Plus One ADU Application

Plus One ADU Application
Section 1 - Applicant Information
Owner/Applicant*

First NameLast Name
Property Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Section-Block-Lot#*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Names on Deed*
# of People in Household*
How many residential units are currently on the property? *
Are you or anyone in the household employed by North Country Rural Development or Essex County Land Bank?*

YesNo
If yes, a conflict-of-interest disclosure may be required.
Race (optional)
Ethnicity (optional)
Gender (optional)
I do not wish to disclose Race, Ethnicity, Gender, or Education

Yes
Section II - Household Composition
List all other household members age and relationship to applicant
Applicant's Highest Education Level Completed
Gross Annual Household Income (Before Taxes) *
Include all income sources: wages, self-employment, unemployment, Social Security, pensions, child support, rental income, public assistance, etc.
Does anyone in the household require special accommodations?*

YesNoIf yes, describe
Section III - Property Information
When did you acquire the property? *
Is there a mortgage on the property?*

YesNo
Mortgage monthly payment
Includes taxes?

YesNo
Includes insurance?

YesNo
Are you behind on payments?

YesNo
If yes, How many months?
Homeowners insurance in place?*

YesNo
Other liens on the property?*

YesNoIf yes, list
Year home was built*
Approximate property size (acres) *
Municipal water and/or sewer?*

WaterSewerBothNone
Does the proposed ADU meet zoning/setback requirements?*

YesNoUnsure
Any zoning code violations or open permits?*

YesNoUnsure
Is the property listed on the NYS or National Historic Register?*

YesNoUnsure
Is the property in an Agricultural District?*

YesNoUnsure
Are other deed holders willing to sign the grant lien documents?*

YesNo
Is the property in a flood zone?*

YesNoUnsure
Check: https://msc.fema.gov/portal/search
Do you have flood insurance?*

YesNo
Proposed ADU Location (check one)*

Attic conversionBasement conversionNew attached additionNew detached structureGarage or other existing building conversionOther
Note: Third-floor attic conversions may require additonal fire safety review.
Document Checklist
Proof of income

Cancelof
Last 3 months of bank statements

Cancelof
Photo ID of all applicants

Cancelof
Copy of deed

Cancelof
Proof of homeowner's insurance

Cancelof
Latest mortgage statement

Cancelof
Tax bills and proof of payment

Cancelof
Plot plans of proposed ADU placement (if available)

Cancelof
Architect/engineer drawing with foundation plans (if available)

Cancelof
Contractor estimates (if available)

Cancelof
Section IV - Certification
I/We certify that the information provided in this application is accurate and complete. I understand that submission does not guarantee funding, and additional documents may be requested.
Signature*
Should be Empty:

Plus One ADU Application

Section 1 - Applicant Information

Section II - Household Composition

Section III - Property Information

Document Checklist

Section IV - Certification