ (Vietnamese) Tiếng Việt ☐ (Korean) 한국어 ☐ Other: __________________
OTHER HOUSEHOLD INFORMATION
1. How did you hear about this property?
☐ Banner ☐ Flyer ☐ LAHD Registry ☐ Walk-By
☐ C.E.S. ☐ Friend/Family ☐ Newspaper ☐ Other _____________
☐ Comm. Center ☐ Internet/Online ☐ TSAHousing.com
2. Is any member of your household disabled according to the Fair Housing Act definition for handicap (disability):
a. A physical or mental impairment which substantially limits one or more major life activities; a record of such an
impairment or being regarding as having such an impairment. For a definition of “physical or mental impairment
and other terms, please see 24 CFR 100.201
b. Handicap does not include current, illegal use of or addiction to a controlled substance.
c. An individual shall not be considered to have a handicap solely because that individual is a transgender.
☐ Yes ☐ No ☐ Do not wish to disclose
3. ☐ Please check here if you have been displaced by governmental action or if your dwelling has been destroyed as a
result of a disaster formally recognized pursuant to federal disaster relief laws. (Third –party verification will be required).
4. Covina Gardens is a non-smoking property. Each applicant 18+ must initial below to acknowledge that you understand
smoking will not be permitted throughout the property up to the property line.

Initials HOH Initials Initials

5. List any Case Worker or Agency that you are working with, that you would like us to be aware of or contact.
Agency Name: Case Worker Name:
Agency/Case Worker Phone: Email:

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Covina Gardens
We are required to adhere to Federal Fair Housing laws and to encourage a balanced resident population at Covina
Gardens. This housing is offered without regard to race, color, religion, sex, gender, gender identity and expression, family
status, national origin, marital status, ancestry, age, sexual orientation, disability, source of income, genetic information,
arbitrary characteristics, or any other basis prohibited by law. As such, we appreciate your checking the appropriate boxes
below regarding your race/ethnicity. You are not obligated to provide this information. If you choose not to disclose, please
indicate below.
Ethnic Categories
☐ Hispanic ☐ Not Hispanic ☐ Non-Disclosed
Racial Categories
☐ Black/African American ☐ Asian ☐ Native Hawaiian/Other Pacific Islander
☐ White/Caucasian ☐ Asian Indian ☐ Native Hawaiian
☐ American Indian/Alaska Native ☐ Chinese ☐ Guamanian or Chamorro
☐ Other ☐ Filipino ☐ Samoan
☐ Non-Disclosed ☐ Vietnamese ☐ Other Pacific Islander
☐ Japanese
☐ Korean
☐ Other Asian
CURRENT RESIDENCE
1. What is your current monthly rent? $ /month
2. Why do you intend to vacate your current residence?
3. What is the size of your current residence? # of Bedrooms
(Please indicate “0” for a studio or bachelor unit)
Yes No
4. Do you expect any additions to the household within the next 12 months? ☐ ☐
Name & Relationship:
Explanation:
5. Is there anyone living with you now who would not be living with you at this property? ☐ ☐
Name & Relationship:
Explanation:
6. Are there any absent household members who under normal conditions would live with you? ☐ ☐
Explanation:
7. Are you currently separated or estranged from your spouse? ☐ ☐
8. Do you or any household members own a car? ☐ ☐
If yes, how many cars? Number of cars:

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Covina Gardens
HOUSEHOLD BACKGROUND INFORMATION
Yes No
1. Have you, or anyone else named on this application, filed for bankruptcy? ☐ ☐
Explanation:
2. Have you, or anyone else named on this application, been convicted of a felony within the last 7 years? ☐ ☐
Explanation:
3. Have you or anyone else named on this application been evicted from a rental unit of any type ☐ ☐
including an apartment, home, mobile home or trailer?
Explanation:
4. Have you or anyone else named on this application been convicted of drug/paraphernalia use, ☐ ☐
possession, or distribution?
Explanation:
RENTAL HISTORY AND HOUSING REFERENCES
Please list all locations you have lived in the last FIVE (5) years starting with CURRENT address. If additional space is
required, use the back of this page.
Landlord’s Name/Address Your Address Own/Rent Dates
(1) Name: Own ☐ From:
Address: Rent ☐ To:
Homeless ☐
Phone:
(2) Name: Own ☐ From:
Address: Rent ☐ To:
Homeless ☐
Phone:
APPLICANT STATUS
Yes No
1. Will you or any ADULT household member require a live-in aide? (Third-party verification will be ☐ ☐
required).
Name of Attendant:
Relationship (if any):
2. Do you currently, at the time of application, receive Section 8 rental assistance? ☐ ☐
Name of Agency:
Contact Person:
3. Do you currently have or are you expecting a Section 8, Choice Voucher, V.A.S.H., or other Voucher? ☐ ☐
Expected Date:
Name of Agency:
Contact Person:

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Covina Gardens
FULL-TIME STUDENT INFORMATION
This apartment is governed by Federal and/or State Housing Program(s) that restrict full-time students. We must
determine your household student status prior to eligibility and, if such eligibility is granted, each subsequent year you
remain in the unit. If unsure of Full-Time status, inquire with academic institution for determination of “Full-Time”
prior to completing the following section.
Yes No
1. Are you or any member of your household above (including minors) currently a Part-Time Student? ☐ ☐
2. Are you or any member of your household above (including minors) currently a Full-Time Student? ☐ ☐
3. Does the entire household consist of people who are currently full-time students? ☐ ☐
4. Does the entire household consist of people who are either currently a full-time student or were a full- ☐ ☐
time student for 5 months or more in the current calendar year?
5. Do you or any member of your household above (including minors) anticipate becoming a Full-Time ☐ ☐
Student?
If Yes to any of the previous questions, complete the following:
Yes No
6. Is anyone in your household receiving assistance under Title IV of the Social Security Act (AFDC, ☐ ☐
TANF, CalWorks – not SSA/SSI)?
7. Is anyone in your household enrolled in a job training program receiving assistance under the Job ☐ ☐
Training Partnership Act (JTPA), Workforce Investment Act (WIA), or other similar federal, state, or
county government program?
8. Is anyone in your household married and filing (or are entitled to file) a joint tax return? (please provide ☐ ☐
a copy of marriage certificate or tax return)
9. Is anyone in your household a single parent with a dependent child(ren) and neither of you or your ☐ ☐
child(ren) are dependents of another individual?
10. Is anyone in your household under the age of 24, who has exited the Foster Care System (currently ☐ ☐
age 18-24)?
INCOME INFORMATION
Income is counted for anyone 18 or older (unless legally emancipated). However, if the income is unearned income such
as a grant or benefit, it is counted for all household members including minors. Answer the questions in this section to
provide the source(s) of all household income. Include all income anticipated for the next 12 months.
(Use the back of this form if you need more space.)
Do YOU or ANYONE in your household receive OR expect to receive income from:
YES NO
1. Employment wages, or salaries, or self-employment? (Include overtime, tips, bonuses, ☐ ☐
commissions, and payments received in cash. Use an additional page to add additional employment
income sources.)
Household Member Name of Company Amount / Month
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
2. Social Security, SSI or any other payments from the Social Security Administration? ☐ ☐
Household Member SSA / SSI / SSDI? Amount / Month
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
3. Pension, retirement benefit or annuities? ☐ ☐
Household Member Type of Pension / Annuity Amount / Month
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________

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Rental Application
Covina Gardens
4. Regular gifts or payments from anyone outside of the household? (This includes anyone ☐ ☐
supplementing your income or paying any of your bills, utilities, groceries, or other expenses.)
Name of Person
Household Member Supplementing Income Amount / Month
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
5. Any other income sources or types not listed? (e.g., alimony or child support (whether or not it is ☐ ☐
received), pay as a current member of the Armed Forces, unemployment benefits or workers’
compensation, public assistance or general relief, payments from a severance package, payments
from any type of settlement, payments from rental property or other types of real estate transactions,
payments from lottery winnings or inheritances, etc.)
Household Member Type of Other Income Amount / Month
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
6. Do you, or any other household member, expect any changes to your income in the next 12 ☐ ☐
months?
Household Member Explanation Amount / Month (if applicable)
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
7. As needed, please provide notes on any other income here:

ASSET INFORMATION
Include all assets held and the income derived from the asset. INCLUDE ALL ASSETS HELD BY ALL HOUSEHOLD
MEMBERS INCLUDING MINORS. Answer the questions in this section to provide the source(s) of all household assets.
(Use the back of this form if you need more space.)
Do YOU or ANYONE in your household have:
YES NO
1. Checking, Savings, Direct Express Cards, CDs, Money Markets, and/or Treasury Bills? ☐ ☐
Household Member Account Type Institution Last 4 of Account
______________________ ______________________ ______________________ ______________________
______________________ ______________________ ______________________ ______________________
______________________ ______________________ ______________________ ______________________
______________________ ______________________ ______________________ ______________________
2. Cash on hand? This is cash not kept in a bank account ☐ ☐
Household Member Cash on Hand
______________________ $_____________________
______________________ $_____________________
3. Real estate, rental property, land contracts/contract for deeds or other real estate holdings? ☐ ☐
(This includes your personal residence, mobile homes, vacant land, farms, vacation homes or
commercial property.)
Household Member Type Value
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
4. Funds held in a payment service account, such as Venmo, PayPal, CashApp, Skrill, etc.? ☐ ☐
Household Member Source Value
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________

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Rental Application
Covina Gardens
5. Crypto Currency such as Bitcoin, Litecoin, Ethereum, etc.? ☐ ☐
Household Member Type Value
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
6. All other asset sources or types not listed? Include name of institution where the asset is held, type ☐ ☐
of asset, value of asset, and any interest or income from the asset.(i.e. Paintings, coin or stamp
collections, artwork, show cars, antiques, Stocks, bonds or securities, trust funds, pensions, IRAs,
Keogh or other retirement accounts, whole life insurance, contents of a safe deposit box, etc.)
Household Member Type Value
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
7. Have you disposed of an asset in the last two years? (Ex.: Cash over $1000, a home, other real ☐ ☐
estate, etc.)
Household Member Type of Other Income Amount / Month
__________________________ __________________________ $_________________________
__________________________ __________________________ $_________________________
8. As needed, please provide notes on any other assets here:

COMMUNITY INTEREST
1. Drug and Crime Free Acknowledgement: Your initials below will acknowledge that you understand that this
apartment community will vigorously enforce a drug and crime free environment. You and your guests agree not to
engage in any drug-related activity, including the manufacture, sale, distribution, use, or possession of illegal drugs.
These activities are a material violation of the lease and good cause for termination of tenancy. Each adult household
member 18+ initials below.

Initials HOH Initials Initials

2. OPTIONAL: We are providing extensive recreation facilities and activities at this property for the enjoyment of our
residents. Since we are always looking for assistance to coordinate special programs and activities, we would
appreciate a brief description of your skills, interests, hobbies and any assistance/leadership you might provide to these
programs.

SIGNATURE CLAUSE
Upon notification by landlord of application processing, I agree to pay Covina Gardens an application screening charge in
the amount required by landlord. I will be issued a Receipt for Application Fee upon payment which will authorize Covina
Gardens to obtain any such credit reports, character reports and/or criminal reports, and verification of rental and
employment history as it deems necessary to verify all information set forth in this application. I understand that I will
acquire no rights to the above property until I sign a rental agreement and submit a security deposit. I further understand
that false, fraudulent misleading or incomplete information may be grounds for denial of tenancy or subsequent eviction.
There are no other agreements express or implied between the parties.
I understand that management is relying on this information to prove my household’s eligibility for housing at Covina
Gardens. I certify that all information and answers to the above questions are true and complete to the best of my
knowledge. I understand that providing false or misleading information or making false statements may be grounds for
denial of my application. I also understand that such action may result in criminal penalties.

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Rental Application
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I authorize and consent to have management verify the information contained in this application for purposes of proving my
eligibility for occupancy. I will provide all necessary information including source names, addresses, phone numbers, and
account numbers where applicable and any other information required for expediting this process. I understand that my
occupancy is contingent on meeting management’s resident selection criteria and any low-income housing program
requirements.
In accordance with state and federal laws, I have been notified that an investigation may be made of the information I
provided on this application together with information as to my character, general reputation, personal characteristics, and
mode of living. I understand that I have the right to dispute the accuracy of information obtained from the entities I have
disclosed above, and, upon written request, the right to a complete and accurate disclosure of any scope of this
investigation and/or a written summary of my rights under the Fair Credit Reporting Act.
All adult household members must sign below:

Head of Household Signature Date Other Adult Signature Date

Other Adult Signature Date

CREDIT INFORMATION
Notice Regarding California Investigative Consumer Reporting Agencies Act:
☐ Landlord does not intend to request an investigative consumer report regarding the Applicant.
Unless the box above is checked, pursuant to California Civil Code section 1786.16(a)(3), the Landlord intends to request
an investigative consumer report in connection with the Applicant’s application for housing. The investigative consumer
report will be made concerning the Applicant’s character, general reputation, personal characteristics, and mode of living.
Among other things, the investigative consumer report may contain information concerning the Applicant’s creditworthiness,
any court judgments against the Applicant, and any criminal charges and/or convictions. Pursuant to California Civil Code
section 1786.22, any files maintained on the Applicant by the investigative consumer reporting agency from which Landlord
obtains the report shall be made available to you during normal business hours and upon reasonable notice, provided you
furnish proper identification, as follows: (1) The Applicant may appear in person at the investigative consumer reporting
agency below to request a copy of the Applicant’s file; (2) the Applicant may make a written request for copies of the
Applicant’s files to be sent via certified mail to a designated addressee; or (3) the Applicant may make a written request for
a summary of the file to be provided over the telephone. “Proper identification” includes documents such as a valid driver’s
license, social security account number, military identification card, and credit cards. If one of these forms of identification
cannot be provided, the agency may ask for other forms of identification in accordance with California Civil Code section
1786.22(c). The investigative consumer reporting agency may charge a fee, not to exceed the actual copying costs, if the
Applicant requests a copy of the Applicant’s file. The agency is required to have personnel available to explain the
Applicant’s file to the Applicant, and the agency must explain to the Applicant any coded information appearing in the file. If
the Applicant chooses to appear in person, the Applicant may choose to bring another person of his/her choice with him/her,
provided that the accompanying person also bring proper identification with him/her. If the Applicant brings another person
with him/her, the agency may require the Applicant to sign an authorization allowing the agency to discuss the Applicant’s
file in the presence of that other person.
The agency that will prepare the investigative consumer report on the Applicant is:
RentGrow 177 Huntington Avenue, Suite 1703 #74213, Boston, MA 02115
Name of Agency Address of Agency
If you would like a copy of the report(s) that is/are prepared, please check the box below:
☐ I would like to receive a copy of the report(s) that is/are prepared.

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Rental Application
Covina Gardens
Landlord agrees that Landlord, or Landlord’s agent, will send the Applicant a copy of the report within three (3) business
days of the date the report is provided to Landlord. The copy of the report will contain the name, address, and telephone
number of the agency that issued the report and how to contact the agency.
If Landlord takes adverse action against Applicant, and the adverse action is based in whole or in part on the contents of the
investigative consumer report, then, pursuant to California Civil Code section 1786.40(a), Landlord shall so advise Applicant
and shall supply Applicant with the name and address of the agency that prepared the report on which Landlord’s decision
was based in whole or in part.
PLEASE SIGN BELOW TO AUTHORIZE A CREDIT REPORT, EVICTION REPORT, AND CRIMINAL BACKGROUND
CHECK. Management will perform a credit and eviction history and may perform a criminal background check of all
applicants as a part of the applicant screening criteria. Your application will not be considered unless you provide
management with your consent to obtain a credit, eviction, and criminal background report on each adult household
member.
All adult household members must sign below:

Head of Household Signature Date Other Adult Signature Date

Other Adult Signature Date

PLEASE MAIL COMPLETED APPLICATIONS TO:

Covina Gardens
200 W. Rowland St. , #Manager’s Office
Covina, CA 91723

For Management Use

Date & Time received by Management: ____________________________ Received by: __________________________

WARNING: “Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly
making false or fraudulent statements to any department of the United States Government. HUD and any owner (or any
employee of HUD or the owner) may be subject to penalties for unauthorized disclosures or improper use of information
collected based on the consent form. Use of the information collected based on this verification form is restricted to the
purposes cited above. Any person who knowingly or willingly requests, obtains or discloses any information under false
pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any
applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other
relief, as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized
disclosure or improper use. Penalty provisions for misusing the social security number are contained in the **Social Security
Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).**

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 Notice of Free Interpretation Services

English- Free Interpretation Services are available. Please ask

for assistance in the of8ice.

Spanish- Interpretación Servicios gratuitos están disponibles.

Por favor pedir ayuda en la o8icina.

Chinese (Traditional)-

Chinese (Simpli7ied)- 费 译 务 请 办

Korean- 무료 통역 서비스를 사용할 수 있습니다. 사무실에서

도움을 요청하십시오.

Tagalog- Libreng Serbisyo Interpretasyon ay magagamit.

Mangyaring humingi ng tulong sa opisina.

Vietnamese- Giải thích miễn phí Dịch vụ có sẵn. Xin hỏi trợ
giúp trong văn phòng.

Arabic- ‫ ﻣﻦ ﻓﻀﻠﻚ اطﻠﺐ اﻟﻤﺴﺎﻋﺪة ﻓﻲ اﻟﻤﻜﺘﺐ‬.‫ﺗﺘﻮﻓﺮ ﺧﺪﻣﺎت اﻟﺘﺮﺟﻤﺔ اﻟﻔﻮرﯾﺔ ﻣﺠﺎﻧﺎ‬.

Hindi- फ्री व्याख्या सेवाएं उपलब्ध हैं। कायार्लय में सहायता के िलए कहें।

Portuguese- Gratuito Serviços de interpretação disponíveis.

Por favor, peça ajuda no escritório.

Russian- Бесплатные услуги переводчика доступны.

Пожалуйста, обратитесь за помощью в офисе.