EQUAL HOUSING OPPORTUNITY TENANT APPLICATION EMERALD HILLS ESTATES ALLEGANY, NEW YORK MAIL ONLY ONE (1) APPLICATION PER FAMILY TO: EMERALD HILLS ESTATES PO Box 235 Allegany, NY 14706 716-373-2202 TDD Number: 1-800-662-1220 NO PAYMENT OR FEE SHOULD BE GIVEN TO ANYONE IN CONNECTION WITH THE PREPARATION, FILING OR PROCESSING OF THIS APPLICATION NO CERTIFIED OR EXPRESS MAIL OR OTHER SPECIAL DELIVERY WILL BE ACCEPTED NO PETS ALLOWED TO BE FILLED OUT BY APPLICANT: NAME Street Address Apt. No. City State Zip Home Phone No. Work Phone No. Social Security No. Age Present Monthly Rent $ No. of Persons in Household No. of Bedrooms Do you expect any change in your family size? If yes, please explain Do you have a car? If yes, how many? 1
FUNCTIONAL STATUS: Mobility Accessible units (handicapped) are available. If you or any member of your family needs an adapted unit please check here: CHECK OFF UTILITIES PAID BY YOU: HEAT ELECTRIC GAS WATER LIST ALL PERSONS WHO WILL LIVE WITH YOU IN THIS DEVELOPMENT: Name Date Of Birth Relationship Social Sec # Attending School Head of Household Co-Tenant INCOME: List all full and/or part-time employment for all household members. Include selfemployed earnings. HOUSEHOLD NAME & ADDRESS GROSS EARNINGS MEMBER OF EMPLOYER CURRENT ANTICIPATE Per Per Per Per Per Per 2
Per Per OTHER SOURCES OF INCOME: (Examples: welfare, social security, SSI, pensions, disability compensation, unemployment compensation, interest, babysitting, care taking, alimony, child support, annuities, dividends, income from rental property, Armed Forces Reserves, scholarships and/or grants.) HOUSEHOLD MEMBER SOURCE AMOUNT ASSETS Checking Accounts Passbook Savings Savings Certificates Credit Union Shares Credit Union Name: Amt. $ Address: Stocks and Bonds (Value): $ War Bonds (Value): $ Do you CURRENTLY own real estate? If Yes, what is the value 3
Have you EVER owned real estate? If Yes, when? CHILD CARE Do you pay for babysitting while a family member is employed? If yes, list childcare provider s name, address and telephone number: Cost per week $ or per month $ MEDICAL INFORMATION: (OVER AGE 62 ONLY) Are you receiving Medicare Benefits? Do you pay for any medical insurance/hospitalization (ex. Blue Cross) Is this a payroll deduction? If yes how often and how much? If insurance is paid directly by you, indicate amount of premium and how often it is paid Do you have any outstanding medical bills you are currently paying? Do you take prescription drugs on a regular basis? Do you anticipate any health-care related expenses for the next 12 months, which are not covered by your health insurance? I (We) certify that the housing I (we) will occupy is/will be my (our) permanent residence. I (we) also certify that I (we) do/will not maintain a separate subsidized rental unit in a different location. I (we) declare that the statements contained in this application are true and complete to the best of my (our) knowledge. WARNING willful false statements or misrepresentations are a criminal offense under Section 1001 of Title 18 of the US Code. Signature Signature Signature 4
Signature NATIONAL ORIGIN: The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to not the race/national origin of individual applicants on the basis of visual observation or surname. Applicant #1 Applicant #2 Ethnicity: Ethnicity: Hispanic or Latino Hispanic or Latino Not Hispanic or Latino Not Hispanic or Latino Race: (Mark one or more) White Black or African American American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Gender: Male Female Race: (Mark one or more) White Black or African American American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Gender: Male Female PLEASE DO NOT MAIL MORE THAN ONE APPLICATION. IF MORE THAN ONE APPLICATION IS RECEIVED FROM ANY ONE FAMILY, ALL APPLICATIONS FROM THAT FAMILY WILL BE DISQUALIFIED. The information solicited on this application is requested by the apartment owner in order to assure the Federal Government, acting through Rural Development that the Federal Laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, marital status, age and handicap are complied with. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, 5
if you choose not to furnish it, the owner is required to note the race/national origin and sex of individual applicants on the basis of visual observation or surname. OFFICE USE ONLY: Date Received: Time Received: Bedrooms Required: Applicant Status: Eligible Ineligible Project Priority Code: Applicant Status: Mobility Impaired Over Age 62 Handicapped Disabled Signature of Reviewer: 6