$173,844. Marlene Glass

Size: px

Start display at page:

Download "$173,844. Marlene Glass"

Ernest Harrison
5 years ago
Views:

1 2014 $173,844 Marlene Glass

2 THE LESTER SENIOR COMMUNITY Developed and Managed by JEWISH COMMUNITY HOUSING CORPORATION (JCHC) APPLICATION FOR RESIDENCY AND PERSONAL DATA FORM FOR OFFICE USE ONLY Name: Date: Unit Type: Unit # Interview Date: Move-In Date: The medical and financial information requested in this Application will be used to determine eligibility for the services of The Lester Senior Community. You may be requested to submit additional medical information and to authorize a credit check. If you are accepted as a resident, the background information will be kept on file and may be used in the event of an emergency. As an Equal Opportunity provider all programs and services shall be made available in accordance with State and Federal regulations and guidelines. An Application for Residency may be rejected where the applicant unreasonably refuses to give requested information, or where the JCHC, in its sole discretion, determines that the applicant is, or within a reasonable period will be, financially unable to pay the costs and expenses of residency or unable to live with or without reasonable assistance, in The Lester Senior Community. ALL INFORMATION SUBMITTED WILL BE KEPT CONFIDENTIAL PLEASE MAIL THIS APPLICATION & A $25 APPLICATION FEE TO LESTER SENIOR HOUSING COMMUNITY 903 ROUTE 10 EAST WHIPPANY, NJ Any questions about this application please call

3 Please print or type I. GENERAL INFORMATION 1. Name: Spouse: 2. Address: Last First Middle Last First Middle Street City & State Zip Code 3. Telephone Number: ( ) 4. Date of Birth: Social Security Number: Spouse: Social Security Number: 5. CIRCLE: Male Female U.S. Citizen Yes No 6. Marital Status: Single Married Divorced Widow Widower 7. Own Home Yes No Renting (If Renting, Fill in Below) Landlord's Name Street Address City State Zip Current Monthly Rent Monthly Utilities (gas, electric) 8. How many years have you lived at your present address? 9. Where did you live before? For how long? 10. Are you currently receiving a rent subsidy? Yes No If yes, do you live in: Private housing Public Housing 11. Business or Profession (Former if Retired) Spouse 12. If more than one occupant, what is the name and relationship to applicant? Spouse Sister Brother Other Please explain A SEPARATE APPLICATION MUST BE SUBMITTED BY OTHER OCCUPANT, IF NOT YOUR SPOUSE 3

4 II. PERSONAL AND HEALTH INFORMATION (Use a Separate Sheet to Answer these Questions if Necessary) 13. Do you have medical insurance? Yes No Medicare: Private: 14. Describe any problems you have in performing activities of daily living, such as personal hygiene, cooking, housekeeping, medications? 15. Do you or your spouse have any problems with your current housing such as cost, maintenance, accessibility (physical barriers), etc? Please explain. 16. Do you or your spouse take care of your own finances such as writing checks, insurance forms, etc. Yes No 17. IN CASES OF EMERGENCY CONTACT: Two names of children or other immediate relatives/friends over 21 years of age (sister, brother, etc.) Name Address Telephone Name Address Telephone 18. Your Doctor s Name Telephone Address 19. How do you or your spouse spend most of your time?(part-time work, hobbies, housework, television, cards, special talents) 20. List and describe your past and present participation in community organizations or groups. 21. What type of apartment do you prefer? Independent Assisted Living One bedroom Studio Two bedroom One bedroom 22. Do you need a parking space? Yes If yes, 1 or 2 No 4

5 III. FINANCIAL STATEMENT THIS SECTION MUST BE COMPLETED BY THE APPLICANT AND/OR SPOUSE IN ORDER TO BE PROCESSED ANNUAL INCOME: 23. Gross yearly income as reported on income tax: $ Applicant $ Spouse $ Monthly Yearly Applicant Spouse Applicant Spouse Salary Social Security Pensions Other Totals ASSETS: (Savings accts, checking accts., Cert. of Deposit, IRA s real estate, stocks, bonds, money market accounts) Income 24. Description & Acct. No. Current Value Applicant Spouse (Name of bank, fund, etc.) 25. LIABILITIES: Totals Home mortgage $ Notes to others Notes to banks Other liabilities Total Liabilities 26. If a third party will be paying all or a portion of your monthly rent, please list below the name and address of that individual (the Guarantor) Name: Address: Telephone Number: ( ) Relationship to Applicant: Note: A letter and financial statement legally binding from the guarantor will be required. 27. By signing this application, you affirm that you did not dispose of any of your assets over the last two years for less than fair-market value. If you did, please provide details on a separate page. 5

6 EMPLOYMENT HISTORY Name and address of Head of Household s present employment: Telephone: Supervisor s Name? How long have you worked there? Name and address of spouse s or co-head employer: Telephone: Supervisor s Name? How long have you worked there? APPLICANT CERTIFICATION I/we certify that if selected to receive assistance, the unit I/we occupy will be my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility. I/we authorize the owner/manager to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verify information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in this application are true and complete to the best of my/our knowledge and belief. I/we understand that false statements or information are punishable under Federal Law. Signature of Head of Household Date: Signature of Spouse/Co-Head Date: Signature of Administrative Agent Date: We Do Business in Accordance With the Federal Fair Housing Law (The Fair Housing Amendments Act of 1988). It is Illegal to Discriminate Against Any Peron Because of Race, Color, Religion, Sex, Handicap, Familial Status, or National Origin. COAH, November

7 APPLICATION DECLARATION I/we understand that this is only an application for an apartment. It is not a lease or a promise by the owner that an apartment will be made available to me. I/we certify that the information in the application is true and complete to the best of my/our knowledge and I/we authorize inquiries to be made to verify the statements above. Any falsification of information is grounds for rejection. I/we understand that all of this information will be treated as confidential and will not be disclosed to others without my authorization. I/we understand that I/we will be required to appear for a personal interview before I/we receive final approval of my application. I/we agree that decisions of the Jewish Community Housing Corporation shall be binding and final in all respects. I/we are enclosing a non-refundable application fee of $25.00 made payable to Jewish Community Housing Corporation. NO APPLICATIONS WILL BE PROCESSED WITHOUT THIS FEE ($200 Fee for Market-Rate Apartment Applications) APPLICANT SIGNATURE DATE SPOUSE SIGNATURE DATE PLEASE BE SURE ALL QUESTIONS ARE ANSWERED. ANY QUESTIONS ABOUT THIS APPLICATION, CALL

8 REQUIRED FINANCIAL DOCUMENTATION Once your application is processed and you are approved, the following documentation (if it applies) must be provided for all members over the age of 18, so we can verify income and household size. Personal identification (Driver s License, passport, birth certificate, social security card, etc.) only 1 of the abovementioned pieces of ID is needed. Checking 6 months of statements Savings Account/s (CD s, IRA s, etc.) statements and current interest rates Bonds Stocks Real Estate (total value minus any outstanding mortgage balance, closing costs, broker s fees, etc.) and income from real estate or business Four most recent consecutive pay stubs for all employed household members Social Security: S.S. Computer Printout or Award Letter Pension Letter received from pension fund Verification of Temporary Assistance for Needy Families (TANF) Verification of Support (Child Support and/or Alimony) Verification of Military Pay Workers Compensation Letter from Workmen s Compensation Verification of Unemployment Benefits 1040 Federal Tax Return (both front and back) (for past 3 tax years) State Tax Return (last 3 tax years) COAH, November

9 HUD Certified Agencies Agency Name Phone, Toll-Free, Fax Number, , Website Address Services Languages Phone: Financial 185 Ridgedale Management/Budget Avenue CCCS OF NEW JERSEY HOUSING PARTNERSHIP FOR MORRIS COUNTY URBAN LEAGUE OF MORRIS COUNTY Toll-free: Fax: smarabotto@cccsnj.org Phone: Fax: Suite 12 contact@hpnj.us Website: Phone: Fax: mdavis@ulmcnj.org Website: Cedar Knolls, New Jersey E. Blackwell Street Dover, New Jersey Madison Avenue, Suite A Morristown, New Jersey Mortgage Delinquency and Default Resolution - Non-Delinquency Post Purchase Workshops - Pre-purchase - Non-Delinquency Post Purchase Workshops - Pre-purchase - Pre-purchase Homebuyer Education Workshops - Fair Housing Pre- Purchase Education Workshops - Mortgage Delinquency and Default Resolution - Rental Housing - English - English - Spanish - English - Spanish Parent Organization NATIONAL FOUNDATION FOR CREDIT COUNSELING, INC. NATIONAL URBAN LEAGUE

melvin kernan Housing Administrative Services A Division of

melvin kernan Housing Administrative Services A Division of Date: Name Address City, State Zip Dear applicant: Thank you for inquiring about affordable housing with melvin kernan. We currently administer AFFORDABLE HOUSING UNITS throughout the Township of Mantua,