HomeMy WebLinkAboutHousing ApplicationNOTE: THERE IS A DIFFERENT APPLICATION FOR AGE-RESTRICTED (55 years or older+) HOUSING ASSISTANCE
Name:
TOWN OF SOUTHOLD HOUSING APPLICATION
To be completed by heads of household over the age of 18, one per household.
Mailing
Address:
Number
Place of Residence
(il' different than above)
Telephone Number:
Street Hamlet/Village Zip Code
Home Work
Social Security Number
School District of Primary Residence:
Number of years you have lived at this address?
residence, list previous residency for last five years.
If you do not currently live in the Town of Southold, did you previously reside in the Town?
Yes No _If yes, indicate where and dates of residency.
Place of employment?
If less than 3 years at current
Name Address Town
Number of years you have worked in the Town of Southold? (if applicable)
HOUSEHOLD INFORMATION: Number in household unit, including yourself
Provide the requested information for each household member, including yourself who will be living
in the housing unit. If you are married, live with a domestic partner, live with someone who will
continue living with you (regardless if you are married), or plan to have a specific person move in with
you, you must include him/her in your application. List head of household first. If you have been
divorced in the last year, please attach divorce decree.
Name Relationship Gender
Date of Birth Social Security #
(any dependent listed above who is older than 18 years of age must document income)
INCOME AND ASSET INFORMATION
Please fill out a separate information sheet for each member of the household 18 years and older.
Below is a list of items that count as income in determining eligibility for affordable housing through the Town
of Southold. Please check YES if you receive any particular income and NO if you do not receive the income.
You will need to provide verification for each item checked YES.
Employment Income:
Name and address of current employer:
Phone:
Position:
How long:
Self-Employed
If yes, annual gross income $
Yes No Gross Monthly Income
Employment
Wages
Overtime
Previous Employer:
Phone:
Position:
Dates:
Other Payments
Alimony
Child Support
Commissions Inheritance
Fees/Tips Trust
Bonuses Lottery
Benefit Payments
Social Security
SSI/SSDI
Workers Comp
Disability pay
Yes No Gross Monthly Income
Unemployment
Severance
Housing/Food Allowance
Asset Information (includes personal property
valued in excess of $10, 000)
Checkmy(
Name of institution
Balance $
7avinyts
Name of institution
Annuities Balance $
Insurance policy (list additional on a separate sheet of paper)
Pension
Retirement Yes No Current asset value
Death Stocks & bonds
Armed Forces
Welfare
Other
Ioney market
Mutual funds
IRA/Keogh/401k
Life Insurance
Real Property
Personal Property (car, boat, etc.)
Please list additional information on a separate sheet
of paper, if necessary.
Other Assets (specify name of joint assets)
Total Income Total Assets
DEBT INFORMATION
Creditor's Name Unpaid Balance ~onthl¥ Payment
HOUSING ASSISTANCE REQUEST
Please indicate the type of housing assistance that you are seeking. Check all that apply.
rn Apartment Bedrooms needed
rn Permanent Housing Bedrooms needed
rn Hamlet/Village Preference
rn Other Comments (please describe)
First Time Homebuyers Program
Closing Cost Assistance (SONYMA)
Mortgage Loan Assistance Programs (SONYMA)
CERTIFICATIONS
I (we) certify the following:
All the information contained and submitted within this application is accurate and complete to the best
of my (our) knowledge.
I (we) understand that any misrepresentation or falsification of information disqualifies me (us) to
participate in the Town of Southold's affordable housing assistance programs.
Consent to Release Information: I (we) authorize representatives from the Town of Southold or their
designees to contact employers, landlords, financial institutions, or other institutions/persons listed on
this application to verify information contained in this application.
I (we) accept that we will need to make declarations relating to my (our) credit history (ies).
If I (we) accept housing assistance consisting of rental or purchase, we will occupy the unit no later
than 90 days upon receipt of notice of acceptance.
I (we) understand that the Town has designated priority populations to participate in its housing
programs.
I (we) understand that properties rented or purchased from the Town's affordable housing programs are
intended to remain perpetually affordable.
I (we) agree to abide by the rules and regulations guiding the Town's affordable housing programs.
Failure to abide by regulations may result in financial penalties and expulsion.
Signature Date
Signature Date
THE INFORMATION PROVIDED IN THIS APPLICATION WILL BE USED BY THE TOWN TO
PROVIDE HOUSING ASSISTANCE TO APPLICANT(S). INFORMATION PROVIDED HEREIN IS
SUBJECT TO DISCLOSURE AND PUBLIC INSPECTION PURSUANT TO THE FREEDOM OF
INFORMATION LAW.
August 2012