FRIEDRICHS RESIDENCE AT WARTBURG 3 Wartburg Place, Mt. Vernon, New York (Westchester County) (61 Studio & One Bedroom Apartments available to seniors ages 62 and older)
1. Mail one application per household. If your name appears on more than one application you will be disqualified. 2. Applications must be signed on pages 4 and 5. 3. Applications must be returned by mail with Supporting Documentation. M a il A pp li c at i on to: Friedrichs Residence Attn: Janet Palazzolo 3 Wartburg Place Mount Vernon, NY 10552
Phone 914.513.5295
This information is to be filled out by the APPLICANT!
1. A PP L ICA N T I N F O R M A T IO N :
Name:
Address: Apt#:
City: State: Zip:
Home Phone: Cell Phone: Work Phone:
SSN: DOB: Gross Income:
Email: …………………………………………………………………………………………………………………
2. CO - A PPL ICA N T I N F O R M A T I O N :
Name:
Address: Apt#:
City: State: Zip:
Home Phone: Cell Phone: Work Phone:
SSN: DOB: Gross Income:
Email: 3. LIST ALL PE RS ONS WHO WILL L IVE WIT H Y OU, ST ART WIT H Y OURSE LF:
FULL NAME RELATIONSHIP DATE OF BIRTH SEX a. H.O.H _
Social Security #: Occupation:
b. _
Social Security #: Occupation:
c. Do you expect any change (s) in your family size? YES NO
If Y ES, EXPLAIN:
……………………………………………………………………………………………………………………
4. ST AT IST ICAL INFOR MAT ION a. The following information is required for statistical purposes so that we may determine the degree to which our programs are utilized by people of different racial & ethnic backgrounds.
R A C I AL G R O U P I DENT I F I C A T ION : Used for statistical purposes only. (Please ch e c k o n l y o n e f rom t h is gro u p for the h ea d of h o u s e h old o n ly ).
S ingle Ra c e Mul ti- Rac e White American Indian or Alaska Native & White Black or African American Asian & White Asian Black or African American & White
American Indian or Alaska Native American Indian or Alaska Native & Black or Native Hawaiian or Other Pacific Islander African American Other Multi Racial b. ET H N I C IT Y : (check only one from this group) Hispanic Non-Hispanic c. OP TIONAL : (Not required to answer) Are you disabled or handicapped? YES NO 5. R E N T :
What is your Current Monthly Rent $ Check Utilities paid by you now: Heat $ per month
Electricity $ per month
Gas $ per month
Water $ per month
Other $ per month …………………………………………………………………………………………………………………………………………… 6. INCOME : List ALL full-time, part-time, seasonal and/or temporary employment for ALL household members. Include overtime pay, commissions, fees, tips, bonuses and/or self-employed earnings.
HOUSEHOLD EMPLOYER'S GROSS EARNINGS (Pre-Tax) MEMBER NAME/ADDRESS CURRENT ANTICIPATED
$ $ Weekly/ biweekly/ monthly (circle one)
$ $ Weekly/ biweekly/ monthly (circle one)
………………………………………………………………………………………………………………………………………………
7. O T H E R S OURCE OF I NCO M E :
(EXAMPLES: welfare, social security, SSI, pensions, disability compensation, unemployment compensation, interest, baby-sitting, care-giving, alimony, child support, annuities, dividends, income from rental property and/or Armed Forces Reserves.)
HOUSEHOLD MEMBER SOURCE AMOUNT
$ $ Weekly/ biweekly/ monthly (circle one) $ $
Weekly/ biweekly/ monthly (circle one)
. 8. HOUSE HOLD ASSE TS : C h e c ki n g A cc o u n t s : Bank: Acct. No.: Amt.: Bank: Acct. No.: Amt.:
Sa vin gs A c c o u n t s : (includes Passbook/Statement and Christmas/Vacation Clubs) Bank: Acct. No.: Amt.:
Bank: Acct. No.: Amt.:
Bank: Acct. No.: Amt.: Ce r t i f i c a te s of D epo s it ( C D' s) : Bank: Acct. No.: Amt.:
Bank: Acct. No.: Amt.:
Bank: Acct. No.: Amt.:
C r e d it U ni o n S h a r e s : Credit Union Name: Amt.:
Address
Stocks/Bonds (value): $ Savings Bonds (value):
Other Amt.: (includes IRA's, mutual funds, etc.) $
Does the applicant or co-applicant NO W own real YES NO estate:
If "yes", what is the estimated value:
Has the applicant or co-applicant EVE R owned real YES NO estate? If "yes", when? ………………………………………………………………………………………………………………………
CONSUMER CREDIT INFORMATION
I/ We hereby authorize Housing Action Council, Inc. and Wartburg Management Services, Inc. to use any consumer reporting agency, credit bureau or other investigative agencies employed by such, to investigate references, or statements or other data obtained from me or from any person pertaining to my employment history, credit, prior tenancies, character, general reputation, personal characteristics and mode of living, to obtain a consumer report and such other credit information which may result thereby, and to disclose and furnish such information to Housing Action Council and Wartburg Management Services, Inc., to the owner, and to agencies that made or will make funding available in connection with this property listed above in support of this application. I have been advised that I have the right, under 606B of the Fair Credit Reporting Act, to make a written request, within reasonable time, for a complete and accurate disclosure of the nature and scope of any investigation.
Applicant Signature Co-Applicant Signature Date . 9. DOCUME NT AT ION
All household members must submit C O P IES of the following documents with their application:
2015 & 2014 & 2013 W2’s a nd Federal Tax Returns with all Schedules Most Recent 6 Pay Stubs & documentation on any other source of income, e.g. social security, pension, disability insurance
6 Months of all Bank, Credit Union, and Investment Statements (all pages)
Most Recent Retirement Fund Account Statements (e.g. 403b, 401k)
Birth Certificate or current Driver’s License
Social Security Card
Deed to Real Property
Current Lease Last 3 canceled rent checks and or rent statements from landlord.
I DECLARE THAT THE STATEMENTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. WARN I NG : WILLFUL FALSE STATEMENTS OR MISREPRESENTATIONS ARE A CRIMINAL OFFENSE.
Applicant Signature Date
Co-Applicant Signature Date
…………………………………………………………………………………………………………………… …
10. HOW D I D Y OU H E AR ABOUT T H I S D E V E L O P M E N T ?
Friend Employer Sign Posted on Building
Website/ Internet (list site)
Newspaper (Identity): On-line Version?
Church/ Synagogue (Identify):
Community Organization (Identify): Other (Identify): . 1/1/2016