RD Wait List Application

Completed Applications to be sent to Management Agent;
Sage Management Corporation of Western New York
916 Upper Mountain Road, Lewiston, NY 14092
Phone: 716-298-4966 Fax: 716-298-4489
www.sagemanagementcorp.com
Lewiston Country Estates
916 Upper Mountain Road
Lewiston NY 14092
24 One Bedroom Apartments
1 Two Bedroom Apartment
Wilson Country Estates
250 Autumnview Drive
Wilson NY 14172
24 One Bedroom Apartments
Middleport Country Estates
89 Telegraph Road
Middleport NY 14105
24 One Bedroom Apartments
Middleport Villa
89B Telegraph Road
Middleport NY 14105
24 One Bedroom Apartments
1 Two Bedroom Apartment

To Qualify You Must

· Be 62 years of age or older, or disabled of any age.

· Meet the income qualifications listed below

· Meet Screening Criteria Listed In Tenant Selection Plan.

Income Level	1 Person	2 Persons	3 Persons
Very Low	$33,950	$38,800	$43,650
Low	$54,250	$62,000	$69,750

Priority is given to those applicants with very low income.

Income Levels Updated: July 12 2024

Please check below to acknowledge you have read the above.*

I acknowledge I have read Things You Should Know About USDA Rural Rental Housing Page 1.

Please check below to acknowledge you have read the above.*

I acknowledge I have read Things You Should Know About USDA Rural Rental Housing Page 2.

Please check below to acknowledge you have read the above.*

I acknowledge I have read NY Know Your Rights Justice Involvement Policy.

Please check below to acknowledge you have read the above.*

I acknowledge I have read NY Know Your Rights Credit Policy.

Head Of Household
Name*

First NameLast Name
Social Security #*
Date Of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Driver's License /State ID #
State Issued
Race*
Gender*
Ethnicity*
The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age and disability are complied with. You are not required to furnish this information but are encouraged to do so.

This information will not be used in evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and sex of individual applicants on the basis of visual observation or surname.

Please List All Other Household Members
If you have more than one person in the household. You must provide all their infomation for the application to be complete. Press the arrow on the right side to drop down the required infomation. If you do not have any other household members, select Next on the bottom of the page. If you do not have the infomation, you can save the application and complete at a later date.
- Full Name
  
  First NameLast Name
- Date Of Birth
- Social Security Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Ethnicity
- Gender
- Race
- The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age and disability are complied with. You are not required to furnish this information but are encouraged to do so.
  
  This information will not be used in evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and sex of individual applicants on the basis of visual observation or surname.
- Full Name
  
  First NameLast Name
- Phone Number
- Date Of Birth
- Social Security Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Ethnicity
- Gender
- Race
- The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age and disability are complied with. You are not required to furnish this information but are encouraged to do so.
  
  This information will not be used in evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and sex of individual applicants on the basis of visual observation or surname.
- Full Name
  
  First NameLast Name
- Phone Number
- Date Of Birth
- Social Security Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Ethnicity
- Gender
- Race
- The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age and disability are complied with. You are not required to furnish this information but are encouraged to do so.
  
  This information will not be used in evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and sex of individual applicants on the basis of visual observation or surname.
- Full Name
  
  First NameLast Name
- Phone Number
- Date Of Birth
- Social Security Number
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Ethnicity
- Gender
- Race
- The information regarding race, ethnicity and sex designation solicited on this application is requested in order to assure the Federal Government, acting through the Rural Housing Service, that the Federal laws prohibiting discrimination against tenant applications on the basis of race, color, national origin, religion, sex, familial status, age and disability are complied with. You are not required to furnish this information but are encouraged to do so.
  
  This information will not be used in evaluation of your application or to discriminate against you in any way. However, if you choose not to furnish it, the owner is required to note the race, ethnicity and sex of individual applicants on the basis of visual observation or surname.
- Name:   First Name   Last Name
  Date of Birth:   Date Of Birth
  Social Security No:   SSN#
  Phone:   Area Code   Phone Number
  Email:   Email
  Address:    Street Address   Address Line 2   City   State   Zip
  License Information:     License #   State
  Race:
  Gender:
  Ethnicity:
  ----------------------------------------------------------------------------------------
- Name:   First Name   Last Name
  Date of Birth:   Date Of Birth
  Social Security No:   SSN#
  Phone:   Area Code   Phone Number
  Email:   Email
  Address:    Street Address   Address Line 2   City   State   Zip
  License Information:     License #   State
  Race:
  Gender:
  Ethnicity:
  ----------------------------------------------------------------------------------------
- Name:   First Name   Last Name
  Date of Birth:   Date Of Birth
  Social Security No:   SSN#
  Phone:   Area Code   Phone Number
  Email:   Email
  Address:    Street Address   Address Line 2   City   State   Zip
  License Information:     License #   State
  Race:
  Gender:
  Ethnicity:
  ----------------------------------------------------------------------------------------
- Name:   First Name   Last Name
  Date of Birth:   Date Of Birth
  Social Security No:   SSN#
  Phone:   Area Code   Phone Number
  Email:   Email
  Address:    Street Address   Address Line 2   City   State   Zip
  License Information:     License #   State
  Race:
  Gender:
  Ethnicity:
  ----------------------------------------------------------------------------------------

Other Household Information
Do you Have a Pet?*

YesNo

If yes, please provide Pet information. If No put N/A for each column*

	Species	Weight	Color
Animal

If yes, please provide documentation of any required licenses and required shots.

Cancelof
Do you have a vehicle?*

YesNo

If yes, please provide vehicle information

	Year	Make	Model	Color	License Plate #	State Issued
1

CERTIFICATION
I hereby certify that I will not maintain a separate subsidized rental unit in another location. I certify that this will be my permanent residence. I certify that I am a U.S. citizen or a qualified alien (a legal or qualified alien refers to any person lawfully admitted to the country who meets the criteria in Section 214 of the Housing and Community Development Act of 1980, 42 USC 1436a I understand I must pay a security deposit for this apartment prior to occupancy. I understand that my eligibility for housing will be based on the USDA Rural Development and NYS Housing and Community Renewal income and occupancy limits and selection criteria. I certify that all information contained in this application is true to the best of my knowledge and that false statements and/or information are punishable by law and will lead to cancellation of this application and/or termination of tenancy after occupancy.
Head of Household*
Date*

MonthDayYear
Date
Co Head
Date

MonthDayYear
Date

RELEASE OF INFORMATION AUTHORIZATION
I do hereby authorize Sage Management and any authorized representative to contact any agencies, offices, groups or organizations to obtain and verify any information or materials which are deemed necessary to complete my application for housing. This could include police/background checks and credit checks.
Head Of Household*
Date*

MonthDayYear
Date
Signature*

Clear
Sage Management Corporation of Western New York, Lewiston Country Estates, Wilson Country Estates, Middleport Country Estates & Middleport Villa do not discriminate on the basis of race. color, religion, sex, national origin, age, marital status, disability, handicap, sexual orientation, gender identity, or familial status.
Should be Empty:

	Name	Income Source	Monetary Value	Frequency
1
2
3
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	Medical Provider	Address	Visits Per Year	Round Trip Mileage
1
2
3
4
5

Wait List Application

Special Unit Questionnaire (HANDICAPPED UNIT ONLY)

Head Of Household

Please List All Other Household Members

Other Household Information

Income

Assets

Declaration of No Assets (ONLY SIGN IF YOU HAVE NO ASSETS)

Medical

Justice Involvement Check

Landlord Reference

CERTIFICATION

RELEASE OF INFORMATION AUTHORIZATION

	Name	Cash Value	Asset Type
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5