The Village of Great Neck Housing Authority
700 Middle Neck Road
Great Neck, NY 11023
APPLICATION FOR SUBSIDIZED HOUSING
INSTRUCTIONS: Please read completely. Using ink, neatly print the information requested on this form. If you need more space, please attach separate sheets of paper.
Please answer carefully and completely as this information will be used to determine eligibility.
APPLICANT INFORMATION:
1. Name______Social Security #______Present Address______Apt. Age______
City/Town State Zip Code______
Home Phone______Work Phone______Cell Phone______
2. Racial Designation: Responding to this question is optional. Your response is being requested to comply with equal opportunity requirements. It is voluntary and for statistical purposes only.
Circle One: White Black Hispanic Asian American Indian
Other
3. Members of Household to Live in Unit, INCLUDING Head of Household:
LAST name, FIRST name and Middle Initial, of each member /Sex
M/F / Relationship to Head / SS Number / Birth Datemm/dd/yyyy / Place of Birth / Age
1. /
HEAD
2.A. RENTAL INFORMATION:
How long have you lived at your present address? ______
Do you: _____Own your own home? _____Rent? _____Live with others?
If you live with others, who?______
Present Landlord’s Name:______
Present Landlord’s Address:______Phone:______
VOGNHA APP 2010
List addresses for the past five years, starting with your current address:
*Address: Years
Name of Landlord Phone
Address of Landlord Rent/Utility Cost
*Address: Years
Name of Landlord Phone
Address of Landlord Rent/Utility Cost
*Address: Years
Name of Landlord Phone
Address of Landlord Rent/Utility Cost
Failure to provide COMPLETE names and addresses for landlords will result in withdrawal of the application.
Current Monthly Housing Expenses:
______Rent/Mortgage ______Electricity ______Gas/Oil ______Water/Sewer
______Taxes ______Telephone ______Cable
Are you currently receiving Section 8 subsidy? ( ) YES ( ) NO
Have you or any other member of your household been forced to move because of Gov action? ( )YES ( )NO
If yes, for what reason?______
Have you been asked to move by your landlord? ( ) YES ( ) NO
If yes, for what reason?______
B. DISABILITY/ACCESSIBILITY INFORMATION:
Has the head of household or the spouse been declared disabled or handicapped by the
Veteran’s Administration______, the Social Security Administration______, or other government agency ?
If other government agency, please specify______
Do any family members require an accessible unit? ______
If you are requesting a Wheelchair-Accessible Unit, please specify your needs:
C. INCOME INFORMATION: Please list all sources of gross income for all applying members. These sources include Social Security, SSD, SSI, Salary (gross amount), Self-Employed Income, Pension or Annuity, Welfare, General Assistance, Child Support, Workmen’s Compensation, Unemployment, Alimony and any other source of earned or unearned income.
Income Before Deductions: Estimate the gross income anticipated for all household members from all sources for the next 12 months. Specify all sources. Please supply documentation for all income listed.
Household Member
/ Type of income / Name and address of employer or source of income / Income from this source for next 12 months1. / Social Security, Salaries, wages, commissions, including overtime
2.
1. / Veteran’s Aid, Pension,
SSI, SSD or
VA
Disability
2.
1. / Gross income from self-employment or profession
2.
1. / Trust income, tips, bonuses, interest and dividends
2.
1. / IRA, pensions, annuities
etc.
2.
1. / Unemployment
or
disability compensation
2.
1. / Alimony, foster care, child support payments, gifts
2.
1. / Rental or any other income
2.
1. / Regular allowance from another person, family, lottery winnings
2.
D. BANKING INFORMATION:
Name of Bank
/Account Number
/Type of Account
/Int. Rate%
/Balance
1. / % / $2. / % / $
1. / % / $
2. / % / $
1. / % / $
2. / % / $
E. ASSET INFORMATION: (Real Estate, Stocks Bonds, US Savings bonds)
Asset Holder
/ Asset Description /Current/Disposed
/ Market Value / Cash Value / Interest Rate / Annual Income$ / $ / % / $
$ / $ / % / $
$ / $ / % / $
$ / $ / % / $
$ / $ / % / $
$ / $ / % / $
Have you sold or transferred any property in the last four (4) years? ( ) YES ( ) NO
If YES, what was the date of the sale? Day Month Year
What was the sale price? What was the value of the mortgage?______
Do you currently own a home or have interest in any real property?
Does anyone in your household own a car? ( ) YES ( ) NO
Make of car Year Registration No.
F. EXPENSE INFORMATION:
Un-reimbursed medical expenses for the past 12 months (include prescription drugs)______
Health insurance costs for the past 12 months ______
Other expenses
______
G. LOCAL PREFERENCE INFORMATION:
Do you currently live in the Village of Great Neck? ( ) YES ( ) NO
If so, how long have you lived in the Village of Great Neck? ______
Do you work in the Village of Great Neck? ( ) YES ( ) NO
Single family unit occupied by you alone, or by you and another family? ( ) Alone ( ) Another family
Do you have a private kitchen? ( ) YES ( ) NO
Do you have a private bathroom? ( ) YES ( ) NO
Do you have a safe adequate source of heat? ( ) YES ( ) NO
Do you have a safe, adequate power (electric) service? ( ) YES ( ) NO
Has the Village of Great Neck notified you or your landlord that your unit is substandard? ( ) YES ( ) NO
H. PROGRAM INTEGRITY INFORMATION:
Do you expect anyone to move in or out of your household within the next 12 months? ( ) YES ( ) NO
Does anyone live with you now who is not listed above? ( ) YES ( ) NO
Do you have any pets? ( ) YES ( ) NO Please describe
Have you ever lived in subsidized housing before? ( ) YES ( ) NO
If yes: When?______Where?______
Under what name?______Head of Household?______
Have you ever used a name other than the one you are using now? ( ) YES ( ) NO
What name?______
Have you ever used a social security number other than the one you listed above? ( ) YES ( ) NO
Have you or anyone in your household ever been arrested for or evicted from Public or Assisted housing for violent criminal or drug related activity? ( ) YES ( ) NO
Has anyone in your household ever been charged or convicted of a crime? ( ) YES ( ) NO
If yes: Who?______When?______
APPLICANT’S CERTIFICATION
I understand that this application is not an offer of housing. I understand that any misrepresentation of information or failure to disclose information requested on this application may disqualify me from consideration for admission or participation. I understand that it is my responsibility to inform the Housing Authority in writing regarding any changes of address, income or household composition.
Therefore, I certify that all of the above information is true and complete to the best of my knowledge and belief.
Signature of Head of Household______Date______
Signature of other applying member ______Date______
ThE Village of GREAT NECK HOUSING AUTHORITY
700 Middle Neck Road
Great Neck, New York 11023
(516) 482-2727
Fax (516) 829-0551
To be completed by each person applying for subsidized housing
APPLICANT NAME:______
SOCIAL SECURITY #:______DATE OF BIRTH:______
The individual named above is an applicant for or recipient of housing assistance which is subsidized through the Department of Housing and Urban Development. Federal regulations require that in order for the family to be eligible, we must verify the family’s income, expenses, rental history, and criminal history. We also require release of pertinent medical history and credit information.
The individual has authorized below your release of any requested information. The information you provide will be used only for the purpose of determining the family’s eligibility for the program. We are required to complete our verification process in a short time period and would appreciate your prompt response.
By submitting this application, I/we authorize The Village of Great Neck Housing Authority to conduct credit, income, criminal history, tenant investigations, and searching alias names of the applicants, the results of which may bear on the admission process.
If you should have any questions, please feel free to contact our office. Thank you for your cooperation.
Janice Sotero, MA, PHM
Executive Director
I UNDERSTAND THAT A PHOTOCOPY OF THIS RELEASE IS AS VALID AS THE ORIGINAL.
I, ______, hereby authorize the release of information requested by The Great Neck Housing Authority.
______
Signature
Name:______
Address:______
Date:______
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any Department of Agency of the United States as to any matter within its jurisdiction.
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