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SBH Poll

How did you hear about Snow Belt Housing?
RehabApplication PDF Print E-mail

Snow Belt Housing Company, Inc.                Cheryl L. Shenkle-O’Neill, Executive Director

7500 South State Street * Lowville, NY  13367

(315) 376-2639 * (315) 376-2518 fax

NYS Relay Service No. – TTD 1-800-662-1220

E-mail: This e-mail address is being protected from spambots. You need JavaScript enabled to view it






Applicant’s Name                                                 Social Security Number         Date of birth



Co-Applicant’s Name                                            Social Security Number         Date of birth



Dependents                      (Name, Age, Relationship)



Other Adult Members of Household                (Non-Dependent)       (Name, Age, and Relationship)



911 Address:  (Street, Township, City, and Zip Code)                           Home Telephone Number



Mailing Address                   (if different than above)                             Cell Number

Email Address

How long at the above address?                                                                                                        



Earned Income (Include employment and self-employment income for all household members for the last tax year):


Name                                        Employer                              Annual Gross Wges                Date     






2011 Income - List all income (year-to-date earnings) for 2011:






Other Income Sources (Veterans, SSI, Pension, Rental Income, Interest, Child Support, Alimony, etc.):


$                                                         Per                  


$                                                        Per                   

Bank Accounts:                                                                    Name/Address of Bank(s)


____Yes   ____No    Checking $___________               ____________________________________ 


____Yes   ____No    Savings   $___________               ____________________________________



Other Assets - Please list your assets and estimate the value of:  home, car(s), other real property, mutual funds, stocks, bonds, etc.


                                            $                                                                           $                           




Debts - Please list your debts and the amounts:  mortgage installment accounts, auto and other loans. 


Debtor                        Purpose                      Pmt Amt                     Balance                    Date Incurred









Home Improvement – Have you owned and occupied your residence for one year or longer?

                                                Yes_____          or               No_____


Number of Rooms                          Number of Bedrooms                               Number of Baths        




*Directions to the Home*:                                                                                                                                      




Name of Title/Deed Holder(s):                                                                                                                          

What is your current property tax assessment?                                                                                     


Type of Home (i.e. single, multi-family, mobile, farm, etc.):                                                                   


Year Built (approximate):                                             Date of Mortgage (approximate):                       


CONFLICT OF INTEREST – Are you related to:


Any Board Member of Snow Belt Housing Company, Inc.?                      Yes_____          No_____

Any employee of Snow Belt Housing Company, Inc.?                             Yes_____          No_____

Any Public Official of the Municipality in which you live?                         Yes_____          No_____


Have you ever applied for a housing grant from another agency in Lewis County?  Yes___      No___


If YES, to what agency? ________________________________________________________________


If applied to another agency and not approved, why was it denied? _____     _________________________






Foundation:                                                                                           GOOD                      FAIR                   POOR


What type of foundation does your house have?                           _____                       ____                    ______


   _________________________                   Condition?                                                         





What type of roof (asphalt, shingle, metal roll)?                              _____                        _____                 ______





What type of siding?                                                                            _____                           _____                _____





Doors and Windows:                                                                         _____                             _____                  _____


How many doors?                       Condition?                                                                        

   Windows?                                               Condition?                                                         



Plumbing:                                                                                             _____                               _____                   _____


   Type of plumbing?                                    Condition?                                                              



:                                                                                               _____                             _____                  _____


   What size electrical entrance?                          Amps


   _____Fuse Type?             _____Breakers?       Do you use many extension cords?                             

Heating System
:                                                                                   _____                          _____                      _____


   What type of heating system?                                                                      


   How old is the heating system?                                                                     Years



What specific home improvements do YOU feel are most necessary?










The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program.  You are not required to furnish this information, but are encouraged to do so.  This information will not be used in evaluating your application or to discriminate against you in any way.  However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.




1.   Check applicable box:


 ___  White    ___  Black/African American    ____  Asian     ____  Asian & White   ____  American Indian/Alaskan Native 


  ____ Native Hawaiian/Other Pacific Islander     ____  American Indian/Alaskan Native & White     ____  Asian/Pacific Islander


  ____ Black/African American & White      ___  American Indian/Alaskan Native & Black/African American      
Other Multi-Racial



2.   Check applicable box:


______   Hispanic or Latino         _____     Not Hispanic or Latino



Federal and State Law prohibit discrimination on the basis of age, sex, race, national or ethnic origin, handicap or familial status.  Snow Belt Housing Company, Inc. is committed to serving its community without discrimination, and will comply with all rules and regulations regarding Fair Housing, Equal Opportunity, and Minority and Small Business Participation.  The following data is for statistical purposes only and will not be used by any local, state or federal agency in making decisions regarding assistance.



Sex of Head of Household:               ________        Male                      ________            Female



Age of Head of Household: ________years of age



Is any member of household handicapped?                _________        Yes               _________         No



Is any member of household disabled?                    __________          Yes          ___________               No














i.           I (we) hereby apply for Rehabilitation/Home Improvement financial assistance from Snow Belt Housing Company, Inc. for funds toward the cost of improvements to our existing owner-occupied home, which I (we) certify is my (our) legal, full-time, primary residence.


ii.          I (we) have read the accompanying Handbook and agree to sign a “5-year affordability/residency requirement agreement” for the amount of the cost of the rehabilitation work done to my (our) home.


iii.         I (we) hereby certify that the above statements are true, accurate, and complete to the best of my (our) knowledge and belief.  False statements made knowingly by applicant will disqualify the applicant from participation in the program and may be subject to prosecution.


iv.        I (we) hereby consent and authorize Snow Belt Housing Company, Inc. to: 


(a)    obtain verification of information required for compliance within the regulations of this program, including expenses, employment, property appraisal, contractor estimates, and credit report;


(b)    upon giving reasonable notice, to enter the applicant’s property for the purpose of determining what improvements are needed and to inspect completed work.


v.         I (we) hereby give Snow Belt Housing Company, Inc. permission to discuss this application and/or project with the following people (family members, partners, case workers, etc.) [check one box and fill in a, b, or c as necessary]:


 As listed below             or              With no one



Name & Telephone number                                                                Relationship



Name & Telephone number                                                                Relationship



Name & Telephone number                                                                Relationship



Applicant’s Signature                                  Date        Co-Applicant’s Signature                        Date



Household Member Signature #3 (adult)        Date        Print Name of Household Member #3      Date



Household Member Signature #4 (adult)        Date        Print Name of Household Member #4      Date



*What is the best way to reach you during business hours (Monday – Friday 9:00 am – 4:00 pm)

 (please provide-contact information)