APPLICATION FOR PUBLIC HOUSING - Mhacy.com
APPLICATION FOR PUBLIC HOUSING - Mhacy.com APPLICATION FOR PUBLIC HOUSING - Mhacy.com
Client # ___________ THE MUNICIPAL HOUSING AUTHORITY FOR THE CITY OF YONKERS Entered Date ____________ 1511 CENTRAL PARK AVENUE – P.O. BOX 35 YONKERS, NY 10710 (914) 793-8497 THIS APPLICATION IS TO BE SUBMITTED THROUGH THE MAI L - DO NOT BRING TO THE OFFICE – PRELIMINARY APPLICATION FOR PUBLIC HOUSING APPLICANT INFORMATION Last Name ______________________First Name _________________MI _____Maiden Name (if appli.) ___________ Married __________ Single ___________ Divorced ___________ Separated ____________________ Non Hispanic: _____________ Hispanic: ______________ Sex: Male ___ Female____ Citizen: Yes_____ or No _____ Race: 1.White __ 2.Black __ 3.American Indian or Alaskan Native __ 4. Asian or Pacific Islander __ 5. Other (Specify) ________ Current Street Address ______________________________________________________ Apartment No. ___________ Have you ever lived in Public Housing? _________ Where? ________________________________________________ Were you ever evicted from Assisted Housing? ________. If yes: Eviction Date:_________________ Agency: ___________________City:___________________ State: ________ Employer _________________________________________________________ Telephone ______________________ City _______________________ State _________Zip Code ___________ CO- APPLICANT INFORMATION Last Name ______________________First Name _________________MI _____Maiden Name (if appli.) ___________ Married __________ Single ___________ Divorced ___________ Separated ____________________ Non Hispanic: _____________ Hispanic: ______________ Sex: Male ___ Female____ Citizen: Yes_____ or No _____ Race: 1.White __ 2.Black __ 3.American Indian or Alaskan Native __ 4. Asian or Pacific Islander __ 5. Other (Specify) ________ Current Street Address ______________________________________________________ Apartment No. ___________ Have you ever lived in Public Housing? _________ Where? ________________________________________________ Were you ever evicted from Assisted Housing? ________. If yes: Eviction Date:_________________ Agency: ___________________City:___________________ State: ________ Employer _________________________________________________________ Telephone ______________________ City _______________________ State _________Zip Code ___________ LIST OF ALL OCCUPANTS WHO WILL RESIDE IN NEW UNIT: LAST NAME FIRST NAME DATE OF BIRTH PLACE OF BIRTH SOCIAL SEC. # SEX RELATIONSHIP TO APPLICANT SELF _______________________________________________________________________________________________________________________________________ TOTAL INCOME OF ALL OCCUPANTS WHO WILL RESIDE IN YOUR NEW UNIT: (Wages, Social Security, Supplemental Security Income ( SSI), Public Assistance (DSS) and Pensions. LIST SOURCE OF INCOME NAME OF PERSON RECEIVING INCOME GROSS $ AMOUNT OF INCOME (Weekly, Bi-Weekly, Annual) ASSETS:(Please specify type) i.e.: Saving, Bonds, IRA, CD, Checking, etc. TYPE OF ASSET BANK NAME ACCOUNT HOLDER AMOUNT Do you own any property? Yes ___ No ___ Are you Handicapped or Disabled? Yes ___ No___ Are you a Veteran? Yes ____ No ____ Do you have a pet that will be moving in with you? Yes_____No _____ (if yes, what kind _________________). ALL THE INFORMATION IS HELD IN CONFIDENCE. THERE WILL BE NO DISCRIMINATION AGAINST ANY PERSON ON THE GROUNDS OF RACE, COLOR, CREED, RELIGION, SEX OR NATIONAL ORIGIN. THE ABOVE IN F ORMATION IS CORRECT TO THE BEST OF OUR KNOWLEDGE. I HAVE NO OBJECTION TO INQUIRIES FOR THE PURPOSE OF VERIFYING THE FACTS HEREIN STATED. ANY CHANGE TO THIS APPLICATION MUST BE SUBMITTED BY MAIL TO THE MUNICIPAL HOUSING AUTHORITY. WARNING: 18 U.S.C. 1001 PROVIDES THAT WHOEVER KNOWINGLY AND WILLINGLY MAKES OR USES A DOCUMENT OR WRITING CONTAINING ANY FALSE, FICTITIOUS, OR FRAUDULENT STATEMENT OR ENTRY, IN ANY MATTER WITHIN THE JURISDICTION OF ANY DEPARTMENT OR AGENCY OF THE UNITED STATES, SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISIONED FOR NOT MORE THAN FIVE YEARS, OR BOTH. _________________________________________ Signature REV 9/2009 _____________ Date
Client # ___________ THE MUNICIPAL <strong>HOUSING</strong> AUTHORITY <strong>FOR</strong> THE CITY OF YONKERS<br />
Entered Date ____________ 1511 CENTRAL PARK AVENUE – P.O. BOX 35<br />
YONKERS, NY 10710 (914) 793-8497<br />
THIS <strong>APPLICATION</strong> IS TO BE SUBMITTED THROUGH THE MAI L - DO NOT BRING TO THE OFFICE –<br />
PRELIMINARY <strong>APPLICATION</strong> <strong>FOR</strong> <strong>PUBLIC</strong> <strong>HOUSING</strong><br />
APPLICANT IN<strong>FOR</strong>MATION<br />
Last Name ______________________First Name _________________MI _____Maiden Name (if appli.) ___________<br />
Married __________ Single ___________ Divorced ___________ Separated ____________________<br />
Non Hispanic: _____________ Hispanic: ______________ Sex: Male ___ Female____ Citizen: Yes_____ or No _____<br />
Race: 1.White __ 2.Black __ 3.American Indian or Alaskan Native __ 4. Asian or Pacific Islander __ 5. Other (Specify) ________<br />
Current Street Address ______________________________________________________ Apartment No. ___________<br />
Have you ever lived in Public Housing? _________ Where? ________________________________________________<br />
Were you ever evicted from Assisted Housing? ________.<br />
If yes: Eviction Date:_________________ Agency: ___________________City:___________________ State: ________<br />
Employer _________________________________________________________ Telephone ______________________<br />
City _______________________ State _________Zip Code ___________<br />
CO- APPLICANT IN<strong>FOR</strong>MATION<br />
Last Name ______________________First Name _________________MI _____Maiden Name (if appli.) ___________<br />
Married __________ Single ___________ Divorced ___________ Separated ____________________<br />
Non Hispanic: _____________ Hispanic: ______________ Sex: Male ___ Female____ Citizen: Yes_____ or No _____<br />
Race: 1.White __ 2.Black __ 3.American Indian or Alaskan Native __ 4. Asian or Pacific Islander __ 5. Other (Specify) ________<br />
Current Street Address ______________________________________________________ Apartment No. ___________<br />
Have you ever lived in Public Housing? _________ Where? ________________________________________________<br />
Were you ever evicted from Assisted Housing? ________.<br />
If yes: Eviction Date:_________________ Agency: ___________________City:___________________ State: ________<br />
Employer _________________________________________________________ Telephone ______________________<br />
City _______________________ State _________Zip Code ___________<br />
LIST OF ALL OCCUPANTS WHO WILL RESIDE IN NEW UNIT:<br />
LAST NAME FIRST NAME DATE OF BIRTH PLACE OF BIRTH SOCIAL SEC. # SEX RELATIONSHIP<br />
TO APPLICANT<br />
SELF<br />
_______________________________________________________________________________________________________________________________________<br />
TOTAL INCOME OF ALL OCCUPANTS WHO WILL RESIDE IN YOUR NEW UNIT: (Wages, Social Security,<br />
Supplemental Security In<strong>com</strong>e ( SSI), Public Assistance (DSS) and Pensions.<br />
LIST SOURCE OF INCOME NAME OF PERSON RECEIVING INCOME GROSS $ AMOUNT OF INCOME<br />
(Weekly, Bi-Weekly, Annual)<br />
ASSETS:(Please specify type) i.e.: Saving, Bonds, IRA, CD, Checking, etc.<br />
TYPE OF ASSET BANK NAME ACCOUNT HOLDER AMOUNT<br />
Do you own any property? Yes ___ No ___<br />
Are you Handicapped or Disabled? Yes ___ No___<br />
Are you a Veteran? Yes ____ No ____<br />
Do you have a pet that will be moving in with you? Yes_____No _____ (if yes, what kind _________________).<br />
ALL THE IN<strong>FOR</strong>MATION IS HELD IN CONFIDENCE. THERE WILL BE NO DISCRIMINATION AGAINST ANY PERSON ON THE GROUNDS OF RACE,<br />
COLOR, CREED, RELIGION, SEX OR NATIONAL ORIGIN. THE ABOVE IN F ORMATION IS CORRECT TO THE BEST OF OUR KNOWLEDGE. I HAVE<br />
NO OBJECTION TO INQUIRIES <strong>FOR</strong> THE PURPOSE OF VERIFYING THE FACTS HEREIN STATED.<br />
ANY CHANGE TO THIS <strong>APPLICATION</strong> MUST BE SUBMITTED BY MAIL TO THE MUNICIPAL <strong>HOUSING</strong> AUTHORITY.<br />
WARNING: 18 U.S.C. 1001 PROVIDES THAT WHOEVER KNOWINGLY AND WILLINGLY MAKES OR USES A DOCUMENT OR WRITING<br />
CONTAINING ANY FALSE, FICTITIOUS, OR FRAUDULENT STATEMENT OR ENTRY, IN ANY MATTER WITHIN THE JURISDICTION OF ANY<br />
DEPARTMENT OR AGENCY OF THE UNITED STATES, SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISIONED <strong>FOR</strong> NOT MORE THAN FIVE<br />
YEARS, OR BOTH.<br />
_________________________________________<br />
Signature<br />
REV 9/2009<br />
_____________<br />
Date
Cliente# __________ LA AUTORIDAD MUNICIPAL DE VIVIENDA DE LA CIUDAD DE YONKERS<br />
Fecha de Entrada ____________ 1511 CENTRAL PARK AVENUE – P.O. BOX 35<br />
YONKERS, NY 10710 (914) 793-8497<br />
ÉSTA APLICACIÓN DEBE ENVIARSE POR CORREO POSTAL – POR FAVOR NO TRAER A LA OFICINA –<br />
APLICACIONES PRELIMINARES DE VIVIENDAS PÚBLICAS<br />
IN<strong>FOR</strong>MACIÓN DEL APLICANTE<br />
Apellido ______________________Nombre _________________Inicial _____Segundo Apellido (si aplica) ___________<br />
Casado(a) __________ Soltero(a) ___________ Divorciado(a) ___________ Separado(a) ____________________<br />
Hispano (a): __________ No Hispano (a): ___________ Sexo: Hombre ___ Mujer____ Ciudadano Americano: Si_____ No _____<br />
Raza: 1.Blanco ____ 2.Negro ____ 3.Indio Americano ____ 4. Asiático o Pacífico ____ 5. Otro (Especifique) _______________<br />
Dirección Actual ______________________________________________________ Apartamento No. ___________<br />
Ha vivido en Subsidios de Vivienda Pública? _________ Dónde? ________________________________________________<br />
Alguna vez usted ha sido desalojado (a) de su Vivienda? _______ .<br />
Si es afirmativo: Fecha de desalojo:______________ Agencia: ___________________Ciudad:________________ Estado: ________<br />
Empleador _________________________________________________________ Teléfono ______________________<br />
Ciudad _______________________ Estado _________Código Postal ___________<br />
IN<strong>FOR</strong>MACIÓN DEL CO-APLICANTE<br />
Apellido ______________________Nombre _________________Inicial _____ Segundo Apellido (si aplica) ___________<br />
Casado (a) __________ Soltero (a) ___________ Divorciado (a) ___________ Separado (a) ____________________<br />
Hispano (a): __________No Hispano (a): ___________ Sexo: Hombre ___ Mujer____ Ciudadano Americano: Si_____ No _____<br />
Raza: 1.Blanco ____ 2.Negro____ 3.Indio Americano ____ 4. Asiático o Pacífico ____ 5. Otro (Especifique) ________________<br />
Dirección Actual ______________________________________________________ Apartamento No. ___________<br />
Ha vivido en Subsidios de Vivienda Pública? _________ Dónde? ________________________________________________<br />
Alguna vez usted ha sido desalojado (a) de su Vivienda? ________.<br />
Si es afirmativo: Fecha de desalojo:_____________ Agencia: ___________________Ciudad:_________________ Estado: ________<br />
Empleador _________________________________________________________ Teléfono ______________________<br />
Ciudad _______________________ Estado _________Código Postal ___________<br />
LISTE TODOS LOS OCUPANTES QUE RESIDIRÁN EN LA UNIDAD:<br />
APELLIDO NOMBRE FECHA DE<br />
NACIMIENTO<br />
LUGAR DE<br />
NACIMIENTO<br />
SEGURO SOCIAL # SEXO RELACION<br />
CON EL<br />
APLICANTE<br />
CABEZA DE<br />
FAMILIA<br />
_______________________________________________________________________________________________________________________________________<br />
INGRESO TOTAL DE TODOS LOS OCUPANTES QUE RESIDIRÁN EN LA UNIDAD: (Salarios, Seguro Social,<br />
Seguro de Ingreso Suplementario ( SSI), Asistencia Pública (DSS) y Pensiones.<br />
LISTA DE INGRESOS<br />
NOMBRE DE LA PERSONA QUE RECIBE<br />
INGRESO<br />
INGRESO TOTAL (ANTES DE LOS TAXES)<br />
(Semanal-Quincenal-Anual)<br />
BIENES:(Por Favor indicar qué clase) i.e.: Cuentas de Ahorros/Cheques, Bonos, IRA, CD, etc.<br />
CLASES DE BIENES NOMBRE DEL BANCO TITULAR DE LA CUENTA CANTIDAD<br />
Usted posee alguna propiedad? Si ___ No ___<br />
Es usted íncapacitado o desabilitado? Si ___ No___<br />
Es usted un Veterano? Si ____ No ____<br />
Tiene una mascota que vivirá con usted? Si_____No _____ (Qué clase? _________________).<br />
TODA LA IN<strong>FOR</strong>MACIÓN ADQUIRIDA SERA CONFIDENCIAL. USTED NO SERA DESCRIMINADO POR RAZA, COLOR, SEXO, RELIGION O POR SU<br />
ORIGEN DE NACIONALIDAD. YO ADMITO QUE LA IN<strong>FOR</strong>MACION ANTERIOR DICHA SEGUN MI CONOCIMIENTO ES CORRECTA, Y NO TENGO<br />
NINGUNA O B J E C IÓ N PARA QUE TODA IN<strong>FOR</strong>MACION EN ESTE <strong>FOR</strong>MULARIO SEA VERIFICADA.<br />
CUALQUIER CAMBIO A ÉSTA APLICACIÓN DEBE SOMETERSE POR CORREO A DICHA OFICINA.<br />
ADVERTENCIA: 18 U.S.C. 1001 PROVEE QUE CUALQUIER PERSONA A SABIENDA Y QUE INTENCIONALMENTE HAGA USO DE ÉSTE<br />
DOCUMENTO O CUALQUIER MATERIAL ESCRITO USANDO FALSOS TESTIMONIOS, FICTICIO O FRAUDELENTO, DENTRO DE LA JURISDICCIÓN<br />
DE CUALQUIER DEPARTAMENTO O AGENCIA DE LOS ESTADOS UNIDOS, SERA MULTADO HASTA $10,000.00 DOLLARES, 5 AÑOS D E P R IS IO N,<br />
O AMBOS.<br />
______________________________________________<br />
Firma<br />
_________________________<br />
Fecha<br />
REV 9/2009
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