Apartment Application

The SEPP Group
Application for Apartment

Thank you for your interest in our properties.

Before submitting your application, please be sure that all blanks are filled in as accurately as possible and all boxes are checked. If an incomplete application is received by management, it will be sent back to the applicant and delay the process.

All applications received are dated and placed on the appropriate waiting list according to eligibility criteria. Should you have any questions regarding any of the enclosed material, please feel free to contact the building manager(s). The phone number for each property may be found on the application as well.

Sincerely,
The SEPP Group

Date:

Household Composition and Characteristics

List the Head of Household and all other people who will be living in the unit. You must indicate one of the approved relationship codes for each household member.

Applicant

Applicant Last Name:

Applicant First Name:

Applicant Middle Initial:

Gender:
Male: Female: Prefer not to disclose:

Current Street Address:

City:

State:

Zip Code:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Birth Date:

Social Security Number:

Please indicate each state where this person has lived:

How did you hear about us?

Will there be a Co-Applicant?

Yes No

Co-Applicant

Co-Applicant Name:
(Last, First, Middle Initial)

Relation to Applicant:
Co-head/Spouse Child Other adult Foster adult/child

Gender:
Male: Female: Prefer not to disclose:

Current Street Address:

City:

State:

Zip Code:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Email Address:

Birth Date:

Social Security Number:

Please indicate each state where this person has lived:

How did you hear about us?

Alternate Contact Person

First Name:

Last Name:

Phone Number:

If applying for Hamilton House, Harry L, Nichols Notch, Creamery Hills, or Watkins Glen Apartments, answer the following question:

Is the head of household or co-head/spouse 55 years or older?
Yes No

If applying for Marian, Windsor Woods and Whitney Point Apartments, answer the following question:

Is the head-of-household or co-head/spouse 62 or older or permanently disabled?
Yes No

If applying for Wells Apartment, answer the following question:

Is the head-of household or co-head/spouse 62 years of age or in need of an accessible apartment?
Yes No

Are you a student enrolled in an institute of higher education?
Yes No

Are you enlisted in the U.S. Military or are you a veteran of the U.S. Military?
Yes No

Do you know that this property is a smoke free building? This means that smoking is prohibited in the unit, on unit balconies and porches and in all indoor and outdoor common areas?
Yes No

Have you or any member of the household ever been convicted of a crime?
Yes No

If yes, indicate if the conviction(s) was a felony, misdemeanor or check both boxes if you have been convicted of both.
Felony Misdemeanor

Are you or is any member of the household required to register with any state lifetime sex offender or other sex offender registry?
Yes No

Have you or any other member ever been evicted from a federally funded housing program for a lease violation including drug use or failure to report a crime?
Yes No

If yes, when?

Rental History

Current Landlord:

Street Address:

City:

State:

Zip Code:

Contact Name (if known):

Phone Number:

How long did you live there?

Reason for leaving?

Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents, etc.)
Yes No

Did you owe the previous landlord any money when you left or do you currently have any outstanding balances owed to this landlord?
Yes No

Have you given this landlord notice that you will be moving?
Yes No

Have you been evicted?
Yes No

Have you received any lease violation notices from your prior landlord?
Yes No

If so, what were the alleged violations?

Do you or a co-applicant currently receive any rental subsidy? (Section 8 Voucher, Rental Assistance, etc.)?
Yes No

Please indicate the type of assistance.

Income and Asset Information

In order to determine eligibility and to ensure that your family receives the correct assistance, please provide the following information:

Applicant

Are you employed?
Yes No

If yes, please proved the name and address of your present employer below.

Employer:

Street Address:

City:

State:

Zip Code:

Phone Number:

Co-Applicant

Are you employed?
Yes No

If yes, please proved the name and address of your present employer below.

Employer:

Street Address:

City:

State:

Zip Code:

Phone Number:

Income

(PLEASE LIST GROSS AMOUNTS)

Please write in 0.00, NA or None if you will receive no income from these souces.

The Owner/Agent will not process the application if these fields are not complete.

Applicant:

Employment Income: Please note frequency, hours and rate of pay.

Applicant: Weekly
Monthly
Annually

Monthly Social Security? (before any deductions)

Applicant:

Monthly SSI?

Applicant:

Monthly SSP?

Applicant:

Monthly Retirement Benefits?

Applicant:

Monthly VA Benefits?

Applicant:

Monthly Unemployment Benefits?

Applicant:

Monthly Alimony Amount?

Applicant:

Monthly Child Support?

Applicant:

Monthly Public Assistance?

Applicant:

Monthly income from a pension or annuity or other asset?

Applicant:

Regular contributions from organizations or from individuals not living in the unit?

Applicant: Weekly
Monthly
Annually

Periodic Payments from Long-Term Care Insurance, Disability, or Death Benefits?

Applicant:

Please specify frequency

Applicant:

Contributions from family for rent, child care or other bills?

Applicant:

Please specify frequency

Applicant:

Do you receive financial aid for education assistance?

Applicant:
Yes No

Annual amount of education assistance?

Applicant:

Any other Monthly / Quarterly / Year Income?

Please explain

Applicant:

Assets

Please write in 0.00, NA or None if the account balance is zero.

Applicant:

Do you have a checking account?
Current Balance

Applicant:
Yes No

Do you have a savings account?
Current Balance

Applicant:
Yes No

Do you have a Prepaid Card account? (Example Direct Express card)
Current Balance

Applicant:
Yes No

Do you have a 401K or other employment savings account?
Current Balance

Applicant:
Yes No

Do you own an IRA or other retirement account?
Current Balance

Applicant:
Yes No

Do you own a home or other real property?
Market Value:

Mortgage Amount Owed:

Applicant:
Yes No

Do you own stocks/bonds/certificates of deposit (CD)?
Current Balance

Applicant:
Yes No

Do you own a life insurance policy?
Current Cash Value

Applicant:
Yes No

Do you or any member of household own an annuity?
Current Balance

Applicant:
Yes No

Deductions

Household income can be reduced based on the amount of qualified monthly expenses. Please let us know if you have out-of-pocket expenses for the following:

Medical Expenses: Households in which the head-of-household, co-head of household or spouse are disabled or at least 62 years old qualify for deductions based on out-of-pocket medical expenses. Please let us know if you or any members of your household have out-of-pocket expenses for the following:

Medical Expenses

Applicant:

Medicare Insurance - Monthly premium

Applicant:

Other Insurance - Monthly deductible

Applicant:

Prescription Drugs - annual out-of-pocket expense

Applicant:

Unit Size

The owner/agent will take your unit preferences/requirements into consideration. The owner/agents occupancy standards indicate a minimum of one person per bedroom and maximum of two people per bedroom. Please indicate any nessessary special features below.

Select how many bedrooms are you looking for:
1 2 3

Special Features:
Mobility Accessible Unit Communication Accessible Unit (Visual) Communication Accessible Unit (Hearing) Special Features

The policy of SEPP Management Company, Inc. (managing agent) and SEPP Inc. (owner or affiliate of owner) is one of equal access to housing in HUD programs for prospective applicants regardless of race, color, religion, sex, handicap, familial status, national origin, sexual orientation, gender identity or marital status.

THE INFORMATION REGARDING RACE, NATIONAL ORIGIN AND SEX SOLICITED BELOW ON THIS APPLICATION IS REQUESTED BY THE APARTMENT OWNER IN ORDER TO ASSURE THE FEDERAL AND STATE GOVERNMENT THAT FEDERAL LAWS PROHIBITING DISCRIMINATION AGAINST TENANT APPLICATIONS ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, RELIGION, SEX, FAMILIAL STATUS, AGE AND HANDICAP ARE COMPLIED WITH. YOU ARE NOT REQUIRED TO FURNISH THIS INFORMATION, BUT ARE ENCOURAGED TO DO SO. THE INFORMATION WILL NOT BE USED IN EVALUATING YOUR APPLICATION OR TO DISCRIMINATE AGAINST YOU IN ANY WAY. HOWEVER, IF YOU CHOOSE NOT TO FURNISH IT, THE OWNER OR ITS AGENT IS REQUIRED TO NOTE THE RACE, NATIONAL ORIGIN AND SEX OF INDIVIDUAL APPLICANTS ON THE BASIS OF VISUAL OBSERVATION OF SURNAME, AND PERSONAL INTERVIEWS. CONSEQUENTLY, WE WOULD APPRECIATE YOUR VOLUNTARY ANSWER TO THE FOLLOWING QUESTION:

Race:
White Black Spanish American Asian/Asian Pacific American Indian
Other (name) Prefer no to disclose

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, religion, sex, familial status, sexual orientation, and reprisal. (Not all prohibited bases apply to all programs). To file a complaint of discrimination, write USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, D.C., 20250-9410. Or call toll free (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer. The SEPP Group and this apartment community do not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities. The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing Section 504 (24 CFR Part 8 dated June 2, 1988). Brandy Jackson 53 Front Street Binghamton, NY 13905 607-723-8989 TDD- 607-677-0080.

PENALTIES FOR MISUSING THIS FORM

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

APPLICANT CERTIFICATION

By signing this document, I certify that if selected to receive assistance, the unit I/we occupy will by my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility. I/we authorize the owner/manager/PHA to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in the application are true and complete. I/we understand that providing false statements or information is punishable under Federal Law.

By the applicant entering their name in the box below, they are electronically signing this application and it carries the same legal value as if it were signed by the applicant in person.

Applicant Name / Electronic Signature*:

Date of Application:

The SEPP Group
Application for Apartment

Select which apartments you would like to apply for:
(must select at least one)

Household Composition and Characteristics

Applicant

Will there be a Co-Applicant?

Co-Applicant

Alternate Contact Person

Rental History

Income and Asset Information

Applicant

Co-Applicant

Income

Assets

Deductions

Medical Expenses

Unit Size

PENALTIES FOR MISUSING THIS FORM

APPLICANT CERTIFICATION

Complete CAPTCHA requirements or your form data may be lost.

Apartment Application

The SEPP Group Application for Apartment

Select which apartments you would like to apply for:(must select at least one)

Household Composition and Characteristics

Applicant

Will there be a Co-Applicant?

Co-Applicant

Alternate Contact Person

Rental History

Income and Asset Information

Applicant

Co-Applicant

Income

Assets

Deductions

Medical Expenses

Unit Size

PENALTIES FOR MISUSING THIS FORM

APPLICANT CERTIFICATION

Complete CAPTCHA requirements or your form data may be lost.

The SEPP Group
Application for Apartment

Select which apartments you would like to apply for:
(must select at least one)