RESIDENCES: Where have you lived in the past? Start with most recent: Type of Rent amount Location Dates Reason for moving Housing (From/To) 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 What is your income source (employment, Social Security, pension, investments, etc.)? __________________________________________________________________________ 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 I hereby affirm that the above information is true and current. Falsification of information can result in termination of the application process or eviction. Signature:____________________________ Date: __________________________ Please return to: A-HOME 141 Tompkins Avenue, 3rd Floor Pleasantville, NY 10570 Phone Number: 914-741-0740 Fax: 914-741-0777 E-Mail: Website: a-homehousing.org
RESIDENCES: Where have you lived in the past? Start with most recent: Type of Housing Rent amount Location Dates (From/To) Reason for moving 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 What is your income source (employment, Social Security, pension, investments, etc.)? __________________________________________________________________________ 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 I hereby affirm that the above information is true and current. Falsification of information can result in termination of the application process or eviction. Signature:____________________________ Date: __________________________ Please return to: A-HOME 141 Tompkins Avenue, 3rd Floor Pleasantville, NY 10570 Phone Number: 914-741-0740 Fax: 914-741-0777 E-Mail: Website: a-homehousing.org
A-%20Peliminary%20APPLICATION.docx