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RAP / SRP CHECKLIST CITY OF ALBANY, NEW YORK ALBANY COMMUNITY DEVELOPMENT AGENCY 200 HENRY JOHNSON BOULEVARD ALBANY, NEW YORK 12210-1550 [PHONE REDACTED] • [PHONE REDACTED] FAX www.AlbanyNY.gov • www.facebook.com/AlbanyACDA Kathy M. Sheehan Mayor The Maximum Income for this program is based on family size and total income for all wage earners over age 18. Household size 1 2 3 4 5 6 7 Max income $63,000 $72,000 81,000 89,900 97,100 104,300 118,700 These programs are for Emergency Assistance Only. The determination of an emergency will be made by ACDA rehabilitation staff. Copy of Photo ID. Copy of Recorded Deed. Copy of Homeowner’s Insurance Declaration page. Proof of all Income (If employed, two months of current paystubs) and award letters showing gross amounts for Social Security / SSI / Pension. Most recent Signed Federal Income Tax Return (with all attachments, including W-2 forms). Letter explaining what work needs to be done. (Assistance up to $5,000 may be available) Have you ever received assistance from ACDA No __Yes Have you ever filed Bankruptcy No Yes Date Discharged (When the owner has filed personal bankruptcy, the bankruptcy must be discharged (proof of discharge is required) and credit worthiness must be re-established, as determined by ACDA) Do you have any open Judgements or Liens No Yes Applicant’s Name: Reviewed By: Date: Page 1 of 3 (Revised 2/16/2017) ---PAGE BREAK--- RAP / SRP APPLICATION Page 2 of 3 CITY OF ALBANY, NEW YORK ALBANY COMMUNITY DEVELOPMENT AGENCY 200 HENRY JOHNSON BOULEVARD ALBANY, NEW YORK 12210-1550 [PHONE REDACTED] • [PHONE REDACTED] FAX www.AlbanyNY.gov • www.facebook.com/AlbanyACDA Kathy M. Sheehan Mayor Co-Applicant’s Name: Address: Zip: Home Phone Work Cell Is this a single-family house? YES NO If not, how many units are there? Are all taxes current on the property? YES NO Are you or any immediate relative an employee, agent, consultant, officer, or an elected or appointed official of the City of Albany or a Neighborhood Improvement Corporation? YES NO Which of the following do you consider your family to be? (Check all that apply.) White Asian Black / African American Hispanic American Indian / Alaskan Native Native Hawaiian / Pacific Islander Other(s) Proof of ALL income must be submitted with this application: If employed, two months of current paystubs and award letters showing GROSS amounts for Social Security / SSI / Pension, and proof of rental income (if received). Please also submit a copy of your photo ID, a copy of your recorded deed, and proof of homeowner’s insurance. Please list all income for ALL household members: TYPE OF INCOME ANY RECEIVED? RECEIVED FROM GROSS ANNUAL INCOME ACDA INCOME VERIFICATION Social Security YES NO Pension / Disability YES NO Rental Income YES NO Wages YES NO Other(s) YES NO For office use only: RAP SRP RAPII ---PAGE BREAK--- Application for Rehabilitation Assistance Program (RAP) (RAPII) and Senior Rehabilitation Program (SRP), Continued HOUSEHOLD COMPOSITION: List the full legal names of all household members. “Household” is defined as all the persons who occupy a housing unit. The occupants may be a single family, one person living alone, two or more families living together, or any other group of related or unrelated persons who share living arrangements. Attach an additional sheet if necessary. Legal Name Relation to Head Sex Age D.O.B. Soc. Sec. # Occupation SELF RELEASE FORM By signing below, I / we certify/certifies that all information in this application is true to the best of my / our knowledge and belief. Verification may be obtained from any sources named in this document. Any knowingly false information supplied by the applicant(s) will render this application null and void. I / We, the undersigned, hereby authorize the Albany Community Development Agency and its agents/ employees to obtain credit, financial, income tax and any additional information necessary to process this application. I / We also authorize the Social Security Administration to disclose information relative to the amount of my gross benefit to the Albany Community Development Agency. APPLICANT APPLICANT Signature: Signature: Printed name: Printed name: Date: Date: Social Sec. – – . Social Sec. – – . Reviewed by: Date: Revised 9/15/2016