Waiting List Application

Click here if prefer to download the application. Please send application via email to rentals@phippsny.org or mail to 257 Park Avenue South 12th Floor, New York, New York 10010.

Phipps Waiting List Application

Dear Applicant,

Phipps Houses is New York City’s oldest and largest nonprofit developer, owner and manager of affordable housing. Our mission is to provide high quality housing for every family we serve. We have numerous properties located in the Bronx, Brooklyn, Manhattan and Queens that you can request to join the waiting list for. Thank you for your interest in Phipps and we look forward to receiving your application!

Sincerely,
The Phipps Rental Department

To be completed by you and all adult household members

Please click here to review income requirements prior to filling in this form.

Which building/development are you applying for?

If you are not applying for a specific building, which borough(s) would you be interested in living in?

Bronx

Brooklyn

Manhattan

Queens

A. Name & Address

First(Required)

Middle (Optional)

Last(Required)

Current Living Address (If you are living in a City-run homeless shelter, please list your current shelter address):(Required)

Street Address Address Line 2 (Optional) City State / Province / Region ZIP / Postal Code

Is this a NYCHA property?(Required)

Yes

If yes, is your name on the NYCHA household form?

Yes

Is this a City-run homeless shelter?

Yes

Contact Information:

Cell Phone(Required)

Home Phone

Email Address(Required)

Mailing Address (if different from current living address):

Building (House) #

Street

Apartment #

P.O. Box

City

State

ZIP Code

Please select the language you prefer to receive written communications in. If you do not select a language, written communications will be sent to you in English.

English

Español

简体中文 (Chinese)

العربية (Arabic)

Français (French)

Русский (Russian)

한국어 (Korean)

اردو (Urdu)

বাাংলা ( Bangla)

Kreyòl Ayisyen (Haitian Creole)

B. Household Information

How many people (including yourself) will live in the apartment for which you are applying?(Required)

Are any members of your household currently subjected to a lifetime registration requirement under a state offender registration program?(Required)

Yes

Will everyone who is currently living with you going to live with you in a new apartment?(Required)

Yes

List ALL the people who will live in the unit for which you are applying, starting with yourself (Self), and provide the corresponding information.
Gender Identification: In this section, list how you identify (optional). Examples: Female; Male;Non-binary; etc.
Disability: If ahouseholdmemberhas an ongoing mobility (M), hearing (H), or visual(V) disability and requires an accessible/adaptable unit,please check the relevantbox. If selected for further processing, you will be mailed a form that you and amedicalprofessionalwillneed to immediately complete and send back. This form is to verify that your household requires an accessible or adaptable apartment. The form can be used for any other future applications for a period of up to 12 months.

List(Required)

First, Middle Initial & Last Name, Suffix

SSN/TIN (Optional)

Relationship to Applicant

Birth Date MM/DD/YYYY

Disability? (H,M,V)

Click the (+) button to add names

If you checked either mobility, visual, or hearing disability, do you or a member of your household require a special accommodation?

Yes

Please specify the accommodation required:

Is anyone in the table above a full-time student?

Yes

If yes, please write their name(s):

Do you anticipate any change(s) in your household within the next 12 months? If yes, please explain:

C. Income and Assets

Please click here to review income requirements.

Are you or a member of your household a Phipps employee?

Yes

If you answered “yes”, you may be required to submit a statement from your employer that your application does not create a conflict of interest.

1. Income from Employment

For any job that is not self-employment, list the amount you make before taxes (Gross Income). For self-employed individuals, use the amount you make after deductions (Net Income). If your application is selected for further processing, you will be contacted with a list of documentation that you will need to provide

List all full and/or part-time employment income for ALL Household Members, including yourself. Include self-employment earnings:

Click the (+) button to add names

Household Member Name

Employer Name & Address

Length of Employment

Amount Paid ($)

How Often? (Ex: weekly, bi-weekly, monthly, annually)

Annual Income

1A. Total Annual Household Income. Please add all amounts from the “Annual Income” boxes listed above:(Required)

2. Income from Other Sources
List all other income sources for each household member, for example, welfare (including housing allowance), AFDC, Social Security, SSI, pension, workers’ compensation, unemployment compensation, interest income, babysitting, care-taking, alimony, child support, annuities, dividends, income from rental property, Armed Forces Reserves, scholarships and/or grants, gift income, etc.

List

Household Member

Type of Income

Amount Paid ($)

How Often? (Ex: weekly, bi-weekly, monthly, annually)

Annual Income

2A. Total Annual Income from Other Sources. Please add all amounts from “Annual Income” boxes listed above:(Required)

3. Total Annual Household Income

Add the income amounts from 1A and 2A, above:(Required)

4. Assets

Does anyone in this household have additional assets? Examples of assets include, but are not limited to checking accounts, savings accounts, investment assets (stocks, bonds, vested retirement funds, etc.), Cashapp, Paypal, Venmo, real estate, and cash savings.(Required)

Yes

If “yes,” please indicate assets for each household member:

Household Member Name

Type of Asset or Account

Bank/Institution

5. Rental Subsidy

Are you presently receiving a Section 8 Housing Voucher or or any other form of rental assistance? Please check the appropriate box at right. Examples of other rental subsidies include CITYFHEPS, NHTD (Medicaid Waiver), Individual Services and Supports (ISS), and VASH. This information will not affect the processing of the application. Minimum income listed may not apply to applicants with Section 8 or other qualifying rental subsidies.(Required)

Yes – HPD Section 8 voucher

Yes – NYCHA Section 8 Voucher

Other

Please specify:

D. Race and Ethnicity

This information is optional and will not affect the processing of the application. Please check the group(s) that best identifies the household:

White

Black or African-American

Asian

Native Hawaiian or Other Pacific Islander

American Indian or Native Alaskan

Choose not to answer

Other

This information is optional and will not affect the processing of the application. Please check the group(s) that best identifies the household:

Hispanic or Latino

Not Hispanic or Latino

Choose not to answer

E. Declaration and Signatures

Signatures (Required for All Household Members 18 and over)

I (WE) DECLARE THAT STATEMENTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY (OUR) KNOWLEDGE. I (We) have not withheld, falsified, or otherwise misrepresented any information. I (We) fully understand that any and all information I (we) provide during this application process is subject to review by The New York City Department of Investigation (DOI), a fully empowered law enforcement agency which investigates potential fraud in City-sponsored programs. I (we) understand that consequencesfor providing false or knowingly incomplete information in an attempt to qualify for this program may include the disqualification of my (our) application, the termination of my (our) lease (if discovery is made after the fact), and referral to the appropriate authorities for potential criminal prosecution.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Signature(Required)

Date

MM slash DD slash YYYY

Signature(Required)

Date(Required)

MM slash DD slash YYYY

THIS APPLICATION IS ONLY VALID FOR SIX (6) MONTHS, AFTER 6 MONTHS YOU MUST RE-APPLY BY SUBMITTING A NEW APPLICATION IN ORDER TO REMAIN ON OUR GENERAL WAITING LIST application, the termination of my (our) lease (if discovery is made after the fact), and referral to the appropriate authorities for potential criminal prosecution.

Consent – Electronic Communications/Electronic Signatures

Your information will be used by Phipps Rentals and may be transmitted to the owner/agent staff and contractors as appropriate, any new owner/agent, HUD, HUD’s agents, or other third parties for the purpose of the administration, evaluation and management of your application/lease as well as for the purpose of preparing reports that may be required by government agencies. The owner/agent will comply with rules established by the Department of Housing & Urban Development when transmitting or sharing your data.

Updating Contact Information: Please note that it is your responsibility to update the owner/agent regarding any changes to your contact information.

Withdrawal of Consent: You have the right to withdraw your consent to submit your lease electronically. If you choose to do so, please note that you will no longer receive information through electronic communication. You may withdraw your consent by emailing Phipps Rental at RENTALS@PHIPPSNY.ORG, or by sending a written withdrawal of consent to 902 Broadway, 13th floor, New York, NY 10010.

Agreement:
By signing this document, you give your consent to electronic disclosures and to the use of electronic signatures. You also consent to conducting any matters related to leasing process electronically as allowed by the Department of Housing & Urban Development (HUD) and other applicable law. By consenting to the electronic delivery of disclosures, you agree that we may provide electronically any communications to you.

You are not required to receive notices and disclosures or sign documents electronically. If you prefer not to do so, you may request to receive paper copies and withdraw your consent at any time.

You understand that certain information cannot be sent electronically because of government or HUD restrictions.

Consent – Electronic Communications/Electronic Signatures

Signature(Required)

Date(Required)

MM slash DD slash YYYY

The owner/agent does not discriminate based on 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).

Name: James Robert Pigott, Jr. Email: Rpigott@phippsny.org

DO NOT USE THE ABOVE CONTACT INFORMATION TO SUBMIT OR TO INQUIRE ABOUT THE STATUS OF YOUR APPLICATION