Champlin Place Wait List Application

Champlin Place Wait List Application

Champlin Place sits on beautiful, wooded acreage in Rochester, New Hampshire and is designed to meet the needs of residents 62 years of age or older who want to live in an affordable, well-equipped, modern apartment in an independent living setting.

We are accepting applications for future availability. If you have any questions about Champlin Place or the application process, please email housing@eastersealsnh.org.

*indicates required fields

Are all members of the household age 62 or older?*

Yes, I certify this to be true.

No, not all members are age 62 years or older.

Head of Household Name*

Phone Number*

Email*

Street Address*

Town, State and Zip Code*

Members of Your Household*

List all persons, including yourself, who will be living in the apartment and considered members of your household.

How many bedrooms does your household require?*

1 Bedroom

2 Bedrooms

Specific features needed*

Do you or any member of your household need any specific features or apartment designs, such as wheelchair accessibility, visual aids (Braille), or apparatus for hearing assistance?

Yes

If yes, what features:

Additions to the household?*

Do you anticipate any additions to the household in the next 12 months?

Yes

If yes, please explain:

Live-in Care Attendant?*

Will you or any member of your household require a live-in care attendant?

Yes

If yes, name of care attendant:

Relationship:

Student Status*

Are you or any member of your household a full or part-time student?

Yes

If yes, who:

Sex Offender List*

Are you or any household member subject to any state sex offender registry?

Yes

Housing Choice Voucher*

Does the household have a tenant-based Housing Choice Voucher (a rental assistance voucher that travels with the Household) that will be used to subsidize rent at Champlin Place?

Yes

If yes, the issuing Housing Authority:

Pets*

Do you have pets?

Yes

If yes, please list dog's breed, height, weight.

Income and Asset Information

Total Household Gross Income*

Total household monthly income (before taxes and deductions)

Value of assets*

Income earned from assets*

Head of Household Race and Ethnicity

The information regarding race and ethnicity is requested to assure the Federal Government that we do not discriminate on the basis of ethnic status or race. You are not required to furnish this information but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way.

Ethic Categories (select one)

Hispanic or Latino

Non-Hispanic or Latino

Referral Source

Please indicate how you learned about Champlin Place.

Please indicate which paper, radio, etc above.

Please list today's date*

Certification

I/We certify that the housing for which this application is being submitted will be my/our only residence.

I/We understand that the above information is being collected to determine my/our eligibility.

I/We understand that the property owner will screen my household in accordance with the property's Resident Selection Plan and that submitting this application is not a guarantee that my household meets the criteria.

I/We certify that the statements in this application are true and complete to the best of my/our knowledge. We understand any false information is punishable by law and could be grounds for denial of this application or termination of residency after occupancy.

I/We understand that the information provided in this application will be verified by the owner.

Send me a copy of my responses

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