namea name="up" id="up">
No images

SBH Poll

How did you hear about Snow Belt Housing?
515 Elderly App 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


DATE RECEIVED:  _________________

                                                                        TIME RECEIVED:   _________________


The Snow Belt Housing Company, Inc. is the managing agent for three elderly housing projects.  Separate waiting lists are maintained for each project.  To request placement on our waiting list(s), please check your choice or choices below:


___ Sunrise Valley Apartments, DeKalb Junction, NY 13630

___ High Falls Apartments, Lyons Falls, NY 13368

___ Whitton Place Apartments, Port Leyden, NY 13433


The policy of the Snow Belt Housing Company, Inc. is to conduct business in accordance with applicable fair housing laws. We do not discriminate against any person because of race, familial status, color, religion, sex, or national origin.


Before we can process your application, it is necessary that you provide the correct legal name for each member of your household as it appears on the social security card, addresses, social security numbers, income and assets. List the tenant first, co-tenant second and other members of the household third, etc.


(If you are unable to fill out this application, someone may fill it out for you. That person must sign the last page as the person whose handwriting appears on the form)


APPLICANT: ________________________________PHONE NUMBER: _____________


PRESENT ADDRESS: _____________________________________________________




NAME                                         DATE OF BIRTH                           SOCIAL SECURITY #






1)      If married (by ceremony or common law) and the spouse are not listed on this application, list his/her name________________________Where does he/she live? ______________________

2)      Do you have any unusual expenses related to employment, such as a care attendant or auxiliary apparatus for a handicapped or disables family member? Yes ______ No ______

If yes, please explain ___________________________________________________

3)      Will any alterations to the apartment be necessary for a member of your family? Yes _____ No______ If yes, please explain_______________________________________________



NAME OF FAMILY MEMBER­                                          SOURCE OF INCOME

1.   A. ________________Social Security monthly amount $___________________________

B. ________________Social Security monthly amount $___________________________

2.   A. ________________Pension monthly amount $________________________________

B. ________________Pension monthly amount $________________________________

3. A. ________________ SSI Benefits monthly amount $____________________________

 B. ________________ SSI Benefits monthly amount $____________________________

4. A. ________________ Wages Gross monthly amount $___________________________

Employer’s Name & Address ________________________________________________

 B. ________________ Wages Gross monthly amount $____________________________

Employer’s Name & Address _______________________________________________

5. A. ________________ Unemployment Comp. monthly amount $____________________

 B. ________________ Unemployment Comp. monthly amount $_____________________

6. A. ________________ Social Services monthly amount $___________________________

 B. ________________ Social Services monthly amount $___________________________

7. A. ________________ Other Income monthly amount $____________________________

                                          Source ___________________________________________

 B. ________________ Other Income monthly amount $____________________________

                                          Source ___________________________________________

8. __________________ Alimony monthly amount $_________________________________

9. __________________ Child Support monthly amount $____________________________

10. _________________ Earned Income Tax Credit ANNUAL amount $_________________

11. _________________ Income from Investments monthly $__________________________

12. Do you anticipate any changes in this income during the next 12 months? Yes _____ No _____

 If yes, please explain __________________________________________________________

13. Does anyone in the household receive any regular contributions or gifts from non-household members? Yes _________ No _________ If yes, explain ______________________________

14. Do you expect anyone not listed on this application to be moving in with you in the future? Yes__________ No ____________If yes, explain __________________________________



1)      Have you sold any property on a deed of trust or mortgage whereby you are receiving periodic payments? ___Yes ___No

If yes, - current outstanding balance of contract $__________________as of _____________.

Interest Rate _______            Payment Amount $ __________

Payments are _____Monthly _____Quarterly _____ Annually _____ Other


Please attach an amortization schedule.


2)      Does anyone in the household own any property? Yes ____ No ____If yes, Type of property ______________________________________________________________________

Location __________________________________Appraised Market Value $______________

Mortgage or outstanding loans balance due $ _______________


Please attach a copy of your most recent tax bill.


3)      Have you disposed of any assets in the last two years? (Examples – given away money to relatives, set-up irrevocable trust accounts) ____ Yes ____No If yes, please describe asset ____________Date of disposition____________ Amount disposed $ ___________

4)      Do you have any other assets not listed above? (Excluding personal property) ______ Yes ______ No If yes, please describe ____________________________________________

5)   Do you have ACCESS to any other income or assets not listed above?  Yes ___ No ___

If Yes, list: ____________________________________________________________




List all assets for all household members.


CHECKING ACCOUNTS ______ Yes _______ No



Account #

Account Balance

Interest Rate






















SAVINGS, CD’s, MONEY MARKETS, ETC. ______ Yes ______ No



Account #

Account Balance

Interest Rate





















OTHER       (TYPE _______________)  ______ Yes  ______ No



Account #

Account Value/Market Value

Interest Rate/ Dividend
























Indicate on whose behalf medical expenses will be incurred for the next twelve months. Medical expenses may include insurance premiums, Medicare premiums, prescriptions, over the counter drugs with proper Dr’s verification, doctor visits, dentist visits, eye doctors, chiropractors, hospital visits, etc.


Health Insurance Company __________________________________________________

Insurer’s Name: _________________________

Health Insurance Company __________________________________________________

Insurer’s Name: _________________________

Premium $ __________ PAID _____ Monthly ______ Quarterly _______ Annually


Medicare Premiums:              

Insurer’s Name __________________Monthly Amount $________________

Insurer’s Name __________________Monthly Amount $________________


Anticipated Medical/Drug Prescription costs NOT covered by insurance or reimbursed:

Monthly Amount $________________


Medical Bills or outstanding costs YOU are making monthly payments for:

Balance Due: ____________  Monthly Payments: ___________ Payable to: __________


Please attach a drug profile for the past twelve months.


Name and Address of all Physicians you are seeing on a regular basis:




Any other medical expenses: Type ____________________________________________

Amounts _______________________________________________________________



1)      Are you applying for status as an “Elderly Household”, where the tenant or co-tenant is 62 or older, or disabled as defined by Rural Development? ______ Yes ______ No If so, do you realize you will be eligible for a $400.00 deduction and medical deductions? Please realize that your eligibility must be verified.

2)      Would you or any one in your household benefit from a handicapped accessible unit? ___ Yes ___ No

3)      Are you currently living in subsidized housing?  _____ Yes _____ No

4)      Have you ever resided in a project financed and/or subsidized by the Government? ____ Yes _____ No If yes, Name and address________________________________________________________________

5)      Have you ever been evicted from Public Housing or any other Federal Housing Program?

6)      ____Yes ____No  If yes, Where ______________________ When __________________

Describe reason: _______________________________________________________________

7)      Have you ever been evicted from other housing?  _____ Yes ______ No

8)      Are your bills current with the electric company?  _____ Yes ______ No

9)      Will you be able to get lights in your name with National Grid? _____ Yes ______ No

10)  How did you hear about this housing? ________________________________________

11)  Will you take an apartment when one is available? _____ Yes ______ No

12)  Briefly describe your reason for applying ________________________________________



1)      Have you ever been convicted of a felony offense?  ______ Yes ______ No

If yes, please describe convictions.  Please use back of application if you need additional space.


2)      Are you currently using illegal drugs?  _____ Yes  ______ No

3)      Have you ever been convicted of sale, distribution, or possession of illegal drugs? _____ Yes ____ No

4)      Have you or any one in your household (regardless of age) been arrested, charged or convicted for any of the following:

a.       Violent criminal activity?  _____ Yes _____ No If yes, please describe__________________

b.      Alcohol related activity?   _____ Yes _____ No If yes, please describe __________________

c.       Manufacture of methamphetamines?_____ Yes _____ No If yes, please describe___________




1.      Name ______________________ Address ___________________________ Phone _______________Tenant Address ____________________________________

2.      Name ______________________ Address ___________________________ Phone _______________ Tenant Address___________________________________

3.      Name ______________________ Address ___________________________ Phone _______________ Tenant Address____________________________________



1.      Name ________________ Address _____________________ Phone ____________

2.      Name ________________ Address _____________________ Phone ____________

3.      Name ________________ Address _____________________ Phone ____________



1.      Name ________________ Address ____________________ Phone ___________

2.      Name ________________ Address ____________________ Phone ___________





Do you own any pets?      _________ Yes __________ No

If yes, please describe ______________________________________________________________



List any cars, trucks or other vehicles owned.  Parking will be provided for one vehicle. Arrangements with management will be necessary for more than one vehicle.


TYPE                                 YEAR/MAKE                           COLOR                     LICENSE PLATE #

_____________                   _____________          ___________              _____________

_____________                   _____________          ___________              _____________

_____________                   _____________          ___________              _________________


“The information regarding race, ethnicity, and sex designation solicited on this application is requested in order to assure the Federal Government, acting through Rural Housing Service, which the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age, and disability are complied with.  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 anyway.  However, if you choose not to furnish it, the owner is required to note the race, ethnicity, and sex of individual applicants on the basis of visual observation or surname.”



Hispanic or Latino _______ 

Not Hispanic or Latino _________


Race: (Mark one or more)

White ________

Black or African American ___________

Asian _________

American Indian/Alaska Native ______________

Native Hawaiian or Other Pacific Islander _________



Male ____________ 

Female _____________


Equal Housing Opportunity-

In accordance with Federal law and the US Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability.  (Not all prohibited bases apply to all programs.)


To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call 800-795-3272 (voice) or 202-720-6382 (TDD).





I/we do hereby authorize the Snow Belt Housing Company, Inc., as managing agent and its staff or authorized representatives to contact any agencies, local police departments, Division of Criminal Justice services, offices, groups or organizations to obtain and verify any information or materials which are deemed necessary to complete my/our application for housing in this USDA, Rural Development 515 housing complex.


_______________________________                                _____________________

Applicant Signature                                                                                        Date



_______________________________                                 _____________________

Co-Applicant Signature                                                                                  Date




I/we hereby certify that I/we do/will not maintain a separate subsidized rental unit in a different location. 

I/we further certify that this will be my/our permanent residence. 

I/we understand I/we must pay a security deposit for this apartment.

I/we understand that my eligibility for housing will be based on Rural Development income limits. 

I/we certify that all information in this application is true to the best of my/our knowledge and that I/we understand that false statements or information are punishable by law and are grounds for denial of this application or termination of tenancy after occupancy. 


_______________________________________                  _____________________

Applicant Signature                                                                    Date


________________________________________                ____________________

Co-Applicant Signature                                                              Date





Applicant(s)/Tenant(s) please complete the following information. Please use your full legal name with middle initial. If your current address is less than five years please list additional address on back of form.


(A)  I, ______________________________ hereby state that I reside at ____________________________________________ that my date of birth is __________, and that my social security number is ______________________.


(B) I, _______________________________ hereby state that I reside at ______________________________________________ that my date of birth is _________, and that my social security number is ______________________.


I am an applicant for housing with the Snow Belt Housing Company, Inc. As a question for Snow Belt’s  tenant selection criteria concerns the existence of a criminal record. I hereby waive the right to privacy, to which I am otherwise entitled, and consent that any record of a criminal conviction pertaining to me be released to the Snow Belt Housing Company, Inc.


SIGNATURE: _______________________________________      DATE: ________________        


SIGNATURE: _______________________________________      DATE: ________________        



Existence of a Criminal Record to be verified by Sheriff’s Department:



Does the applicant(s)/tenant(s) have a criminal record? __________________________________

If yes, please describe ____________________________________________________________


Does the applicant(s)/tenant(s) posses a felony conviction? _______________________________


Has the applicant(s)/tenant(s) ever been involved in any illegal drug activity? ________________


Were the applicant(s)/tenant(s) ever convicted of any drug related offense(s)? ________________





I authorize and direct any Federal, State, or Local Agency, Organization, Business, or Individual to release to Snow Belt Housing Company, Inc. any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under one of the following programs:


*Rent Assistance Payments (RAP)            *DHCR

*Rent Supplement                                      *Section B Housing Assistance Payment Programs



I give my consent for the release also for the minor children in my care who live with me. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) and Rural Development in administering and enforcing program rules and policies.


Information Covered


I understand that, depending on program policies and requirements, previous or current information regarding myself or my household may be needed. Verifications and inquiries that may be requested, include but are not limited to:


        *Identity and Marital Status               *Employment

        *Income and Assets                            *Residences/Rental Activity

        *Medical or Child Care Allowances   *Social Security Numbers

        *Credit and Criminal Activity


I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in the housing assistance program.





The groups or individuals that may be asked to release the above information on (depending on program requirements) include but are not limited to:


*Welfare Agencies                                     *Past and Present Employers

*Post Offices                                              *State Unemployment Agencies

*Schools and Colleges                               *Social Security Administration

*Support and Alimony Providers               *Medical and Child Care Providers

*Veterans Administration                          *Banks and other Financial Institutions

*Retirement Systems                                  *Utility Companies

*Credit Providers and Credit Bureaus       *Previous Landlords (Including Public Housing Agencies)




I understand and agree that HUD or a Public Housing Authority (PHA) may conduct computer

matching programs to verify the information supplied for my certification or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove incorrect information. HUD or the PHA may in the course of its duties exchange such automated information with other Federal, State, or Local Agencies, including but not limited to: State Employment Security Agencies, Department of Defense, Office of Personnel Management, the U.S. Postal Service, the Social Security Agency, and State Welfare and Food Stamp Agencies.




I agree that a photocopy of this authorization may be for the purposes stated above. The original of this authorization is on file with the management office and will stay in effect for a year and one month from the date signed. I understand I have a right to review my file and correct any information that I can prove is correct.


Head of Household


_______________________________________________         __________________

Signature                                         (Print Name)                                                   Date


Co-Head of Household


_______________________________________________         __________________

Signature                                         (Print Name)                                                   Date


NOTE: This general consent may not be used to request a copy of a tax return. If a copy of a tax return is needed, IRS Form 4506 “Request for copy of Tax Form” must be prepared and signed separately.