Senior Housing Application 1People2Income3Info4Make a Budget5Certification6Disclosure Which senior housing are you applying for?*Please select one...Gleneida HousingGleneida Senior ApartmentsLakeview HousingSenior Housing at Mahopac HillsList each person who would live with you if you receive housing assistance. (Start with yourself.) Name* First Last Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexAnnual IncomeSocial Security*Add a person? Yes No Name First Last Date of BirthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexRelationshipAnnual IncomeSocial SecurityAdd another person? Yes No Name First Last Date of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SexRelationshipAnnual IncomeSocial Security List Annual IncomeName First Last Social Security BenefitSSIPension/VAOtherPerson Two Income Yes No Name First Last Social Security BenefitSSIPension/VAOtherPerson Three Income? Yes No Name First Last Social Security BenefitSSIPension/VAOther InformationCurrent Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone:Evening Phone:Email: Please identify any specific needs your household has:Are you Disabled? Yes No Do you need the design features of a wheelchair accessible unit? Yes No Have you ever been convicted of a felony? Yes No If yes, please explain:Do you own any property? Yes No If yes, type of property:Have you sold/disposed of any property in the last 2 years: Yes No If yes, market value when soldHave you disposed of any other assets in the past 2 years: Yes No If yes, explain: Check one box each “a” and “b” (For statistical purpose only) a. Is the head of household? American Indian or Alaska Asian Black or African Native Hawaiian or Pacific Islander White b. Ethnicity of the Head of Household: Hispanic or Latino Not Hispanic or Latino Make a Budget Use this worksheet to see how much money you spend this month. Then, use this month’s information to help you plan next month’s budget. Some bills are monthly and some come less often. If you have an expense that does not occur every month, put it in the “Other expenses this month” category. Date MM slash DD slash YYYY My income this monthPaychecks (salary after taxes, benefits, and check cashing fees)Other income (after taxes) for example: child supportTotal monthly incomeMy expenses this monthRent or mortgageRenter's insurance or homeowner's insuranceUtilities (like electricity and gas)Internet, cable, and phonesOther housing expenses (like property taxes)FoodGroceries and household suppliesMeals outOther food expensesTransportationPublic transportation and taxisGas for carParking and tollsCar maintenance (like oil changes)Car insuranceCar loanOther transportation expensesHealthMedicineHealth insuranceOther health expenses (like doctors' appointments and eyeglasses)Personal & FamilyChild careChild supportMoney given or sent to familyClothing and shoesLaundryDonationsEntertainment (like movies and amusement parks)Other personal or family expenses (like beauty care)FinanceFees for cashier's checks and money transfersPrepaid cards and phone cardsBank or credit card feesOther feesOtherSchool costs (like supplies, tuition, student loans)Other payments (like credit cards and savings)Other expenses this monthTotal monthly expensesMonthly Income - Monthly Expenses =Maybe your income is more than your expenses. You have money left to save or spend. Maybe your expenses are more than your income. Look at your budget to find expenses to cut. Applicant CertificationConsent I certify that the Statement made on this pre-application are true and complete to the best of my knowledge and belief. I understand that providing false statements or incomplete information may result in punishment under the Federal Law.SignatureDateMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Putnam County Housing Corporation Comprehensive Housing Counseling Program DisclosureConsent I/We understand that the purpose of the housing counseling program is to provide one-on-one counseling to assist me/us with our counseling needs.I/We understand that the purpose of the housing counseling program is to provide one-on-one counseling to assist me/us with our counseling needs. The counselor will analyze my/our financial situation, identify those barriers preventing me/us from resolving our current situation, and develop a plan to remove those barriers. I/We further understand that it will not be the responsibility of the counselor to fix the problem for me/us but rather to provide guidance and education to empower me/us in fixing those issues. Type of services we provide are: • Mortgage Delinquency and Default Resolution Counseling -Provides counseling to homeowners at risk or in foreclosure • Pre-purchase Counseling -Preparing clients to become first time homebuyers • Rental Housing Counseling -Assists clients with their housing and financial situation • Reverse Mortgage Counseling -Provides statutory-required counseling to clients age 62 or older who are interested in obtaining an FHA-insured HECM. • Services for Homeless Counseling -Counseling is provided to individuals needing information regarding emergency shelters, transitional housing and referrals. • Pre-purchase Homebuyer Education -Partners with eHomeAmerica to provide online homebuyer education for a fee of $99.00 Funders include U.S. Department of Housing and Urban Development, New York State Attorney General’s Office, the New York State Division of Housing and Community Renewal and the State of New York Mortgage Agency. Putnam County Housing Corporation offers the following services and has financial relationships with following industry partners: • HUD Housing Choice Voucher Program (Section 8) • HUD Comprehensive Housing Counseling Program • NYS Attorney General’s Home Ownership Protection Program (HOPP) • SONYMA/NCC Restart Program • Family Self-Sufficiency Program (FSS) • Federal Home Loan Bank (FHLB) Homebuyer Dream Program with local partners: Tompkins Mahopac Bank; M & T Bank; PCSB Bank; and Hudson Valley Federal Credit Union. • Lakeview Housing Development Fund • Gleneida Housing Development Fund • Gleneida Senior Apartments • Senior Housing at Mahopac HillsI/We understand that Putnam County Housing Corporation provides information and education on alternative services, programs and products. I/We further understand that we are not obligated to receive any other services offered by the organization or its exclusive partners. SignatureDate MM slash DD slash YYYY
