• First Name:
• Last Name:
• Date of Birth:
• -- January Febuary March April May June July August September October November December -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ---- 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
• Social Security Number:
• Street Address:
• City:
• State:
• Zip code:
• Do you live in Albany?
•  Yes     No
• Do you work or have a commitment for
  a job in the city of Albany?
•  Yes     No
• Home Phone:
• Work Phone:
• Message Phone:

List all family members, including yourself, who will be residing in the household:

• Name
• Ethnicity
• Race
• Age
• Sex

• SELECT ONE Hispanic or Latino Non-Hispanic or Latino
• SELECT ONE White Black/African American American Indian/Alaska Native Asian Native Hawaiian/ Other Pacific Islander
• ---- Male Female

• SELECT ONE Hispanic or Latino Non-Hispanic or Latino
• SELECT ONE White Black/African American American Indian/Alaska Native Asian Native Hawaiian/ Other Pacific Islander
• ---- Male Female

• SELECT ONE Hispanic or Latino Non-Hispanic or Latino
• SELECT ONE White Black/African American American Indian/Alaska Native Asian Native Hawaiian/ Other Pacific Islander
• ---- Male Female

• SELECT ONE Hispanic or Latino Non-Hispanic or Latino
• SELECT ONE White Black/African American American Indian/Alaska Native Asian Native Hawaiian/ Other Pacific Islander
• ---- Male Female

• SELECT ONE Hispanic or Latino Non-Hispanic or Latino
• SELECT ONE White Black/African American American Indian/Alaska Native Asian Native Hawaiian/ Other Pacific Islander
• ---- Male Female

• Do you anticipate that any additional members will be added to the household within the next year?
•  Yes     No

• If yes, please explain:

• Are you or your spouse 62 years of age or older?
•  Yes     No

• Are you or your spouse disabled?
•  Yes     No

• Has any adult member of your household worked 9 out of the last 12 months?
•  Yes     No

• Are you a graduate or participant in a New York State recognized educational or employment training program?
•  Yes     No

• Are you presently eligible for or receiving TANF or family assistance?
•  Yes     No

• Did you receive or were you eligible to receive AFDC or JOBS during the past two years?
•  Yes     No

NOTE: TANF (Temporary assistance to needy families) replaced the welfare program known as ADC. TANF is only for households with minor children. (Safety net is NOT TANF)

Income Information: Sources of income include wages, self-employment income, welfare (TANF if you have minor children), other welfare such as home relief (HR is not TANF), Social Security, SSI, Pensions, income from interest or dividends, child support, foster care payments, annuities, financial aid, etc.

List the type, amount and frequency of all income received from any family member who will be living with you, including yourself.

• Name
• Type of Income
• Yearly Amount
•  

• Self
•  

Special unit requirement(s) questionnaire

• Do you, or does any member of your family require a handicap accessible apartment
  
  If yes, complete the following:
•  Yes     No

• Do you, or does any member of your family have a condition that requires:
•  

•   A separate bedroom
    A barrier-free apartment
    One-level unit
    Physical Modification to a typical apartment
    Unit for vision impaired
    Unit for hearing impaired
    BR/Bath on 1st Floor
•  

• Can you and all your family go up and down stairs unassisted
•  Yes     No

• If no, please indicate how the AHA should accommodate your family:

• Will you or any of your family members require a live-in aide to assist you?
•  Yes     No

• If yes, please explain

• If you checked any of the above listed categories of units, please explain exactly what you need to accommodate your situation:

• What is the name of the family member who needs the features identified above?

• Who should be contacted to verify your need for the features you have identified above? (name, address and phone)