Property Tax Exemption, Water, Home Repair Grant/Loan

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First found фев 15, 2016

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NHS Development Corporation
114-02 Guy R Brewer Blvd, Jamaica NY 11434,
(718)517-6645
APPLICATION: PROPERTY TAX EXEMPTON OR DELINQUENT WATER BILL OR HOME REPAIR GRANT/LOAN
Intake Date: _____________
Referred By: _________________
REQUEST FOR SERVICE /PROGRAM
Property Tax Exemption
Other
DEP Water/Sewer Issues
Home Repair Grant/Loan
_____________________________
(The questions below refer to whomever is listed on the deed of the
property in question.)
Please Print Clearly
CLIENT/BORROWER INFORMATION
Name: __________________________________________________
First
Street:
MI
Gender: Male
Last
______________________________ City:_____________ State:_________
Home: (_____) _______–_______
Female
Work: (______) _______–_________
Zip code________
Email: _______________________
Fax: (_____) _______–_________ Mobile/Cell (_____) _______–________ Birth Date_____/______/______
Age:
Social Security Number:________________
Race (please check):
__________ (at time of application)
White
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native / Black
Asian and White
Black/African American and White
Other
Ethnicity
Hispanic: Yes
(please check)
Marital Status (please
check):
Widowed
Handicapped: Yes
No
Single
No
Foreign Born
Married
Veteran:
Are you a member of the clergy? Yes:
Yes
(please check)
Divorced
No
Disabled:Yes
Yes
No
Separated
No:
No:
If so, which what is the name of your church/mosque/synagogue/religious organization:
________________________________________________________________________________________
NHSDC
Please Print Clearly
CO-CLIENT/SPOUSAL/CO-BORROWER INFORMATION
Name: __________________________________________________
First
Street:
MI
Gender: Male
Female
Last
_______________________________ City:_____________ State:_________ Zip code________
Home: (_____) _______–_______
Work: (______) _______–_________
Email: ______________________
Fax: (_____) _______–_________ Mobile/Cell (_____) _______–________ Birth Date_____/______/______
Age of co-applicant:
Social Security Number:_______________
Race (please check):
______________ (at time of application)
White
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native /Black
Asian and White
Black/African American and White
Other
Ethnicity
Hispanic: Yes
(please check)
Marital Status (please
Handicapped: Yes
check):
Single
No
No
Married
Veteran:
Foreign Born
Divorced
Yes
Are you a member of the clergy? Yes:
No
(please check)
Separated
Disabled:Yes
Yes
No
Widowed
No:
No:
If so, which what is the name of your church/mosque/synagogue/religious organization:
_______________________________________________________________________________________
Please Complete
HOUSEHOLD INFORMATION
Current Housing Arrangement (please check):
Rent
Homeless
Homeowner with mortgage
Household Type (please select the most accurate)?
Female headed single parent household
Two or more unrelated adults
Living with family member/not paying rent
Homeowner without a mortgage
Male headed single parent household
Married without children
Single adult
Other
Family/Household Size (include self): ______How many dependents (other than those listed by any co-borrower)?
________
What ages are they? ____,____,____,____,____,____,____,____,____
Total Household Income: ______________________(per year) OR __________________(per month)
PERSONAL PROFILE INTAKE FORM
Page 2 of 3
Are there non-dependents who will be living in the home?
Yes
______________________
__________________________
_____________________________
Relationship
Relationship
Age
Age
No
If yes, list below:
Relationship
Age
Education: (please check):
Below High School Diploma
Two-Year College
High School Diploma or Equivalent
Bachelors Degree
Masters Degree
Certificate
Some College
PHD
MORTGAGE INFORMATION
What Type of 1st Mortgage Do You Have:
Fixed
Adjustable
FHA
Conv.
Other
Subprime
If Adjustable, how many yrs: _________________ Interest Rate______________
Monthly Mortgage Payments: $___________________# of Months in Arrears______ Mortgage balance____________
Mortgage Company: __________________________________________________________________________
Property Type: ______________________
Yrs. Owned: ____________
Last Re-fi_________________
Please check all that apply:
I live in this house
Single Family
2 Family
This is a second home
3 Family
4 Family
This is a rental property
5 + unit
Condo
Co-op
HOW CAN WE HELP YOU?
Why are you here? Describe Your Problem/Issue:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
WATER BILL RELATED ISSUES (WITH THE DEPARTMENT OF ENVIRONMENTAL PROTECTION)
(ANSWER ONLY IF YOU CAME IN FOR ASSISTANCE WITH A WATER-RELATED ISSUE)
Department of Environmental Protection Account Number: _________________________________________
Whose name is the water bill in: _______________________________________________________________
Property address relating to the water bill:________________________________________________________
_____________________________________________________________________________________________
Do you have overdue water bills:Yes
No
Have you entered into a payment plan with DEP? Yes
PERSONAL PROFILE INTAKE FORM
Amount Past Due:______________________
No
If so, when: ____________________
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