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SBH Poll

How did you hear about Snow Belt Housing?
 
Regular Rental Application 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


Rental Application


Date: ________________
Name of Applicant ___________________________________________________________

Current Address: ____________________________________________________________

__________________________________________________________________________
Phone #:________________________  
Current Rent: ______________________
Dates Resided____/____/______to_____/_____/______

Utilities Included: ____________  Is it subsidized ______________

Reason For Moving: ___________________________________________________________________

Landlord Name: ______________________________________________________________________

Landlord Phone Number: _______________________________________________________________


Rental History

Previous Address: _____________________________________________________________________

_____________________________________________________________________

Rent: ____________________ Dates Resided____/____/______to_____/_____/______

Reason For Moving: ___________________________________________________________________

Landlord Name: ___________________________________________________________________

Landlord Phone Number: ________________________________________________________________

Previous Address: ______________________________________________________________________

_______________________________________________________________________

Rent: ______________________ Dates Resided____/____/______to_____/_____/______

Reason For Moving: _______________________________________________________________________

Landlord Name: _______________________________________________________________________

Landlord Phone Number: _________________________________________________________________

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General Questions


Are you receiving housing assistance? ______ If not are you on the waiting list?___________

Are you current with your utility companies? _____ If not how much is in collection?__________

Electric Company Name _________________ Account Number _______________________

Heat Company Name __________________ Account Number ________________________

Do you have any pets? ______ Type ______________________Does anyone smoke? ________

Vehicle 1: Year _________ Make ____________ Model _________________________

Color ________________ Plate # ______________ HH Member: _____________________

Vehicle 2: Year _________ Make ____________ Model _________________________

Color ________________ Plate # ______________ HH Member: _____________________

Military Status ______________If So Whom: ______________________________________

Has anyone in the household been convicted of a felony: ___________________________

Has anyone in the household been convicted of sale, distribution, or possession of illegal drugs?

______________________________________________________________________________________

 

Type of Apartment Desired

 

Number of Bedrooms _____ Upper or Lower Apartment ________ Location: ____________

Amount of Rent you can afford? ____________
Do you need a Handicapped Accessible unit?______________

 

Household Information

Please fill in for all household members that will be living in the rental unit:

 

Head of Household Name: ______________________ Alias’s/ Maiden Name ______________

Relation to Head of Household:   Self    DOB ___/____/_____
Social Security #: _____________________

Drivers License #: _____________________ Disabled or Handicapped ________________
60 or Over ____

Source of Income: _______________ Monthly Income: _____________________________

Employer Name: ___________________________ How Long Employed? ______________

Employer Address: _______________________________ Phone # __________________

 

Household Member #2 Name: ______________________Alias’s/ Maiden Name: ___________

Relation to Head of Household: ___________ DOB ___/____/_____
Social Security #: ___________________

Drivers License #: _____________________ Disabled or Handicapped ________________
60 or Over ____

Source of Income: _______________ Monthly Income: ___________________________

Employer Name: ___________________________ How Long Employed? _____________

Employer Address: _______________________________ Phone # _________________

 

Household Member #3 Name: _____________________ Alias’s/ Maiden Name: ___________

Relation to Head of Household: ___________ DOB ___/____/_____
Social Security #: ___________________

Drivers License #: ____________________ Disabled or Handicapped __________________
60 or Over ____

Source of Income: _______________ Monthly Income: ______________________________

Employer Name: ___________________________ How Long Employed? _______________

Employer Address: _______________________________Phone # ____________________

 

Household Member #4 Name: ____________________Alias’s/ Maiden Name: ______________

Relation to Head of Household: ___________ DOB ___/____/_____
Social Security #: ___________________

Drivers License #: ___________________ Disabled or Handicapped __________________
60 or Over ____

Source of Income: ___________________ Monthly Income: _______________________

Employer Name: ___________________________How Long Employed? _______________

Employer Address: _______________________________ Phone # ________________

 

Household Member #5 Name: ____________________Alias’s/ Maiden Name: ___________

Relation to Head of Household: ___________ DOB ___/____/_____
Social Security #: ___________________

Drivers License #: __________________ Disabled or Handicapped __________________
60 or Over ____

Source of Income: ___________________Monthly Income: ________________________

Employer Name: ___________________________ How Long Employed? ______________

Employer Address: ______________________________Phone # ________________


Character References

 

Please list three character references (Cannot be relatives):


1. Name: ___________________ Relationship: _______________ Phone # ______________

Address: __________________________________________________________________

 

2. Name: ___________________ Relationship: _______________ Phone # ______________

Address: __________________________________________________________________

 

Credit References

 

Please list two credit references (Example- National Grid, Frontier, Time Warner Cable, AT&T)

1. Name: ___________________Address: _____________________ Phone # _____________

2. Name: __________________  Address: _____________________ Phone # _____________

 

Emergency Contact: ________________________Address: ___________________________

Phone # _____________________Relationship: ____________________________________

 

Name of Nearest Relative: ___________________ Address: ___________________________

Phone # ____________________________ Relationship: _____________________________

 

Referred to us by: ___________________________________________________________________________

(How did you hear about us?)

 

I/WE HEREBY CERTIFY THE INFORMATION PROVIDED TO BE TRUE TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF. I/WE DO HEREBY AUTHORIZE SNOW BELT HOUSING COMPANY, INC., 7500 SOUTH STATE STREET LOWVILLE NY 13367 AND ITS STAFF OR AUTHORIZED REPRESENTATION TO CONTACT ANY AGENCIES, 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 PROPERTY MANAGED BYSNOW BELT HOUSING COMPANY, INC.

 

Applicant Signature: _______________________________________ Date: _____________

Co-Applicant Signature: ____________________________________ Date: _____________

Co-Applicant Signature: ____________________________________ Date: _____________

Co-Applicant Signature: ____________________________________ Date: _____________

Comments: _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION

 

CONSENT

 

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

*PHFA

 

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.

 

GROUPS OR INDIVIDUALS THAT MAY BE ASKED

 

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)

 

COMPUTER MATCHING NOTICE AND CONSENT

 

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.

 

CONDITIONS

 

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.