GENERAL INFORMATION:  Fill out completely.  Ranking is based on preference and date of application

Last Name:    First Name:  Phone (H):

City:       State:       Zip:    Phone (W):

Alternate Person To Contact: Phone:     

FAMILY COMPOSITION: (Persons who will move into the Project)

Absent Parent's Name:  Address:

Absent Parent's Name:  Address:

Absent Parent's Name:  Address:

Anticipated Changes In Family Composition:

The following information is Being Requested to Comply with Equal Opportunity Requirements; and to assure that no discrimination occurs.  Your answers will not affect (either positively or negatively) your selection for the program.

Preference I: Paying over 50% of Family Income for Rent.

III. INCOME (Total Income, e.g.  Wages, Social Security, Pension, Social Services, Interest and Other.)

                                                                        TOTAL      

                                           Multiply Total By 50% and divide by 12          

Did you file a federal income tax form last year ?

Number of bedrooms apartment

Present Monthly Rent     Monthly Utilities Cost    Total

Present total rent and utilities more than the amount in the gray box above ? If checked (yes), please mail copy of rental receipt and copy of Niagara Mohawk and/or utility bills.  If you pay for all utilities , please check below what utilities you for:

Heating                                        Cooking                        Water Heating

Gas  Oil Electric       Gas  Electric      Gas  Oil  Electric          Electric Lights

IV. Preference II: Living in Sub-Standard Housing - (lacks a major or has a serious code violation: Plumbing, Heating, Electrical)

Is your home substandard ?

If you claim sub-standard housing, you must submit statement from city code enforcement, landlord, or other appropriate agency or individual describing deficiencies.

Describe your current housing conditions:

Were you ever evicted ?  If yes, give reason below:

Do you presently have roaches ?

V. Assets (List all assets, e.g. Home, Stock, Bonds, Savings Account)

TYPE     VALUE    |  TYPE   VALUE

Name of Bank for Checking Account    Acct #

Name of Bank for Savings Account    Acct #

Others ?  If Yes, Please List    

Does anyone outside of your household pay for any bills or give you any money ? If Yes, Please explain:

Do you or any household member own or have an interest in any real estate, boat, and/or mobile home?  If Yes, please list:

Have you sold any real estate in the last two years?

Do you own any stocks or bonds?  If Yes, Please List:

Do you own a car?   Model:   Year:   Tag #:

Do you own a second car or other Motor Vehicle?

Model:   Year:   Tag #:

Preference III: Involuntarily Displaced

VI. DISPLACED:

Have you been displaced by Government Action ?

Are you presently displaced due to landlord action ?

Are you displaced by disaster (fire, flood )?

Are you displaced by a result of domestic violence?

Are you presently without or about to be without housing?

If yes, to any, please send a letter of certification that will verify displacement from appropriate agency or individual, giving details.

Preference IV: Veteran (Watervliet Resident Only)

If a Watervliet resident: are you or has any member of family been or is in Military Service?  If yes, please attach Discharge Papers

Handicapped:

Do you claim to be disabled or handicapped for the purpose of Housing?

Do you need a handicapped accessible unit?

General Comments:  Why do you want to or need to move ?

VII. List Three (3) References Excluding Relatives:

Name: Address: Phone:

Name: Address: Phone:

Name: Address: Phone:

VIII. Credit Reference

Name: Address: Acct #:

Name: Address: Acct #:

Niagara Mohawk Account #:

IX. List Your Landlords For The Past 5 Years, Including Your Present Landlord:

(1). Landlord Name: Address:

Apt Address: Landlord Phone:

Reason For Leaving:

(2). Landlord Name: Address:

Apt Address: Landlord Phone:

Reason For Leaving:

(3). Landlord Name: Address:

Apt Address: Landlord Phone:

Reason For Leaving:

X.

Have you or any other adult members ever used any name(s) or Social Security number(s) other than the one you are currently using?  If Yes, Explain:

Maiden Name of Wife or Alias:

Have you ever lived in Public Housing ? Where?

Have you ever lived in the City Of Watervliet?

If Yes:  Address: How Long?

Landlord's Name:

Have you or anyone in your household ever been convicted of any crime other than traffic violations? If Yes, explain - (applies to Public Housing Applicants Only):

Have you ever committed any fraud in a Federal Assistance Housing Program or been requested to repay money for knowingly misrepresenting information for such housing programs?  If Yes, Explain: