Enclave 6/2020
Housing Action Council
APPLICATION FOR FAIR & AFFORDABLE
HOMEOWNERSHIP OPPORTUNITY
Enclave at Pleasantville Pleasantville, New York
APPLICATION DEADLINE AUGUST 14, 2020
(7) Three Bedrooms - $230,000
Mail or Hand Deliver Completed Application to:
Housing Action Council - 55 South Broadway, 2
nd
Floor, Tarrytown, NY 10591
Maximum Income Limits as of April 2020 - (Income limits are subject to change)
3 Persons
4 Persons
5 Persons
6 Persons
$90,640
$100,640
$108,720
$116,800
Minimum Occupancy Requirements - Must have at least 3 persons in household to be eligible.
1. APPLICANT INFORMATION:
Name: ______________________________________________________________________________
Address:______________________________________________________________ Apt#: __________
City: _________________________________ State: __________________ Zip:____________________
Home Phone: ________________ Cell Phone: _________________ Work Phone: ____________________
SSN: _________________________DOB: _____________________Gross Income: __________________
Email: ______________________________________________________________________________
2. CO-APPLICANT INFORMATION:
Name:______________________________________________________________________________
Address: ______________________________________________________________ Apt#: _________
City: _________________________________ State: __________________ Zip: ___________________
Home Phone: ________________ Cell Phone: _________________ Work Phone: ____________________
SSN: ___________________________DOB: _____________________Gross Income: __________________
Email: ______________________________________________________________________________
Enclave 6/2020
Housing Action Council
3.
LIST ALL PERSONS WHO WILL LIVE WITH YOU, PLEASE START WITH YOURSELF:
FULL NAME RELATIONSHIP DATE OF BIRTH SEX ATTENDING SCHOOL
a.
___________________________ ____H.O.H____ _____________ _____ ________________
Social Security #:
______________________________ Occupation: ________________________________
b.
___________________________ ____________ _____________ _____ ________________
Social Security #:
______________________________ Occupation: ________________________________
c.
___________________________ ____________ _____________ _____ ________________
Social Security #:
______________________________ Occupation: ________________________________
d.
___________________________ ____________ _____________ _____ ________________
Social Security #:
______________________________ Occupation: ________________________________
e. ___________________________ ____________ _____________ _____ ________________
Social Security #:
______________________________ Occupation: ________________________________
f. Do you expect any change (s) in your family size? _____YES _____NO
If
YES
, EXPLAIN: ________________________________________________________________________
………………………………………………………………………………………………………………………………………….
4. STATISTICAL INFORMATION
a. The following information is needed for statistical purposes only in order to determine the degree to
which programs are utilized by people of different racial & ethnic backgrounds. Provide information
for the head of household
only.
RACIAL GROUP IDENTIFICATION: Used for statistical purposes only. (Please check only one from this
group for the head of household only).
Single Race
Multi-Race
_____ White _____ American Indian or Alaska Native & White
_____ Black or African American _____ Asian & White
_____ Asian _____ Black or African American & White
_____ American Indian or Alaska Native _____ American Indian or Alaska Native & Black or
_____ Native Hawaiian or Other Pacific Islander African American
_____ Other Multi Racial
b. ETHNICITY
: (check only one from this group) ______ Hispanic ______ Non-Hispanic
Enclave 6/2020
Housing Action Council
5. RENT:
What is your Current Monthly Rent $_______ Do you receive a rent subsidy? _____Yes _____ No
Check Utilities paid by you now:
Heat $_____________ per month If Yes, what portion of the Rent, do you pay?
Electricity $_____________ per month ___________
Gas $_____________ per month If Yes, what is the source of your Rent Subsidy?
Water $_____________ per month ___________
Other $_____________ per month
………………………………………………………………………………………………………………………………………….
6. INCOME:
List ALL full-time, part-time, seasonal and/or temporary employment for ALL household members for the past
two years. Include overtime pay, commissions, fees, tips, bonuses and/or self-employed earnings.
HOUSEHOLD
MEMBER
EMPLOYER
ADDRESS OF
EMPLOYER
DATES OF
EMPLOYMENT
GROSS INCOME
Weekly/ biweekly/ monthly
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Housing Action Council
7. OTHER SOURCES OF INCOME:
(EXAMPLES: Social security, SSI, pensions, disability compensation, unemployment compensation, interest, baby-
sitting, care-giving, alimony, child support, annuities, dividends, income from rental property and/or Armed
Forces Reserves.)
HOUSEHOLD MEMBER SOURCE AMOUNT
_________________________ _______________________________ $ __________ $___________
Weekly/ biweekly/ monthly (circle one)
_________________________ _______________________________ $ __________ $___________
Weekly/ biweekly/ monthly (circle one)
…………………………………………………………………………………………………………………………………………….
8. HOUSEHOLD ASSETS:
Checking Accounts
:
Bank: ___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Bank:
___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Savings Accounts:
(includes Passbook/Statement and Christmas/Vacation Clubs)
Bank: ___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Bank:
___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Bank:
___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Certificates of Deposit (CD's)
:
Bank: ___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Bank:
___________________________ Acct. No.(last 4 digits):__________Current Balance: ___________
Credit Union Shares
:
Credit Union Name: ___________________________Current Balance: ___________________________
Address ____________________________________________________________________________
Stocks/Bonds (value): $
_____________________ Savings Bonds (value): ______________________
Other Assets:
(includes IRA's, mutual funds, etc.)
$ _______________________________________
Does the applicant or co-applicant own real estate NOW: _____YES _____NO Where? _______________
If "yes", what is the value: _______________________________________________________________
Has the applicant or co-applicant EVER
owned real estate? _____YES _____NO
If "yes", when? _______________________________ Where? _________________________________
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Housing Action Council
9. DOWNPAYMENT
What is the source(s) of funds for your Down-payment/ Closing Costs? _____________________
Do you anticipate receiving a GIFT for Down-payment or Closing Costs?
______ Yes ______ No Source _______________________________________________
………………………………………………………………………………………………………………………………………….
10. DOCUMENTATION
All household members must submit COPIES of the following documents (as applicable) with their
application:
_________ 2019, 2018 & 2017 W2’s or 1099’s
_________ If self-employed, 2019, 2018 Federal Tax Returns AND
Profit & Loss Statement through
5/31/2020
_________ One Month’s Most Recent Pay Stubs
_________ Proof of child and/or spousal support payments
__________ Proof of social security income, disability or other government income
__________ Proof of retirement or trust fund income (e.g. pensions, distributions from 403(b), 401(k) or
other retirement accounts, annuities
_________ Valid government-issued photo identification (e.g., driver’s license, passport)
_________ $40 Non-refundable Application Fee payable to Housing Action Council
ADDITIONAL DOCUMENTATION WILL BE REQUESTED AFTER THE LOTTERY
I (WE) DECLARE THAT THE STATEMENTS CONTAINED IN THIS APPLICATION ARE
TRUE AND COMPLETE TO THE BEST OF MY(OUR) KNOWLEDGE. WARNING:
WILLFUL FALSE STATEMENTS OR MISREPRESENTATIONS ARE A CRIMINAL
OFFENSE.
_____________________________ __________________
Applicant Signature Date
_____________________________ __________________
Co-Applicant Signature Date
click to sign
signature
click to edit
Enclave 6/2020
Housing Action Council
CONSUMER CREDIT INFORMATION
I/ We hereby authorize Housing Action Council to use any consumer reporting agency, credit bureau or other
investigative agencies employed by such, to investigate references, or statements or other data obtained from me or from
any person pertaining to my employment history, credit, prior tenancies, character, general reputation, personal
characteristics and mode of living, to obtain a consumer report and such other credit information which may result
thereby, and to disclose and furnish such information to Housing Action Council, to the Sponsor or his representative and
to agencies that made or will make funding available in connection with this property listed above in support of this
application. I have been advised that I have the right, under 606B of the Fair Credit Reporting Act, to make a written
request, within reasonable time, for a complete and accurate disclosure of the nature and scope of any investigation.
______________________ __________________________ _________________
Applicant Signature Co-Applicant Signature Date
11. HOW DID YOU HEAR ABOUT THIS DEVELOPMENT?
Friend If friend, how did your friend hear about this? ____________________________
Employer Sign Posted on Site
Website/ Internet __________________________________________________________ (list site)
Church/ Synagogue (Identify):_____________________________________________________________
Community Organization (Identify):_________________________________________________________
Other (Identify): ________________________________________________________________________
12. CHECKLIST
Are all sections of the application filled out?
Did you include copies of the required documents?
Did you sign in both places?
INCOMPLETE APPLICATIONS MAY BE REJECTED
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