City of White Plains
Affordable Rental Housing Program
Application
CONTACT INFORMATION & RESIDENCY
Provide name, address, telephone numbers and e-mail of person principally responsible for this application:
First Name: Middle Initial: Last Name:
Address: Apt. #
City: State: ZIP Code:
Cell Phone: Work Phone: Home Phone:
E-mail Address:
DEMOGRAPHIC PROFILE
Notice: Providing demographic information is optional and is not a required component of the application
process. Responses to the demographic profile will not be used in any way to determine eligibility for an
affordable housing rental apartment. The demographic profile is used to help the City of White Plains ensure
that the Affordable Rental Housing Program is providing fair housing and equal opportunity to all.
Directions: Answer both Part A and Part B for the principal applicant of this application. For Part A, please
provide only one response for ethnicity and for Part B, please provide response(s) for all racial categories that
pertain to you:
Part A Part B
Ethnic
Categories:
Hispanic or Latino
Not-Hispanic or
Latino
Racial
Categories:
American Indian or Alaska Native
American Indian/Alaskan Native
and Black/African American
American Indian/Alaska Native
and White
Asian
Asian and White
Black or African American
Black or African American and
White
Native Hawaiian or Other Pacific
Islander
White
Other Multi-Racial
Directions: Please check all categories that pertain to the principal applicant of this application:
Are You: Female Head of Household
Person with Disabilities
Homeless
62 years or older
OCCUPANCY, EMPLOYMENT AND INCOME
1. List the name, relationship, and date of birth for all persons who will reside in the affordable rental unit
2. Provide employment information for each person 18 years or older (if retired, please enter former
employment information)
3. Provide the gross annual income for all persons 18 years or older who will reside in the unit, including students
NOTE: student income for full time students will not be considered for purposes of determining income
eligibility
4. List annual salary/wages separately from other income such as alimony, child support, SSI, SSD, pension,
investment income, dividends, etc.
3. Provide enrollment status for any students living in the affordable housing rental unit (a student is considered
full time if 12 or more credits are taken in a single semester)
Name: Relationship:
DOB:
Employer:
Employer
Address:
City: State: ZIP Code:
Salary/Wages: Other Income:
Student: Yes
No
Enrollment
Status:
Full Time
Less Than
Full Time
Retired: Yes
No
Name: Relationship:
DOB:
Employer:
Employer
Address:
City: State: ZIP Code:
Salary/Wages: Other Income:
Student: Yes
No
Enrollment
Status:
Full Time
Less Than
Full Time
Retired: Yes
No
Name: Relationship:
DOB:
Employer:
Employer
Address:
City: State: ZIP Code:
Salary/Wages: Other Income:
Student: Yes
No
Enrollment
Status:
Full Time
Less Than
Full Time
Retired: Yes
No
Name: Relationship:
DOB:
Employer:
Employer
Address:
City: State: ZIP Code:
Salary/Wages: Other Income:
Student: Yes
No
Enrollmen
t Status:
Full Time
Less Than
Full Time
Retired: Yes
No
Add a separate sheet to report additional names, annual incomes, and employment information, if needed.
ADDITIONAL QUESTIONS
How did you hear about the White Plains Affordable
Rental Housing Program? Please check all that apply
City of White Plains Website
Internet Search
Friend or Family Member
Housing Counseling Agency
Apartment Management Company
Real Estate Agency
Other
Do you have
any pets?
Yes
No
Do you receive a
pension(s)?
Yes
No
SUPPORTING DOCUMENTATION
For each person 18 years and older who will reside in the apartment:
1. Federal and State Income Tax Returns
2. Copy of forms reporting unearned income (child support, alimony, SSI, SSD, investment income, dividends, etc.)
3. Copy of most recent bank statement
4. Copies of last four (4) pay check stubs
5. Copy of Pension Award statement, if applicable
6. Copy of Social Security Statement, if applicable
7. Proof of Residency: Driver's License, or Passport, or Utility Bill, etc.
8. Employment Verification Form (see attachment)
9. Enrollment verification from an accredited college or university for all full time students (a student is full time
when 12 or more credits are taken in a single semester)
APPLICATIONS WILL NOT BE PROCESSED WITHOUT THE REQUIRED SUPPORTING DOCUMENTS.
CERTIFICATION
I/WE CERTIFY THAT THIS INFORMATION IS COMPLETE AND ACCURATE. I/WE AGREE TO PROVIDE, UPON
REQUEST, DOCUMENTATION ON ALL INCOME SOURCES TO THE AFFORDABLE RENTAL HOUSING PROGRAM.
SIGNED: DATE:
SIGNED: DATE:
ALL STATEMENTS ARE SUBJECT TO VERIFICATION. MISREPRESENTATIONS OR FALSE STATEMENTS MAY
CONSTITUTE CAUSSE FOR DISQUALIFICATION OR EVICTION FROM THE AFFORDABLE HOUSING PROGRAM.
PURSUANT TO NY PENAL LAW SECTION 210.45, IT IS A CRIME PUNISHABLE AS A CLASS "A" MISDEMEANOR TO
KNOWINGLY MAKE A FALSE STATEMENT HEREIN.
SUBMISSION INFORMATION
E-mail: planning@whiteplainsny.gov
Fax: (914) 422-1301
-OR-
Mail: City of White Plains
Department of Planning
70 Church Street
White Plains, NY 10601
City of White Plains
Department of Planning
(914) 422-1300
Employment Verification Form
Date: ______________
Employee's Name:
_____________________________________________________
Employer's Name and Address:
____________________________________________
Employment Start Date: ____________________
Job Title ______________________
Base Pay: $_______ per hour / week / month (circle one}
Average Hours Worked per Week at Base Pay Rate: $_______
Overtime Pay Rate: $____________
Total Base Pay Earnings (past 12 months}: $____________
Total Overtime Earnings (past 12 months): $____________
Projected Pay (next 12 months): $____________ With Overtime: $____________
Manager/Supervisor/ Human Resource - Supplying Information
Name Title
Signature Phone Date
Employment Verification Form
Date: ______________
Employee's Name:
_____________________________________________________
Employer's Name and Address:
____________________________________________
Employment Start Date: ____________________
Job Title ______________________
Base Pay: $_______ per hour / week / month (circle one}
Average Hours Worked per Week at Base Pay Rate: $_______
Overtime Pay Rate: $____________
Total Base Pay Earnings (past 12 months}: $____________
Total Overtime Earnings (past 12 months): $____________
Projected Pay (next 12 months): $____________ With Overtime: $____________
Manager/Supervisor/ Human Resource - Supplying Information
Name Title
Signature Phone Date
Table 1: 2020 HUD Income Eligibility
AMI: Area Median Income
Table 2: 2020 HUD Rent Limits
The above rents correspond to the household incomes listed in Table 1. The rents are
set annually by the Federal government.
If utilities are not included in the rent, there is a reduction in the rent based on a utility
allowance that is determined by the Federal government.
Household
Income
I Person
2 People
3 People
4 People
5 People
6 People
30% AMI
$26,450 $30,200 $34,000 $37,750 $40,800 $43,800
50% AMI
$44,050 $50,350 $56,650 $62,900 $67,950 $73,000
60% AMI
$52,900 $60,400 $69,200 $75,500 $81,600 $87,600
80% AMI
$70,480 $80,560 $90,640 $100,640 $108,720 $116,800
100% AMI
$88,100 $100,700 $113,300 $125,800 $135,900 $146,000
Eligible Income Range: Household income may be up to 99% AMI
level, but tenant will likely be over-income at the annual recertification
1 Bedroom
2 Bedroom
3 Bedroom
100% AMI
$2,203 $2,518 $2,833 $3,145
80% AMI
$1,762 $2,014 $2,266 $2,516
60% AMI
$1,323 $1,510 $1,730 $1,888
CHECKLIST
CHECKLIST - PLEASE SUBMIT ALL REQUESTED DOCUMENTS FOR ALL ADULTS WHO WILL RESIDE IN THE
HOUSEHOLD
2019 Federal and State Income Tax Returns (Please do not submit the W2 form)
Copy of Form reporting unearned income (Investment Income, Dividends, Child Support payments,
Alimony, SSI, SSD, etc.)
Copy of the most recent Bank Statement
Copies of the last four (4) Paycheck Stubs
Copies of Pension or Social Security Statement, if applicable
Proof of Residency: Drivers License or Cellphone/Telephone Bill or Utility Invoice
Employer Verification Form for each adult residing in the household
Enrollment verification from an accredited college or university for all full time students (a
student is full time when 12 or more credits are taken in a single semester)
APPLICA
TIONS WILL NOT BE PROCESSED WITHOUT ALL OF THE ABOVE DOCUMENTS
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