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
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signature
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click to sign
signature
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