<p> A</p><p>PRELIMINARY HOUSING APPLICATION For A-HOME’s Independent Supportive Housing Programs</p><p>Date of application______</p><p>Last Name: ______First Name: ______MI: ____ Current Address:______City, State, Zip Code:______Home phone number: ______Work phone number:______Cell phone number:______E-Mail Address:______</p><p>Family Composition: list all individuals who will be residing in the unit Name first, last Relationship Age</p><p>SELF</p><p>Are you a resident of Westchester County?  YES  NO Are any of your family Westchester residents?  YES  NO</p><p>How did you learn about A-HOME? ______</p><p>Name, Agency and Phone # (if applicable) of person who referred you to A-HOME: ______</p><p>Why are you applying? (Check all that apply)  Economic/ Financial (cannot afford present rent/mortgage/maintenance)  Homeless  Potentially Homeless  In temporary or time limited housing  Companionship House/apartment is too big or small  Better Living environment  House/apartment not equipped for a disabled person  More Independence  Other (specify)______</p><p>Do you have a Section 8 housing voucher?  Yes  No If yes, which Section 8 office? (County/ Municipality/ specify)______1 A</p><p>RESIDENCES: Where have you lived in the past? Start with most recent: Type of Rent amount Location Dates Reason for moving Housing (From/To)</p><p>FINANCIAL INFORMATION What is the total annual income you and all individuals who will be living with you? _____under $20,000 _____$20,000-$40,000 _____$41,000-$60,000 _____$61,000-$80,000 _____$Over $80,000</p><p>What is your income source (employment, Social Security, pension, investments, etc.)?</p><p>______</p><p>Which type of independent housing program would you like to apply for? (Check all that apply).  Senior shared living (55 years old +)  Senior apartments (55 years old +) (studio, one bedroom)  Disabled shared living  Single parent family apartment (one bedroom, two bedroom)  Low-income family apartment (two bedroom)  Accessory apartment program ( studio one bedroom,  two bedroom)  First time home ownership</p><p>I hereby affirm that the above information is true and current. Falsification of information can result in termination of the application process or eviction.</p><p>Signature:______Date: ______</p><p>Please return to: A-HOME 141 Tompkins Avenue, 3rd Floor Pleasantville, NY 10570 Phone Number: 914-741-0740 Fax: 914-741-0777 E-Mail: a-home@a-homehousing.org Website: a-homehousing.org</p><p>2</p>