GleneidaCourtApartments

ThisisanapplicationforGleneidaCourtApartmentslocatedat10,12or14GleneidaCourt,Carmel,NY 10512.

Thisnon-smokingcomplexconsistsof24,onebedroomunits.

Eligibilityislimitedtopersons62yearsofageorolder. Income restrictionsdoapply. Applicationsare placedonawaitlistbasedontimeanddatereceived. Applicantswillbecontactedandinterviewedfortenancyoncetheirnamereachesthetopofthewaitlist.

Pleasemailcompletedapplicationtothemanagingagent:

PutnamCountyHousing Corp.

Managing Agent

11SeminaryHillRoad

Carmel,NY10512

Foranyquestions,pleasecontactPutnamCountyHousingCorporationat845-225-8493betweenthehours of8:30a.m.and4:30p.m.MondaythroughFriday.TDDRelay#800-662-1220.

11 Seminary Hill Road, Carmel, New York 10512

845-225-8493 Fax 845-225-8532

APPLICANTINFORMATIONforhousinginGleneidaCourt,locatedoffofSeminaryHillRoad,Carmel,NewYork.Pleasecompletethisapplication.Incompleteapplicationswillnotbeprocessed. Applicationsareplacedinorderofdateandtimereceived.Anapplicant may beinterviewedonlywhenPutnamCountyHousingCorporation(ManagingAgent)receivesthetenantapplicationandyournamereachesthetopofthewaitinglist.

LEGAL NAME: ______D.O.B.______SS#______

ADDRESS:______

PHONE NUMBER: ______WORK NUMBER:______

MALE______FEMALE______

TWORELATIVESORFRIENDSWHOGENERALLYKNOWHOWTOCONTACTYOU

Name ______Name ______

Address______Address ______

______

Phone ______Phone ______

MARITALSTATUS(CIRCLEONE)

MarriedUnmarriedSeparatedWidow

Ifyouaremarriedwillyourspouselivewithyou?Yes

No

Ifnot,wherewillyourspouselive?

Ifnot,doyouintendforyourspousetolivewithyouanytimeinthefuture?YesNo

Ifyes,explain_

Automobiles

MAKE / MODEL / YEAR / LICENSE PLATE / TITLE IN NAME
LEGALNAMEOFALLPERSONS WHOWILLLIVEINYOURAPARTMENT. Listall

personswhowouldliveinyourapartment-Listtheheadofhousehold first. GivetherelationshipofeachhouseholdmembertotheApplicant:

Name / Relationship
tohead / BirthDate / Age / SocialSecurity
# / Student
YIN
1.
2.
3.

FELONYCONVICTIONSYESNO

IFYESEXPLAIN______

anyonelivewithyounowwhoisnotlistedabove? Yes_Noifyes,explain _

Doyouplantohaveanyonelivingwithyouinthefuturewhois notlisted

Above?Yes

No

Ifyes,explain_

DoyouoryourCo-applicanthaveanychildrenundertheageofeighteen

(18)Whoarenotlivingwithyounow?Yes

No

If yes, EXPLAIN

Isanymemberofyourhouseholdpregnant? Yes

NoHOUSINGINFORMATION

Numberofbedroomsincurrentunit

DoyouownRent

Ifrental,amountofcurrentmonthlyrentalpayment$_

Listyourresidence(s) for yourlasttwo years.CurrentResidencefirst.

From----To:-----WASIT'SUBSIDIZED?YINADDRESS: APT.#

CITYSTATEZIPCODELANDLORD NAME: PHONE#

LANDLORD ADDRESS:

STREETCITYSTATEZIP DOYOUOWEBACKRENT? _ DIDYOUMOVE VOLUNTARILY?

From:---To:---WASITSUBSIDIZED?YINADDRESS: APT.#

CITYSTATEZIPCODELANDLORD NAME: PHONE#

LANDLORDADDRESS:

STREETCITYSTATEZIP

DOYOUOWEBACKRENT?

DIDYOUMOVEVOLUNTARILY?

Whyareyoumovingfromyourcurrenthousing?_

CREDITINFORMATIONListfourcreditreferencesotherthancurrentandformer landlords. Referencesmayincludehomemortgages,carloans, otherpersonalloans,ered"Itcards,utilitcycompanies,etc.

Name / Address / Account# / Phone#

CURRENTHOUSEHOLDEXPENSES(ESTIMATED)

Rent: / Auto: / Medical:
Electric: / AutoInsurance: / Handicap:
Gas: / LifeInsurance: / Loans:
Water: / HealthInsurance:
Cable: / Childcare:

TOTALHOUSEHOLDINCOMELISTallmoneyreceivedbyeveryonelivinginyourhousehold. Thisincludesmoneyfrom Wages,Social SecurityBenefits,AFDC,ChildSupport, UnemploymentBenefits,SSI, Worker'sCompensation,RetirementBenefits, VeteransBenefits,Rental PropertyIncome, StockDividends, Interest, Etc.

Householdmember / SourceofIncome / GrossMonthly
Amount
SocialSecurity / $_
SSIBenefits / $_
SSD / $_
Pension / $_
Veteran'sBenefits / $_
UnemploymentCompensation / $_
InterestIncome / $_
OtherIncome / $_

Doyouanticipateanychangesinthisincomeinthenext12months?YesNo_

Haveyoureceivedanylumpsumpaymentsinthepasttwelvemonths

-insurancesettlement,inheritance,etc.?Yes

No_

DoyouanticipatereceivinganylumpsumpaymentsinthenexttwelveMonths? Yes No. _

Areyoucurrentlyintheprocessof applyingforanyadditionalsourcesofPublicassistance-AFDC,SocialSecurity, UnemploymentBenefits,SSI,SSD,Workers'CompensationBenefits,ect.?Yes No Ifyes,

describe

ASSETSListallassetsincluding,butnotlimited to,amountinbankaccounts,Safedepositboxes,cashinhand,realestate,stocksandbonds,

DESCRIPTION / LOCATION OF
ASSETS / ACCOUNT
NUMBER / DOLLAR
AMOUNT ORFACEVALUE
CHECKINGACCOUNT
SAVINGSACCOUNT
CD/MONEY
MARKET
IJFEINSURANCE
TrustAccounts
OTHERSTOCKS,BONDS,ETC.

RealProperty:Doyouownanyproperty? Yes

No

IfYes,TypeofProperty_Location, _

AppraisedMarketValues._Mortgage/OutstandingLoansBalanceDue$. _AmountofAnnualInsurancePremium $. _AmountofMostRecentTaxBill $ _

Haveyousold/DisposedofAnyPropertyin theLastTwoYears?YesNo

IfYes,TypeofProperty_

MarketValueWhenSold/Disposed$._AmountSold/Disposedfor$. _DateofTransaction _

Haveyoudisposedofanyother assetsinthepasttwoyears?

Yes

NoIfYes,Explain,

MEDlCALICBILDCJJRE/HllNDICJJP ASSISTANCEEXPENSES

MEDICALCOSTS:CompletethispartONLYIFApplicantorCo-Applicantis62orolder,disabledorhandicapped.

MedicarePremiums...... MonthlyAmount$._

MonthlyAmount$_

MedicalInsuranceCoverage-NameofInsuranceCompany_Address MonthlyAmount$

AnticipatedMedical/Drug/PrescriptionCostnotcoveredbyInsuranceNORReimbursed: MonthlyAmount $.

MedicalBillsorOutstandingCostsyouaremakingMonthlyPaymentFor:BalanceDue$ MonthlyPayments _

AreyouseeingaPhysicianRegularly?Name_AddressProjectedCostsNOTCovered

ByinsuranceNORReimbursedfortheNext12months$_

AnyOtherMedicalExpenses:

Listtype&Amounts---"''------

HandicapAssistanceE;penses: CompleteONLYifhandicapExpensesAllowtheHandicaporAnotherHouseholdMembertoWORK?

ListtypeofExpenses,WeeklyAmount,andPaidtoWhom:

AllowtheHandicaporAnotherHouseholdMembertoWORK?ListtypeofExpenses,WeeklyAmount,andPaidtoWhom:

AreyoudisplacedYes

NoIfYES,Displacement

Agency_

Isyourcurrentunitcondemned/substandard? YesNo._Areyoupayingmorethan50%ofyourgrossincomeforrentandutilities?Yes No. _

Areyouapplyingfor an"elderlyhousehold"status? YesNoToqualifyfor"ElderlyHousehold"status,youmust meetthefollowingCriteria(Pleasecheckonethatapplies)

A.) 62 Years old or olderB.) Handicappedand18orolder _C.)Disabledand18orolder

Areyouaveteran?YesNoIfYes,DateofService_Haveyoueverresidedinaprojectfinancedand/orsubsidizedbytheGov't?Yes NO IfYES,Name&Address. _

Haveyoueverbeenevictedfrompublichousingandanyotherfederalhousing?Program?Yes No _

IfYeVVhere_

DescribeReasons_

HaveYouEverBeenEvictedFromOtherHousing? YesNo

Howdidyouhearaboutthishousing?_

VVillyoutakeanapartmentwhenoneisavailable?YesNo_

Brieflydescribeyourreasonsfor applying?------

PETS:DoyouownanypetsYESNO_

lfYES,Describe_

GENERALAPPLICATION QUESTIONS

Doyoubelievethatyouarequalifiedforapriorityavailabletopersonswithhandicaps?YES NO _

Doyouhaveneedsthatmightbebetterservedbyawheelchairaccessibleunit?YESNO

Areyoucurrentlyusinganillegalcontrolledsubstance?YES_NO_

Areanymembersofyourfamilycurrentlyusinganillegalcontrolledsubstance? YES NO

Haveyoueverbeenconvictedofillegaldistributionormanufactureofacontrolledsubstance? YES NO

Haveyouoranyoneinyourhouseholdeverbeenconvictedofanyfelonyormisdemeanorotherthantrafficviolations?YES NO

Haveyouor anymemberofyourhouseholdevercommittedanyfraudinafederallyassistedhousingprogramorbeenrequestedtorepaymoneyforImowingly misrepresentinginformationforsuchhousingprograms?

YESNO

HaveyouoranyothermemberofyourhouseholdeverusedanynameorSocialSecuritynumbers otherthantheoneyouhavegivenonthisapplication?

YESNO

AGREEMENTS, REPRESENTATIONS liNDCERTIFICJITIONS

Applicantauthorizedtheownertoobtaina"consumerreport"asdefinedintheFairCreditReportingAct,15 U.S.C. Sec.1681a(d), seekinginformationonthecreditworthiness,creditstanding,creditcapacity,character, generalreputation,personalcharacteristics,or modeoflivingofapplicant(s).

IfullyunderstandthatTitle18,Section1001oftheUnitedStatesCode,statesthatapersonisguiltyofafelony,forJmowinglyandwillinglymakingfalseorfraudulentstatementstoanydepartmentoragencyoftheUnitedStates.I,therefore,verifythattheforegoinginformationistrueandcorrecttothebestofmyJmowledgeandbelief.

ApplicantDate: Co-Applicant Date: Otheradult: Date: Representative: Date:

ThefollowinginformationisrequestedbytheFederalGovernmentinordertomonitorcompliancewithFederallawsprohibitingagainstseekingtoparticipate inthisprogram.Youarenotrequiredtofurnishthisinformation,butareencouragedtodoso.Thisinformationwillnotbeusedinevaluatingyourapplicationortodiscriminateagainstyouinanyway.However,ifyouchoosenottofurnishit,wearerequiredtonotetherace/nationaloriginofindividualapplicantsonthebasisofvisualobservationorsurname:

Gender:Ethnicity:

Male_Female_

HispanicorLatinoNotHispanicorLatino_

Race:(Markoneormore)

WhiteBlackorAfricanAmericanAmerican Indian/AlaskaNative_AsianNativeHawaiianorOtherPacificIslander

CERTIFICATION/AUTHORIZATIONCERTIFICATION:

!/Weherebycertifythat!/Wedo/willnotmaintainaseparatesubsidizedrental

unitinanotherlocation. !/Wefurthercertifythatthiswillbe my/ourpermanentresidence.!/Weunderstand!/Wemustpayasecuritydepositforthisapartmentpriortooccupancy. 1/Weunderstandthatmyeligibilityforhousingwillbebasedonionincome/occupancylimitsandbyPutnamCountyHousingCorporation'sselectioncriteria.!/Wecertifythatallinformationinthisapplicationistruetothebestofmy/ourImowledgeand!/WeunderstandthatfalsestatementsorinformationarepunishablebyJawandwillleadtocancellationofthisapplicationorterminationoftenancyafteroccupancy.

SIGNATURE:

APPLICANTCO-APPLICANT

DATEDDATED

AUTHORIZATION

!/WeDoHerebyAuthorizePutnamCountyHousingCorporationanditsstaff orauthorizedrepresentativetocontactanyagencies,localpolicedepartments,offices,groupsororganizationstoobtainandverifyanyinformationofmaterialswhicharedeemednecessarytocomplete my/ourapplicationforhousing inprogramsadministered/managedbyPutnamCountyHousingCorporation.

SIGNATURE:

APPLICANTCO-APPLICANT

DATEDDATED

REV.09/03/09

DearApplicant:

WearepleasedthatyouhavechosentoapplytoourSeniorHousingComplexes. ThePutnamCountyHousingCorporationhasbeenstudyingchangesthatareoccurringinthemanagementofapm1ments. Manyownershavedecidedtoregulatetheuseoftobaccoproductswithintheirproperties.

Toensurethehealthandsafetyofallpersonslivinginourcomplexes,wehavedecidedtoadoptasmoke-freepolicyforourbuildingsandindividualunitsasofJanuarv1, 2011. Allresidentswillbeprohibitedfromsmokinginthetenantslivingspace,commonm·eas(hallwaysandlobby)andwithin30feetofbuildingentrances.

Weareadvisingallapplicantsonourwaitinglistsofthischange.

A.Incomepermonth.Xl2peryear

.

I.Earnings

.

2.Pensions

3.Benefits\''·...

4.Other(interests)

i.

\

TOTALINCOME:

B.Expenses:.

HOUSING

..

Rent/Mortgage

Home-RepairsMaintenance(appliances,lawncare,snowremoval,

paint,etc.)·.

Taxes,Insurance,OtherChargesCounty,Town,Village,SchoolWater/SewerFees

HomeownersInsurance

UTILITIES.

Fuel

Electricity'

TRANSPORTATION,.

AutoExpenses(gas,oil,repair,tires,registration,ins.ifnoauto,transportationexpense)

.

FOOD&BASICNEEDS

PERSONAL&RECREATION

Clothing

b. Expenses-continutedper monthX12peryear

Personal(beautybarbersho.p,toiletries,cigarettes,liquor)

ContributionsGifts(includeChristmas,church,charities)

Telephone.

Recreational(travel,movies,restaurant,bingo,etc.)

MEDICAL/INSURANCE

Medical(incl.dentist,doctor,prescrip-tions,overcounterdrugs,vitamins,healthinsurance)

LifeInsurance/Accidental

MonthlyInstallmentPayments1.

2.

3.

TOTALEXPENSES:

Subtract A-B=