Fillable AFFORDABLE DWELLING UNIT (ADU) PROGRAM APPLICATION (City of Falls Church)

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AFFORDABLE DWELLING UNIT (ADU) PROGRAM APPLICATION (City of Falls Church)

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BROWSE CITY OF FALLS CHURCH (VA) FORMS

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City of Falls Church
AFFORDABLE DWELLING UNIT (ADU) PROGRAM
APPLICATION
Housing and Human Services
300 Park Avenue Falls Church, Virginia 22046,
Office Hours: 8 a.m. – 5 p.m. Monday - Friday
Tel: 703-248-5005, TTY 711, Fax: 703-248-5149
Website: www.fallschurchva.gov/HHS
Email: hhsinfo@fallschurchva.gov
I. APPLICANT & CO- APPLICANT (Please print full name of each applicant)
Applicant Information:
Last Name :____________________________First Name:______________________ Initial_________
Current Street Address:_________________________________________________________________
City:__________________________________ Sate:________________ Zip Code__________________
Home Phone :___________________Cell Phone:____________________ Work Phone:_____________
Co-Applicant Information:
Last Name :____________________________First Name:______________________ Initial_________
Current Street Address:_________________________________________________________________
City:__________________________________ Sate:________________ Zip Code__________________
Home Phone :___________________Cell Phone:____________________ Work Phone:_____________
Please indicate which ADU program you are interested in? Both Purchase Rental
II. HOUSEHOLD COMPOSITION & INFORMATION
List All Persons (beginning w/ yourself) Who Will Live in the Unit
Last Name
First Name
Social Security
Number
Relation to
Head
Gender
F or M
Date of
Birth
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Ethnicity (must check one) Hispanic Non-Hispanic
Race, please check applicable box (for statistical purposes only):
White Black/African-American Asian Asian & White Other Multiracial
Black/African-American & White American Indian/Alaskan Native
American Indian/Alaskan/ Native& White American Indian/Alaskan Native & Black
Native Hawaiian/Other Pacific Islander
Selection Criteria
A) Are you or the co-applicant disabled and/or 62 years of age or older? Yes No
B) Do you or the co-applicant live in the City of Falls Church? Yes No
C) Do you or the co-applicant work for
the City of Falls Church or its schools? Yes No
D) Do you or the co-applicant work in the City of Falls Church? Yes No
E) Have you or any member of your household been convicted of a felony? Yes No
III. HOUSEHOLD INCOME & ASSETS
Earned Income: List sources of income for persons who will live in the unit
Names of Family Members
Receiving Any Income from Wages
Company Name
Occupation
Annual
Earnings
Total Annual Household Income
Other Income: List other income received by persons who will live in the unit. This may include but is not limited to Social
Services (Welfare), Supplemental Security Income (SSI), Social Security, Pension/Retirement, Unemployment Compensation,
and other income such as Worker's Compensation, Child Support, or Alimony.
Names of Family Members Receiving
Income from Sources Other than Wages
Source of Income
Annual Income
from Source
Total Annual Income
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Declaration: The following questions refer to both the applicant & all adult occupants. Please circle the appropriate answer.
A) Have you filed for bankruptcy in the past seven years? Yes No
B) Are there any outstanding judgments or collections against you? Yes No
C) Have you had property foreclosed on in the past seven years? Yes No
D) Are you currently delinquent on any Federal debt or any other loan? Yes No
E) Are all applicants U.S. citizens or do they have green cards? Yes No
F) Has anyone on this application owned residential property in the last 3 years? Yes No
If “YES” and residential property was owned with a spouse,
are you now divorced and applying singly? ______________________________________________________
ASSETS: Please indicate assets held by all members of the household. This may include but is not limited to Checking
Accounts, Savings Accounts, Money Market Accounts, Stocks/Bonds, Real Estate, etc.
Names of Family Members
Type of Asset
Name of the Bank/Lender/
Investment Company
Amount
Total Amount of Assets
The applicant understands that the information provided in this application shall be the basis for determining eligibility for this
program. Falsification of information on this application is grounds for disqualification.
The applicants certify that all information provided in this application, and all information furnished in support of this application, is
given for the purpose of obtaining assistance through this Program, and is true and complete to the best of the applicant's
knowledge and belief.
The applicants acknowledge that this application is a request for assistance through the City of Falls Church Affordable Dwelling
Unit Program, and does not
constitute approval or acceptance by the City of Falls Church Housing and Human Services.
The applicants hereby authorize employees of the Housing and Human Services, or its agents to contact any person, business,
or organization listed in this application for purposes of determining eligibility for the Affordable Dwelling Unit Program.
The applicants certify that all occupants in the household are listed on this application and also certify that all income and
sources of income have been listed.
Any changes in this information must be reported and can affect the applicant’s continuing eligibility. Read carefully before signing.
This application will not be considered if it has not been signed.
____________________________________________ ___________________________________________
Applicant Signature Date Co-Applicant Signature Date
Information furnished to the City of Falls Church Housing and Human Services will be maintained and disseminated for governmental purposes in accordance
with the Virginia Freedom of Information Act, Code of Virginia, Section 2.1.340 through 346.1 as amended, and the Privacy Protection Act of 1976, Code of
Virginia Sections, 2.1-377 through 386, as amended. Please allow seven (7) working days for preparation of materials. The City of Falls Church does not
discriminate on the basis of disability in its employment practices or in the admission to, access to, or operations of its services, programs, or activities. Cindy
Mester, 300 Park Avenue, Falls Church, Virginia 22046 has been designated to coordinate compliance with the ADA non-discrimination requirement.
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AFFORDABLE DWELLING UNIT (ADU) PROGRAM APPLICATION (City of Falls Church)

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Completed 3 August 2020

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