1
APPLICANT QUESTIONNAIRE
Household Information
List all household members and all sources of income for each member that will be living in this apartment. Please include
overtime, tips, bonuses, commissions, unemployment benefits, public assistance, child support, pension, social security
benefits.
*If employment listed below is less than two years, please list previous employment for each member of the household.
Name of Each First
Household
Member Last
HEAD
2
3
4
Relationship
to Head of Household
HEAD
Male / Female
Social Security Number
Date of Birth
Student Yes/No
Income anticipated for the next 12 months for each household member.
Name of Employer
Dates Employed
Position
Annual or Monthly Income
Name of Employer
Dates Employed
Position
Annual or Monthly Income
Alimony, Child Support
Social Security, Pensions,
Retirement Funds, Etc.
Self Employment Income
Other Income
Other Income
Include all assets held and the income derived from the assets.
Assets Bank Name Account Number List Average Balance
Checking
Checking
Savings
Investments
Investments
Desired Apartment Size (chec
k
one): 1B
R 2 B
5
Date Desired:
100 Commons Way, Deer Park, NY 11729
2
Do you fall into the category of “Frail Elderly” as defined below (check appropriate box)? YES NO
“Persons age 55 or more who require assistance with one or more activities of daily living or instrumental activities of daily
living. Also, persons age 55 or more who have limitations in mental capacity or emotional strength and motivation that affect
their capacity to viably live independently; that is without assistance or intervention.”
Current Address:
Home Phone:
Work Phone:
Cell Phone:
Do you have any pets? Yes No If yes, please list all pets.
Housing Information
Do you own or rent at your current address? Rent Own
If you have rented an apartment during the past TWO years, please list apartment information below:
Current Landlord’s
Name/ Address Your Address Dates From: To:
Name:
Address: Amount Paid
Phone:
Previous Landlord’s
Name/ Address Your Address Dates From: To:
Name:
Address: Amount Paid
Phone:
Signature Clause
I certify that all information and answers to the above questions are true and complete to the best of my knowledge. I consent
to release the necessary information to determine my eligibility. I understand that providing false information or making false
statements may be grounds for denial of my application.
I authorize my consent to have management verify the information in this application for the purpose of providing my eligibility
for occupancy. I will provide all necessary information including source names, addresses, phone numbers, and account
numbers where applicable and any other information required for expediting this process. I understand that my occupancy is
contingent on meeting management’s resident selection criteria and requirements.
All ADULT household members must sign below:
Signature Date
Signature Date
100 Commons Way, Deer Park, NY 11729
click to sign
signature
click to edit
click to sign
signature
click to edit
Statistical Information
The following information is required for statistical purposes so that the Department of Housing and
Urban Development (HUD) may determine the degree to which its programs are being utilized by people
of different racial & ethnic backgrounds.
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
African American
Native Hawaiian or Other Pacific Other Multi Racial
Islander
ETHNICITY: (check only one from this group) Hispanic Non-Hispanic
Do you need a handicapped accessible/adaptable apartment? Yes No
100 Commons Way, Deer Park, NY 11729
3
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome