HomeMy WebLinkAboutHousing Application - Age Restricted (55+)APPLICATION FOR AGE-RESTRICTED (55 years or older) HOUSING ASSISTANCE EXCLUSIVELY FOR SENIOR HOUSING
TOWN OF SOUTHOLD HOUSING APPLICATION
To be completed by heads of household over the age of 18, one per household.
Name:
Mailing
Address:
Number Street Hamlet/Village Zip Code
Place of Primary Residence (address listed on Federal income tax return) if different than above
Telephone Number:
Home Work
Social Security Number
Number of years you have lived at this address?
If less than 5 years at current residence, list previous residency for last five
years.
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 (children, live-in aid, etc), 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:
Name and address of current employer:
Phone:
Position:
How long:
Self-Employed
If yes, annual gross income $
Benefit Payments Received: (per Month)
Social Security
Employment Income: Gross Monthly Income
Wages
Overtime
Commissions
Fees/Tips
Bonuses
Other Income
Asset Information (includes personal property valued in
excess of $10, 000)
Checking
SSI/SSDI Name of institution
Workers Comp Balance $
Disability pay
Unemployment
Savm~s
Severance Name of institution
Annuities Balance $
Insurance policy
Pension
(list additional on a separate sheet of paper)
Retirement Yes No Current asset value
Death Stocks & bonds
VA benefits
Welfare
Alimony
Child Support
Inheritance
Trust
Lottery
Housing/Food Allowance
Reverse Mortgage
Money market
Mutual funds
IRA/Keoglf401k
Life Insurance
Real Property
Personal Property (car, boat, etc.) Specify
Other Assets (list-specify name of joint assets)
Other (list)
Total Income Total Assets
DEBT INFORMATION
Creditor '6' Name
Please list additional information on a separate sheet
of paper, if necessary.
Unpaid Balance
Monthly 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