List and describe in detail below.) Other Assets Value Other Income Value Other Obligations Value Other Expenses Value I certify that, to the best of my knowledge and belief, this report is complete, true and correct. Signature Date Signature Date

Name of the member Postal address of the member to receive the complete application Telephone number of the member Request for Habitat’s Own Housing Program We are committed to the letter

Newly Built, Fair and Affordable Single Family Homes Now Available for Sale Town of Cortlandt Westchester County APPLICATION DEADLINE APRIL 14, 2017 **

FREEDOM HOMES RESIDENCY APPLICATION 1680 Strawberry Road, Mohegan Lake, New York (Westchester County)

Date: CUSTOMER DATA COMMERCIAL RELATIONSHIP START FORM AND DATA UPDATE NATURAL PERSON POLICY KNOW YOUR CUSTOMER RESOLUTION No.JB 2010-1683 – Full Names and: Surname:

APPLICATION TO PURCHASE CONDO 289 Manville Road, Unit 3A Pleasantville, New York (Westchester County) 1. Submit only one (1) application per residence. If your name appears on more than one

Fair and Affordable Single Family Homes Available Now for Purchase in the Town of Yorktown Westchester County DEADLINE TO APPLY APRIL 24, 2017 IF INTERESTED

FAIR AND AFFORDABLE HOUSING APPLICATION HAWKES CROSSING THORNTON HILL Off Hawkes Ave / Route 134., OSSINING, NEW YORK DEADLINE: JANUARY 2, 2019 Once completed mail application or

Instructions for Completing the Beaufort Memorial Hospital Financial Assistance Application For your convenience, check each box as the item is obtained and / or completed. Return this

APARTMENTS 322 KEAR ST, YORKTOWN HEIGHTS APPLICATION DEADLINE FEBRUARY 8, 2018 Mail or hand-deliver the application to: Housing Action Council at 55 South Broadway, Tarrytown, NY

Individual Development Account (CDI) for Technology Assistance: Savings Program Application Date of application: Personal Information Note: all the information you provide on this

Financial Statement Patient Name: Medical Record No: Guarantor Name: Guarantor Address: Guarantor City, State, Zip Code: Date: Dear A copy of an Application is attached

FINANCIAL ASSISTANCE, BILLING AND COLLECTION POLICY APPENDIX A: APPROVED DOCUMENT LIST We will review and consider the financial income of the household to grant possible discounts on services.

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