7

• Browser built in viewer
• PDF Viewer
• Universal Document Viewer
• Google Docs View
• Google Drive View
• Download Document [pdf]
Not Your Device? Search For Manuals / Datasheets:



File Info : application/pdf, 11 Pages, 447.71KB

Document Document

The information requested in this form is required by the government. Agency regulating this project.

Cabot Housing, LLC C/O YMCA of the North Shore
245 Cabot St. Beverly, MA 01915
Tel: 978-998-0053 US Relay 711

Please do not use whiteout. If you make a mistake, cross it out, write the correct answer and put initials next to the crossed out information.

Please submit the original application only

Email or faxed applications will not be entered into the lottery

PRELIMINARY APPLICATION FOR HOUSING
Note: Applicants ascertained from the lottery will be placed on an existing waiting list after all current applicants.
Please Print Clearly
Preliminary applications are used to pre-qualify prospective applicants for the waiting list as specified in the Tenant Selection Plan located at the management office. All applicants will be asked to complete a full application upon being selected from the waiting list and may be interviewed for housing only after the receipt of the full application.
Please complete all sections of this preliminary application and return to the address listed above. If a question is not applicable, write "N/A" in that section. If all sections are not completed, the preliminary application will be returned to you for completion and will not be placed on the waiting list. Applicants must sign and date the application.

Head of Household Name:

A. GENERAL INFORMATION

Address: Phone Number:

Street

Apt. #

City

State

ZIP

Email:

Preliminary Application Page 1 of 5

B. HOUSEHOLD COMPOSITION, STUDENT STATUS & UNIT TYPE

Please note that this site is designed for single individual households. Also, all of the units are governed by the Low-Income Housing Tax Credit Program. A family consisting of one person will not be eligible for a unit if the person is a full-time student 5 months out of the calendar year at an educational institution (other than a correspondence school) with regular faculty and students. There are three exceptions that may apply to single person families.

1) The person was historically in foster care. 2) The person is enrolled in a job-training program receiving assistance under the Job Training
Partnership Act.
3) The person is married and files a joint income tax return.

PLEASE LIST THE NAME OF THE PERSON WHO WILL RESIDE IN THE APARTMENT:

Name

Relationship to Head of Household

Birth Date

Social Security Number

Student Status (Must Circle which is
applicable)

1.

Head

Full-time / Part-time / Not Student
If you circled full-time, what exception listed above do you
meet? 1 2 3 or None

Unit Size

Unit Type (Please Check all That Apply)

Studio

Mobility /Wheelchair Accessible

Hearing/Vision Adapted

*The following additional questions are asked for the sole purpose of providing applicants with disabilities an equal opportunity to enjoy your housing. Answering them is voluntary, but if you don't let us know what you need to have an equal opportunity to enjoy your housing we can't satisfy your needs. This application includes a notice of the right to request a Reasonable Accommodation (Attachment A).

  1. Do you need only certain accessible features of a unit? Yes No
If yes, please list the features that you need to be accessible:

2. Do you or any member of the household have any accessibility or reasonable accommodation
  requests or alternate ways we need to communicate with you? Yes No
If yes, please explain: __________________________________________________________
Preliminary Application Page 2 of 5

D.PREFERENCES
Cabot Housing will utilize a local preference for 70% of the units being filled through this lottery solely at rent-up of vacant units not filled with residents on the current waiting list. This preference does not make anyone eligible who was not otherwise eligible, and they do not change the YMCA's right to apply. Documentation to support the request for preference must be provided. Request for preference will be denied without proper documentation received no later than the application deadline. For more information on each preference and the required documentation, see attachment D to this application.

I currently live in Beverly, Salem or Peabody at the time of application.
Note that this includes a shelter located in one of these cities, or if you are homeless, the last place you resided before becoming homeless.
I am an employee of Beverly, Salem or Peabody.

Yes N/A Yes N/A

I am an employee of a businesses located in Beverly, Salem or Peabody.

Yes N/A

I have a child /children attending the city of Beverly, Salem, or Peabody's school, such as METCO students.

Yes N/A

E: INCOME

Please list all of your sources of income. NOTE: "Income" includes but is not limited to all money received as a result of employment, Social Security benefits, Supplemental Security Payments, Pensions, Veteran's Benefits, Unemployment Compensation, Public Assistance, Child Support, Alimony and interest earned from assets. Please indicate the total annual income from the named source, PRIOR to deductions (taxes, etc.).

Household Member Name

Source of Income

Annual Amount

Preliminary Application Page 3 of 5

F: ASSETS

Please list your assets. NOTE: "Assets" includes but is not limited to money held in checking accounts, savings accounts, trust accounts, certificates of deposit, credit unions, savings bonds, life insurance policies, mutual funds, stocks, bonds, annuities, 401(K), Keogh, brokerage accounts, investments, real estate and investment properties.

Household Member Name

Type of Asset

Amount

% Interest

Have any assets been disposed of within the past two years?

 Yes  No

If yes, explain by providing the type of asset, date of disposal, market value of the asset and the amount received for it:

G. TOTAL GROSS ANNUAL INCOME

TOTAL GROSS ANTICIPATED ANNUAL INCOME

$

(before taxes and deductions) over the next 12 months

TOTAL GROSS ANNUAL INCOME

$

H. ADDITIONAL QUESTIONS
1. How were you referred to this property?
2. Do you currently have a mobile Voucher/Certificate? Note: We do not discriminate based on Voucher/Certificate holder status. This
question is being asked for the sole purpose to determine an applicant household's ability to pay rent for a unit.

Yes

No

Preliminary Application Page 4 of 5

Certification: I further certify that this will be my sole and permanent residence. I understand I must pay a security deposit for this apartment prior to occupancy. I understand that my eligibility and suitability for housing will be based on applicable income limits and by management's tenant selection plan. I certify that all above information is true to the best of my knowledge. I understand that intentional false statements or information are punishable by law and will lead to cancellation of this preliminary application or termination of tenancy after occupancy. I understand that this is a preliminary application to determine my eligibility for available waitlists, and that I will be required to complete a full application once an apartment becomes available for me. I understand all changes to this application, including but not limited to address change, family composition change, and annual household income change must be made to the management office in writing, and that failure to do so may result in my application being cancelled. You must sign and date below:

Signature (Head of Household):

Date:

Attachment A: Notice of Nondiscrimination, Right to a Reasonable Accommodation and Free Language Assistance for People with LEP

The YMCA of the North Shore does not discriminate on the basis of any protected status, including disability, in the admission of or access to, or treatment or employment in its programs and activities. The YMCA of the North Shore provides persons with disabilities the opportunity to request a Reasonable Accommodation to apply to and participate in such programs and activities. The YMCA. Also provides people whose primary language is not English and as a result have limited English proficiency the opportunity to request free language assistance to apply to or participate in its programs and activities. Kathy Churchill, Director of Housing, coordinates the YMCA of the North Shore's compliance with all nondiscrimination requirements, including Section 504. Contact her with any questions or concerns relating to the YMCA of the North Shore's compliance with nondiscrimination requirements: Telephone (978) 564-3099, Relay #711 or at YMCA of the North Shore, 245 Cabot Street, Beverly, MA 01915.
Preliminary Application Page 5 of 5

NOTICE OF NON-DISCRIMINATION, THE RIGHT TO REASONABLE ACCOMMODATION FOR PERSONS WITH DISABILITIES, AND THE RIGHT TO FREE LANGUAGE ASSISTANCE FOR PEOPLE WITH LIMITED ENGLISH PROFICIENCY
Non-Discrimination
The YMCA of the North Shore (YMCA)does not discriminate on the basis of any status protected by federal, state, or local law, in the admission or access to, or treatment or employment in, its programs, services and activities including, but not limited to, the following: race, color, religion, sex, national origin, familial status, disability, sexual orientation, gender identity or expression, marital status, age, ancestry, genetic information, membership in the armed services or status as a veteran , receipt of public assistance, because someone is, has been or is threatened with being the victim of domestic violence, dating violence, sexual assault or stalking, or has obtained, or sought, or is seeking relief from any court in the form of a restraining order for protection from domestic abuse.
The YMCA has designated Kathy Churchill to coordinate compliance with applicable federal and state nondiscrimination requirements and to address grievances applicants and residents may have. The following is her contact information:
The YMCA of The North Shore 245 Cabot Street
Beverly, MA 01915 Telephone: (978) 998-0053; Relay: 711
Also, if you believe you have been discriminated against, you may file a formal complaint with the Department of Housing and Urban Development (HUD) and local Fair Housing Agency. The contact information for HUD's Fair Housing Office and the Fair Housing Agencies in the states where our sites are located is attached to this notice.
Reasonable Accommodation for People with Disabilities
If you or any member of your household have a disability and as a result need any of the following in order to have an equal opportunity to apply to or live in our development, or participate in services and programs we offer, please let us know:
· A change in a rule, policy, procedure or service; · A physical change or modification in your apartment, such as grab bars or lowering
the cabinets; · A specific type of unit such as one that is accessible to individuals with mobility
impairments, visual impairments or hearing impairments; · A physical change or modification in some other part of the housing site; and · A preferred way for us to communicate with you or give you information, such as
Braille, large print or using a hearing interpreter;
These kinds of changes are called reasonable accommodations. We will provide a requested reasonable accommodation if:
· your disability is obvious or you can document that you have a disability; · the nexus or connection between your disability and the need for the
accommodation is obvious or you can document it; and
Notice Of Right To Reasonable Accommodation, Non-Discrimination and Assistance for LEP

· your request does not pose an undue financial and administrative burden or fundamental change in the program, which means in simple language if it is not too expensive and too difficult to arrange or do, or does not require us to do something that the housing program is not designed to do or would prevent us from doing what we are required to do.
We will give you an answer as to whether we can provide the accommodation within ten (10) business days unless there is a problem getting the information we need, or unless you agree to a longer time. We will let you know if we need more information or documentation from you or if we would like to talk to you about other ways to meet your needs.
If we turn down your request, we will explain the reasons. If you want, you may then give us information that addresses the reason why we turned down your request.
A REASONABLE ACCOMMODATION REQUEST FORM is available at the management office listed below. Let us know if you need help filling out the form or if you want to give us your request in some other way. Reasonable Accommodations may be requested orally or in writing. Please do not hesitate to contact the management office.
NOTE: All information you provide will be kept confidential and be used only to enable you to have an equal opportunity to apply to or enjoy your housing, including services and the common areas.
Free Language Assistance for People with Limited English Proficiency
If your primary language is not English and as a result you have difficulty reading, writing or understanding English, we will provide you free language assistance so you can apply to our housing program or communicate with us regarding a housing related matter. If your primary language is not English and as a result you have Limited English proficiency, please put a checkmark next to your primary language on the attached "I SPEAK" form and return the form to the management office as listed below. We will do our best to try to accommodate your request in a timely manner. Please contact the management office if you have any suggestions regarding how we can best meet your language needs or if you have any questions about our free language assistance.

Property Contact Information:

Name of Property: Cabot Housing

Office Address:

Telephone: 978-998-0053

Email:

CabotLottery@northshoreymca.org

Relay: 711

The YMCA of the North Shore does not discriminate on the basis of any protected status, including disability, in the admission of or access to, or treatment or employment in its programs and activities. The YMCA of the North Shore provides persons with disabilities the opportunity to request a Reasonable Accommodation to apply to and participate in such programs and activities. The YMCA. also provides people whose primary language isn't English and as a result have limited English proficiency the opportunity to request free language assistance to apply to or participate in its programs and activities. Kathy Churchill, Director of Housing, coordinates the YMCA of the North Shore's compliance with all nondiscrimination requirements, including Section 504. Contact her with any questions or concerns relating to the YMCA of the North Shore's compliance with nondiscrimination requirements: Telephone (978) 998-0053, Relay #711or at YMCA of the North Shore, 245 Cabot Street, Beverly, MA 01915.

Notice Of Right To Reasonable Accommodation, Non-Discrimination and Assistance for LEP

Contact Information for the Department of Housing and Urban Development Region I FHEO Office and State Fair Housing Agencies Where The YMCA of the North Shore
Conducts Business The Department of Housing and Urban Development Boston Regional Office of FHEO U.S. Department of Housing and Urban Development Thomas P. O'Neill, Jr., Federal Building 19 Causeway Street, Room 321 Boston, MA 02222-1092 (617) 944-8300 | 1-800-827-5005 | TTY (617) 565-5453
Massachusetts Massachusetts Commission Against Discrimination (MCAD) Boston Office One Ashburton Place Sixth Floor, Room 601 Boston, MA 02108 Phone: 617-994-6000 TTY: 617-994-6196
The YMCA of the North Shore does not discriminate on the basis of any protected status, including disability, in the admission of or access to, or treatment or employment in its programs and activities. The YMCA of the North Shore provides persons with disabilities the opportunity to request a Reasonable Accommodation to apply to and participate in such programs and activities. The YMCA. also provides people whose primary language isn't English and as a result have limited English proficiency the opportunity to request free language assistance to apply to or participate in its programs and activities. Kathy Churchill, Director of Housing, coordinates the YMCA of the North Shore's compliance with all nondiscrimination requirements, including Section 504. Contact her with any questions or concerns relating to the YMCA of the North Shore's compliance with nondiscrimination requirements: Telephone (978) 998-0053, Relay #711or at YMCA of the North Shore, 245 Cabot Street, Beverly, MA 01915.
Notice Of Right To Reasonable Accommodation, Non-Discrimination and Assistance for LEP

I SPEAK FORM
Notice Of Right To Reasonable Accommodation, Non-Discrimination and Assistance for LEP

Notice Of Right To Reasonable Accommodation, Non-Discrimination and Assistance for LEP

The YMCA of the North Shore does not discriminate on the basis of any protected status, including disability, in the admission of or access to, or treatment or employment in its programs and activities. The YMCA of the North Shore provides persons with disabilities the opportunity to request a Reasonable Accommodation to apply to and participate in such programs and activities. The YMCA. also provides people whose primary language isn't English and as a result have limited English proficiency the opportunity to request free language assistance to apply to or participate in its programs and activities. Kathy Churchill, Director of Housing, coordinates the YMCA of the North Shore's compliance with all nondiscrimination requirements, including Section 504. Contact her with any questions or concerns relating to the YMCA of the North Shore's compliance with nondiscrimination requirements: Telephone (978) 998-0053, Relay #711or at YMCA of the North Shore, 245 Cabot Street, Beverly, MA 01915.
Notice Of Right To Reasonable Accommodation, Non-Discrimination and Assistance for LEP