Housing Application

NOTE: THERE IS A DIFFERENT APPLICATION FOR AGE-RESTRICTED (55 years or older+) HOUSING ASSISTANCE











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 Residence
(if different than above) __________________________________________________________

Telephone Number:________________________________________________________________
Home Work

Social Security Number ____________________________________________________________

School District of Primary Residence:___________________________________________________

Number of years you have lived at this address? ____________If less than 3 years at current 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? _______________________________________________________________
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 $______________ Previous Employer:

____________________________________________
Phone: _____________________________________
Position: ____________________________________
Dates: ______________________________________
Yes No Gross Monthly Income Yes No Gross Monthly Income
Employment
Wages Other Payments
Alimony
Overtime Child Support
Commissions Inheritance
Fees/Tips Trust
Bonuses Lottery
Housing/Food Allowance
Benefit Payments Asset Information (includes personal property valued in excess of $10, 000)
Social Security Checking
SSI/SSDI Name of institution
Workers Comp Balance $
Disability pay
Unemployment Savings
Severance 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 Money market
Welfare Mutual funds
Other IRA/Keogh/401k
Life Insurance
Real Property
Personal Property (car, boat, etc.)
Other Assets (specify name of joint assets)
Total Income Total Assets

DEBT
INFORMATION
Creditor’s Name Unpaid Balance Monthly Payment





Please list additional information on a separate sheet of paper, if necessary.


HOUSING ASSISTANCE REQUEST

Please indicate the type of housing assistance that you are seeking. Check all that apply.
? Apartment Bedrooms needed ______________________________
? Permanent Housing Bedrooms needed _______________________________
? Hamlet/Village Preference___________________________________________________
? 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.


July 2011