APPLICATION DEADLINE: JUNE 10, 2016

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1 APPLICATION DEADLINE: JUNE 10, 2016 Affordable Rental Housing for Seniors 55+ Grace Terrace in Mt. Vernon One Bedroom + 1 Bathroom Apartments Available Located at 125 S. Fifth Avenue, Mt. Vernon, New York Building & Community Features 66 One Bedroom Apartments, 10 Story Elevator Building, Community Room, Laundry Room, Non-Smoking, Resident Superintendent, Conveniently located near Shopping and Transportation # of Apartments Rents 21 $ $ $925 8 $1153 Maximum Household Income 1 person - $22,650 2 person - $25,890 1 person - $30,200 2 person - $34,520 1 person - $37,750 2 person - $43,150 Minimum Income $19,040 $26,800 $34,600 These 8 units are Project Based Section 8 units and are setaside for households who do not meet the minimum income requirements. These tenants will pay no more than 30% of their household income towards their rent. (Maximum Income 1 Person: $37,750 and 2 Persons $43,150) *Rents and Maximum Income Limits Subject to Change Questions: Housing Action Council at (914) or hac@affordablehomes.org or

2 GRACE TERRACE in MOUNT VERNON APPLICATION DEADLINE: JUNE 10, 2016 Only one (1) application per household. If your name is on more than one application you will be disqualified. Mail or Hand Deliver Application to: Housing Action Council at 55 South Broadway, Tarrytown, NY Phone: APPLICANT/ HOUSEHOLD INFORMATION (List all members of your household) NAME FIRST, MIDDLE INITIAL, LAST RELATIONSHIP TO HEAD OF HOUSEHOLD M/F SOCIAL SECURITY # DATE OF BIRTH 2. CURRENT HOUSING INFORMATION Current Address: Rent Own Phone# ( ) CURRENT RENT $ AVERAGE MONTHLY UTILITY COSTS $ Are you currently receiving Section 8 rental assistance? IF YES, does it come with the project or apartment? OR DO YOU HAVE A HOUSING CHOICE VOUCHER? Yes No Yes No Yes No 3. INCOME INFORMATION: INCLUDE ALL ANTICIPATED GROSS INCOME FOR THE NEXT TWELVE MONTHS FOR EACH MEMBER OF YOUR HOUSEHOLD 1. Employment Wages or Salaries (Include overtime, tips, bonuses, commissions & payments received) Household Member #1 Yearly Salary $ Company Name Company Address Supervisor/Contact Person Phone # Fax # Household Member # 2 Yearly Salary$ Company Name Company Address Supervisor/Contact Person Phone# Fax# 1

3 2. Self Employment (Attach Federal Tax Return or Profit & Loss Statements) Household Member Type of Business Anticipated Earnings for next 12 months $ 3. Unemployment Benefits, Workers Compensation, Public Assistance (circle type) Household Member Amount received per week $, Per month $ From (name of organization) Address Contact Person Phone # Fax # 4. Social Security, SSI, or any other payments from the Social Security Administration Household Member Gross amount per month before medicare deduction $ Household Member Gross amount per month before medicare deduction $ 5. Veteran Benefits, Pensions, Retirement Benefits or Annuities (circle type) Household Member Amount per month $ From Address: Household Member Amount per month $ From Address Contact Person Phone # Fax # 6. Regular Payments from any type of Settlements (Such as Insurance Settlements) Household member Amount per month $ From (Company Name) Address Contact Person Phone # Fax # 7. Alimony Payments (Any awarded amounts- collected or uncollected) Household Member Payor Amount per month $ 8. Disability, Death Benefits or Life Insurance Dividends (circle type) Household member Amount per month $ Source Address 2

4 9. Regular Gifts or Payments from anyone outside of the Household Household member Amount per month $ From Address Phone # Fax # 10. Lottery Winnings or Inheritances Family member Amount per year $ 11. Payments from Land contracts or other forms of Real Estate Household member Source Amount per year $ 12. Any other source of Income not listed above Household Member Source Amount $ Explanation 4. ASSET INFORMATION: MUST INCLUDE ALL ASSETS HELD BY YOU OR A MEMBER OF YOUR HOUSEHOLD. AN ASSET IS DEFINED AS ANY LUMP SUM AMOUNT THAT YOU HOLD AND CURRENTLY HAVE ACCESS TO. 1. Checking and Savings Accounts Bank Address Acct. # Chk /Sav Amount $ Int. % 2. CD s, Money Market Accounts and Treasury Bills Source Address Type of Acct. Acct. # Amount $ Interest (%) or Dividend ($) 3. Stocks, Bonds and Securities (circle type) Household Member Company Account # Address Contact Person Phone # Fax# 3

5 Value of Account $ as of (date) Dividend Paid $ How often Household Member Company Account # Address Contact Person Phone # Fax # Value of Account $ as of (date) Dividend Paid $ How often 4. Trust Funds Household Member Source Address Contact Person Value of Account$ Interest Paid % Is this a revocable trust? Is this an irrevocable trust? 5. Pensions, IRA s, Keoghs, or other retirement accounts (circle type) Household member Source Address Contact Person Phone # Fax # Value of Account $ Interest Paid % Household member Source Address Contact Person Phone # Fax # Value of Account $ Interest Paid % 6. Real Estate, rental property, land contracts/contracts for deeds or other real estate holdings (Include your personal residence, mobile homes, vacant land, farms, vacation homes, etc.) Household Member Type Value$ Assessor s Name Address Phone # 7. Cash on hand over $500 (Money not held in bank accounts) Household Member monetary value of contents $ 8. Personal Property as an investment (attach appraisal) This includes paintings, coin or stamp collections, antiques, etc. Household 4

6 Member Type Value$ 9. Safety Deposit Box Yes No If Yes, what is the value of the contents $ 10. Have you or any household member disposed of or given away any asset(s) for LESS than Fair Market Value within the last few years? Yes No If yes what is the value $ Explanation 5. REFERENCES Name NUMBER & STREET CITY,STATE, ZIP CODE PHONE # Personal Emergency Contact Previous Landlord 6. AUTOMOBILES: IF you own and operate a car, please complete. Head of Household License# State Co Head/Spouse License # State MAKE MODEL YEAR COLOR PLATE#/STATE MAKE MODEL YEAR COLOR PLATE#/STATE 7. SCREENING QUESTIONNAIRE Have you or any one else named on this application filed bankruptcy? Yes No Have you or any one else named on this application been convicted of a felony? Yes No Have you or anyone else named on this application been convicted for dealing or manufacturing illegal drugs? Yes No Have you or any one else named on this application been convicted of property damage? Yes No Have you ever been evicted from a rental unit of any type including an apartment, home, mobile home, or trailer? Yes No PLEASE EXPLAIN ANY YES ANSWERS TO THE QUESTIONS ABOVE 8. PETS: Do you have a pet? Please describe. 5

7 9. STATISTICAL INFORMATION a. The following information is required for statistical purposes so that the Department of Housing and Urban Development (HUD) may determine the degree to which its programs are utilized by people of different racial & ethnic backgrounds. RACIAL GROUP IDENTIFICATION: Used for statistical purposes only. (Please check only one from this group for the head of household only). White American Indian or Alaska Native & White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian & White Black or African American & White American Indian or Alaska Native & Black or African American Other Multi Racial b. ETHNICITY: (check only one from this group) Hispanic Non-Hispanic c. Do you need a handicapped adapted/adaptable apartment? YES NO 10. HOW DID YOU HEAR ABOUT THIS DEVELOPMENT? Friend Employer Sign Posted on Building Website/ Internet (list site) Newspaper (Identity): On-line Version? Church/ Synagogue (Identify): Community Organization (Identify): Other (Identify): Signature and Certification Clause I authorize my consent to have management verify the information contained in this application for purposes of proving my eligibility for occupancy. I will provide all the necessary information including source names, addresses, phone numbers, account numbers where applicable and any other information required for expediting this process. I understand that my occupancy is contingent on meeting management s resident selection criteria the Low Income Housing Tax Credit Program and the Westchester County Fair & Affordable Housing Program. I understand that management is relying on this information to prove my household s eligibility for the Low Income Housing Tax Credit Program and Westchester County Fair & Affordable Housing Program. I certify that all information and answers given above are true and complete. I understand that inquiries will be made to verify them, including a credit check, and I acknowledge that willful misrepresentation or falsification to any of the above will be deemed to be a default in a substantial and material obligation under any lease and a cause for immediate termination of said lease and eviction from the premises, if in occupancy or, if not in occupancy, a sufficient cause for the automatic declaration of ineligibility. ALL HOUSEHOLD MEMBERS MUST SIGN BELOW Signature Date Signature Date 6