Apartment Application
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1
2
3APARTMENT APPLICATION
Directions:
Print or type all requested information and sign certification. Original application will be time and date stamped upon
receipt and entered into NYS Homes and Community Renewal’s Automated Waiting List (AWL) in chronological order. Applicant will be
given a print out of AWL summary with application number. Applicants can monitor waiting list position and update their contact
information using the AWL’s public access function @
Applicant Address:
Apartment #:______________ Street Address: _______________________________________ City:________________
State:____________ Zip Code:__________ Phone #:_______________________ Phone #:_______________________
Persons to Reside in Apartment:
(Must be completed. Head of household must be 18 years of age or older.)
R
H
ELATIONSHIP TO
EAD OF
N
A
*
S
*
S
S
N
.
AME
GE
EX
OCIAL
ECURITY
O
H
**
OUSEHOLD
* Must be supplied for any person less than 21 years of age: voluntary for other household members.
** Voluntary Information.
Apartment Size
:
(Select one or two sizes. Household size must meet applicable occupancy standards.)
Studio (1-2 ppl)
1-BR (1-2 ppl)
2-BR (2-4 ppl)
3-BR (4-6 ppl)
4 BR (5-8 ppl)
5 BR (8-10 ppl)
S
I
E
P
R
A
:
OURCES OF
NCOME FOR
ACH
ERSON TO
ESIDE IN
PARTMENT
Earnings (Include Self-Employment)
No. of Persons Employed
N
E
’
N
Z
C
H
L
A
E
AME
MPLOYER
S
AME AND
IP
ODE
OW
ONG
NNUAL
ARNINGS
A
E
DDRESS
MPLOYED
C
E
. N
YR
URRENT
ST
EXT
$
$
$
$
$
$
$
$
$
$
$
$
Special Requirements:
(Note that special requirements can extend your wait for an apartment.)
(Enter total estimated income for all household members,
Gross Household Income:
$___________________
from all sources, for the next 12 months.)
Veterans Admission Preference:
If head- or co-head of household is an honorably discharged veteran of the US Armed
Services, or such veteran’s surviving spouse, who served on active duty in time of war and resides in New York State, check box and
attaches DD-214 to qualify for admission preference.
Victim/Displaced Due to a Presidentially Declared Disaster:
If head or co-head of household is a victim/or is
currently displaced due to the Hurricane Irene, check box and attach proof to qualify for admission preference.
Certification:
(Head of household and co-head must sign and date.)
I certify statements made in this application have been examined by me and to the best of my knowledge and belief are true, correct
and complete. I have no objection to inquiries being made for the purpose of verifying the facts herein stated. I understand that if any of
the Information declared is false, my application will become void and I will lose my place on the wailing list. I further understand that the
filing of this application does not in any way bind the Housing Company to reserve or assign an apartment to me.
Head of Household Signature: ____________________________________________ Date: ___________
Co-Head of Household Signature: _________________________________________ Date: ___________
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