Re-Certification Application

The Wren
Sharon, MA
Annual recertification for the affordable housing program is required as part of your lease agreement. You will not be
allowed to renew your lease without being recertified as eligible for the program. Your recertification must be
completed at least 60 days prior to your current lease expiring. That means 100% of the required documentation must
be submitted more than 60 days prior to your lease expiring.
We recommend you start this process now as it typically takes households 30-40 days to complete the recertification
process. Please read your lease for more details.

MAXIMUM Household Income Limits For Lease Renewal:

$127,680 (1 person), $145,880 (2 people), $164,150 (3 people), $182,350 (4 people)

Directions:
This application consists of the following sections:+

1) The Program Application and Definitions

2) Required Documentation Guide
3) Additional Forms (if applicable)

The first two sections must be filled out entirely in order for your application to be processed. Every space given to initial
must be initialed, even if you answer “N/A”. If a question does not apply to you, check “N/A”. LEAVE NOTHING BLANK.
You must include all income and asset documentation as directed with this application. Send or drop off all applications
by the date you established with the leasing office to:

SEB Housing
Re: The Wren
257 Hillside Ave
Needham, MA 02494
Fax: 617.782.4500
Phone: 617.782.6900
Email: info@[Link]

If faxing or scanning, be sure to transmit both sides of double sided pages

1
 Section 1

The Program
Application and
Definitions

2
The Wren. Please provide all the following contact information for the Head of Household
(please print clearly):
Applicant’s Name:

Address:

City: State: Zip:

Cell Phone:( ) Home Phone:( )

Work Phone:( )

Email address: @

Please note: Providing your email should facilitate the process of completing your application as you will be notified of missing
documentation faster than if we can only send notifications via postal mail. If you do not provide your email address or do not have an email address,
we will contact you via postal mail. We will not contact you about future lotteries unless requested.

Anticipated Move-In/Lease Renewal Date:

Bedroom Size Information: Circle the bedroom size for which you are applying.
 1 bedroom
 2 bedroom
Do you currently receive or do you have a Section 8 mobile voucher or certificate? (The Lottery Agent does
not discriminate based on source of income. This question is asked for the sole purpose of determining ability
to pay rent.)
 Yes  No

Please fill out the chart below for everyone who will be occupying the unit:
IS THIS PERSON A
FULL-TIME STUDENT
HEAD OF RELATIONSHIP TO
OR WILL BE A FULL-
NAME AGE HOUSEHOLD OR APPLICANT LISTED AT THE
TIME STUDENT IN
DEPENDENT TOP OF THIS PAGE
THE NEXT 12
MONTHS?
Yes No
Yes No
Yes No
Yes No

I certify that my Household Size is (total number of entries in table above) _________.

Initial(s): _________ Initial(s): _________

3
HOUSEHOLD TYPE You must check one of the following boxes for your household Type. The Information Packet has
more details on Types.
□ 1 person household (Type I)
□ 1 person household with a disability or medical need for TWO bedrooms (Please note that verification from medical
provider of need for a 2BR unit will be required at certification otherwise household may be removed from Waiting Lists) (Type II)

□ 2 person household: 2 heads-of-household (Type I)

□ 2 person household: 1 head-of-household plus one dependent (Type II)
□ 2 person household with a disability or medical need: 2 heads-of-household where (A) heads-of-household cannot be
required to share a bedroom as a consequence of sharing would be a severe adverse impact on their mental or physical
health OR (B) there is a separate disability or medical need for two bedrooms. (In either case, please note that verification
from medical provider of need for separate rooms for heads of households or of need for a 2BR unit will be required at certification
otherwise household may be removed from Waiting Lists) (Type II)

□ 3 person household: all types (Type II)

□ 4 person household: all types (Type II)

PREFERENCE INFORMATION

Are you, or any member of your household, in need of an accessible unit? This is defined as persons with
a physical disability that meet standards established by the Department of Housing and Community Development and
state laws for disabled accessible housing and who needs the features of a disabled-accessible unit.
 Yes
 No
If yes, in Section 2: Preferences, you will be required to attach documentation as directed.

REASONABLE ACCOMODATION

Persons with disabilities are entitled to request a reasonable accommodation in rules, policies, practices, or services,
(“practices”) when such accommodations may be necessary to afford persons with disabilities an equal opportunity to use
and enjoy the housing. If you have a reasonable accommodation request related to this Application/Certification, please
describe it here. If you have any other requests, including a reasonable accommodation request related to the
Owner/Developer’s practices, or a reasonable modification request related to the physical structure of the building or
unit, do not list it here. That request must be made directly to the Owner/Developer.

Does any member of the household have any reasonable accommodation requests or alternative ways we need to
communicate with you?
 Yes
 No

If yes, please explain in the space provided here or write a signed statement and attach it:

4
RELATED PARTY
Is any member of the household related to or employed by the developer or related to or employed by the Property
Management Company?
 Yes
 No
If yes, please explain the relationship in the space provided here:

DATABASE INFORMATION

How did you find out about this affordable housing opportunity?
(please be as specific as possible, if found “online” please provide web address)

5
 INSTRUCTIONS FOR COMPLETING THE FOLLOWING INCOME TABLE

Please complete the Income Table on the following two pages. You will later be asked to attach supporting documentation
in the form of the five most recent consecutive pay stubs and/or income statements for all sources of income, W-2
statements and the most recent federal income tax returns (including all attachments and amendments) for each member
of the household.

For the purpose of income determination, “Household shall mean all persons whose names appear on the lease, and also
all persons who intend to occupy the housing unit as their permanent primary residence, even if they are not included on
the lease. The incomes of all household members will be included, with the exception of income from employment for
household members under the age of 18 or any income over $480/year of full-time students who are dependents (but please
note that documentation of income for those dependents still needs to be supplied).

Please note:
1. Gross income from current wages, salaries, tips, etc. is the full amount, before any deductions, and is the amount used to
determine estimated current annualized income.
2. For self-employed applicants- include the contract or job name in the space provided. You will be directed to all the
additional documentation you will need to submit in Section 2.
3. “Interest Income” refers to any amount that you receive from any asset except for amounts drawn down from a retirement
account or 401K as those go on the lines for “pension” or “retirement funds”.

6
 INCOME
Household Member Current GROSS
Source of Income Monthly Income
Name
Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Self-Employed (contract/job name)

Self-Employed (contract/job name)

Self-Employed (contract/job name)

Child Support/Alimony

Child Support/Alimony

Social Security Income

Social Security Income
Social Security Income
Social Security Income

SSDI
SSDI

Pension (list source)

Pension (list source)
Retirement Distributions

7
Household Member Current GROSS
Source of Income Monthly Income
Name

Unemployment Compensation

Workman’s Compensation

Severance Pay

Title IV/TANF

Full-Time Student Income

(18 & Over Only)
Full-Time Student Income
(18 & Over Only)

Periodic payments from

family/friends & Recurring Gifts
(i.e. rent assistance from family)

Interest Income (source)

Interest Income (source)

Interest Income (source)

Interest Income (source)

Interest Income (source)

Interest Income (source)

Other Income (name/source)

Other Income (name/source)

Gross Monthly Household Income

$ /month
(GMHI)

GMHI x 12 = Gross Annual Household Income $ /year

8
 ASSETS
If a section doesn’t apply, cross out or write N/A. In the next section you will be directed to submit detailed
bank/balance statements for EVERY ASSET listed here. If any household member has divested themselves
of an asset for less than full and fair present cash value of the asset within two years prior to this application,
the full and fair cash value of the asset at the time of its disposition must be listed below.
Last 4 Digits of Acct
Bank Name Amount
Number
Checking Balance $
Accounts Balance $
Balance $
Balance $
Balance $
Savings Balance $
Accounts Balance $
Balance $
Money Transfer Circle all that apply Venmo CashApp Balance $
Applications in the next space → PayPal Other
Trust Account Balance $
Balance $
Certificates
Balance $
(or CDs)
Balance $
Savings Bonds Maturity Date: Value $
Maturity Date: Value $
401k, IRA, Company Name: Value $
Retirement Company Name: Value $
Accounts Company Name: Value $
(Net Cash Value) Company Name: Value $
Interest/
Name: # of Shares: Value
Dividends
Mutual Funds $ $
$ $
$ $
$ $
Stocks
$ $
$ $
Bonds $ $
$ $
Investment Appraised
Property Value $
REAL ESTATE
Do you, or anyone on this application, own any property or
have owned property in the past 2 years? □ Yes □ No

Are you, or anyone on this application, entitled to receive any

amount of money from the sale of any property? □ Yes □ No
(currently or thru an upcoming court settlement)
If yes to either question, type of property:
Location of property: $
Appraised Market Value: $
Mortgage or outstanding loans balance due: $

9
 Section 2

Required
Documentation
Please note: the following questions are applicable to
every single person who will be occupying the unit.
Therefore, the use of “I” or “my” in the following
questions includes all household members.

You MUST initial every question in Section 2 and, where

provided, check “N/A” or “Yes”.

Every time you answer “Yes”, you must submit all

documentation as directed in that question. When
submitting paperwork to SEB Housing, please do not
use staples anywhere (including this Certification
Application)

10
1. Earnings/Wages (CURRENT EMPLOYMENT, ALL JOBS CURRENTLY WORKED): For each current job I have
attached copies of the five (5) most recent consecutive pay stubs or five most recent statements for every source of
employment for household members 18 year or older as listed on the Income Tables in Section 1. All attached pay-
stubs or statements have the name of the employer, date, wages, and name of the household member and cover the
5 most recent consecutive pay periods (which will be a 5 week period if paid every week, or a 10 week period if
paid every 2 weeks, or a 5 month period if paid only once each month). If you have worked less than 5 pay periods
at your current job and therefore do not have 5 pay stubs, in addition to all the pay stubs you have, you will need
to provide a signed Offer Letter for that job.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

2. Earnings (FORMER EMPLOYMENT): For EACH AND EVERY former employer, previous source of employment
income, or employment position left since the beginning of my most recent year of tax filing (e.g. all positions left
from January 1st, 20XX through present), I have attached ONE of the following:

(A) A letter signed by that household member and a letter signed and dated from the former employer verifying
the last day of income and the Year-To-Date income at time of separation OR
(B) Only for jobs where my last day of employment was prior to November 1st in the previous calendar year, I have
attached the last paystub from the job that shows a Year-To-Date income that matches the Wages on the W-2 for
that job OR
(C) The Initial determination of unemployment benefit statement that lists former employers, length of
employment, gross income by quarter, and EIN Number OR
(D) I have completed only the top portion of the Verification of Terminated Employment form attached in Section
3 of this application and understand that SEB will submit this to the contact provided by me on the form in hopes
of having it returned in the next 1-2 weeks but in the event that the former employer does not return the form I will
submit the materials listed in part A, B, C of this section
(E) A signed and dated letter from me stating the company name and address, my last date of employment with
them, my year-to-date gross income at separation, and whether I anticipate being rehired. Please note that we may
also require additional verification from your employer depending upon the proximity of termination to the date
of your application.

I understand proof of termination is required for every single job left since my most recent previous year of tax
returns (no matter how small), that this is to verify my current income, and that being terminated from one or
multiple jobs will in no way affect my affordable housing program eligibility.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

3. Earnings (Social Security, SSDI, Pension, Income from Retirement Distributions, Public Assistance, TANF): I
have attached copies of the most recent statements for every source of income listed on the line above for every
household member 18 years or older. I understand that for Social Security and/or SSDI payments I need to submit
the yearly benefit letter I receive from the Social Security Administration Office detailing my payments for the next
12 months.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

11
4. Earnings (SELF EMPLOYED ONLY, INCLUDING UBER, LYFT ETC, SEE BELOW): For every self-
employed household member 18 years or older, I have attached copies of ALL of the following:
(A) The Self-Employment Income Affidavit and Profit & Loss statements at the back of this application, completed,
signed, and dated.
(B) All supporting documentation including current financial statements, accountant statements, quarterly tax
returns (if you file quarterly), and income and expense receipts AND

If I have a job or earn any income that is part of the “Gig Economy,” such as Uber, Lyft, TaskRabbit, etc., or any
other type of limited independent contracting, I will provide all information and documentation listed above. This
includes the Profit and Loss statements as well as documentation of my year to date income (i.e. income reports,
ride totals, etc.). I understand that 1099 independent contractors are self-employed for tax and affordable housing
purposes.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

5. Earnings (Unemployment and PFML): For unemployment benefits, I have attached a copy of the benefit
summary and payment history for the past 12 months for every household member 18 years or older who is
currently receiving unemployment and understand that it must be assumed that the household member will
continue to receive unemployment over the next 12 months. For every household member who reported
unemployment on their most recent tax return or has received unemployment benefits within the past twelve
months but who no longer receives it, I have attached a copy of my current unemployment benefit statement that
explicitly states that my claim is inactive and my payment history for the past 12 months. The statement shows the
last two unemployment payments received, my current benefit rate, and my current total benefit balance. I
understand that if this documentation indicates that I have current benefits and have received recent payments, my
unemployment will be calculated as part of my income, regardless of my current employment status. For PFML,
for every household member who is currently receiving PFML, has reported this income on their most recent tax
return, or has received it within the last twelve months, I have submitted a copy of my benefit letter that specifies
the rate, start and end dates of my benefit period, and frequency of pay along with my year-to-date payment history.
 N/A
 Yes
Initial(s): _________ Initial(s): _________

6. Earnings (Workman’s Comp, Severance pay) I have attached copies of the three (3) most recent consecutive pay
stubs or three most recent statements for payments I am receiving through Workman’s Compensation or Severance
settlement and if my current compensation or pay is not going to continue for the next 12 months, I have attached
the legal document stating the monthly, yearly or total amount to which I am entitled in addition to the timeline
and/or termination of such pay.
 N/A
 Yes
Initial(s): _________ Initial(s): _________

12
7. Household member with NO EARNINGS: If a member of my household is 18 years or older and is not employed
and not receiving any income, I have attached a letter from him/her attesting to this fact AND this letter has been
signed and dated by that household member AND the letter has been notarized.

 N/A
 Yes

Initial(s): _________ Initial(s): _________

8. Divorce and/or Separation: Divorce/Separated from Spouse: I understand that children can only be considered
part of the household if a head of household has at least joint physical custody of the child. The below
documentation is required, depending on your household's situation:
(A) If I am still married, even if estranged or separated, and no divorce action is pending, then I understand that I
must complete an affidavit certifying that I am estranged from my spouse, as well as provide address
verification to confirm that we are not currently living together. I have confirmed this to SEB Housing in writing
so that they can provide me with a copy of the applicable affidavit to complete.
(B) If my spouse or I have filed for divorce but are not yet divorced, I have provided a copy of the filed divorce
complaint or petition, documentation of my next scheduled court date (such as a scheduling order), and all
temporary orders that have been issued by the court pertaining to custody, child support, alimony, or asset
division. If no such temporary orders have been issued, in addition to a copy of the filed divorce complaint or
petition, I have also provided a signed, dated, and notarized statement stating that my divorce is pending and
that no temporary orders relating to custody, child support, alimony, or asset division have been issued by the
court.
(C) If I am divorced, I have included a copy of my divorce judgment and separation agreement (if applicable).

 N/A
 Yes
Initial(s): _________ Initial(s): _________

9. Child Support and/or Alimony: If I am entitled to receive Child Support and/or alimony (even if I am not receiving
it), I have attached ONE of the following:
(A) A copy of my divorce decree or settlement agreement, along with any further temporary orders or modification
judgments addressing changes made to alimony or child support payments, OR
(B) A statement from the Department of Revenue (DOR) that shows my case information summary (specifying the
amount and frequency of my child support payments) and a copy of my payment history for the past 12
months, OR
(C) In the event that I am receiving child support but do not have a court order and my child support is not paid
through the DOR, I have attached a notarized letter from the person who pays me support specifying the
amount of support I receive, the frequency with which it is paid, and how it is paid (e.g. Venmo, cash, bank
transfer).
(D) In the event that I am not receiving the child support or alimony I am entitled to receive, I have attached a copy
of my divorce decree AND proof of a legal claim filed against the person that owes me money and, if applicable,
DOR statements and/or legal claims showing payments made and/or owed)

 N/A
 Yes
Initial(s): _________ Initial(s): _________

13
10. Periodic Payments: If I am receiving periodic payments not covered by any other paragraph in this section of the
certification application, or listed anything under “Other Income” on the Income Table, I have attached a signed
and dated letter from the source of income that includes ALL of the following:

(A) The Year-To-Date income received AND

(B) The anticipated monthly income for the next 12 months AND
(C) The letter has me listed as the recipient of the payments AND
(D) The letter is notarized.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

11. Section 8 mobile voucher or certificate: I have attached a copy of my completed and signed current voucher
from the appropriate Housing Authority.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

12. Households with Students: For every household member 18 years or older who is a full-time student AND has
income from employment AND is a dependent of a household member who is also on the application, I have
attached proof of their full-time student status in the form of: Letter from the Registrar, Transcript or other
enrollment verification. Please note that the employment income for the student must be still documented.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

14
HOUSEHOLD ASSETS:
Assets include but are not limited to the following: Checking or savings accounts, Venmo/Paypal/Cash-Apps, CDs,
money market accounts, Treasury bills, stocks, bonds, securities, trust funds, gifts, pensions, IRAs, Keoghs, other
retirement accounts, real estate, rental property, other real estate holdings, all property held as an investment, and safe
deposit box contents (include the value). All accounts must include complete statements with all pages and list
dividend and interest information if applicable regardless of how little money may currently be in the account.

13. I have completed the Asset Table in Section 1 and read the above paragraph on Household Assets and have attached
every page of complete, detailed statements for the 3 most recent months or most recent complete quarterly
statement on all assets held by each household member and all statements include information on interest,
dividends, and gains or losses, if any.

Initial(s): _________ Initial(s): _________

14. For EACH and EVERY DEPOSIT into EACH and EVERY checking and savings account, I have provided
documentation from the source of the money deposited. If a deposit is from earnings of any kind, I have followed
all the directions in the applicable paragraphs on Earnings on the previous pages (i.e. submitted 5 most recent pay-
stubs, verification from source of earnings etc). If a deposit is from child support and/or alimony, I have followed
all the directions in the paragraphs on Child Support/Alimony on the previous pages. If a deposit is a periodic
payment, repayment, gift, reimbursement, I have followed all the directions in the paragraph on the previous page
titled “Periodic Payments”. If a deposit is from a loan of any kind (including student loans), I have provided
documentation showing the terms of the loan and the disbursement schedule. For any other deposit types, I have
provided sufficient documentation of the purpose, frequency, amount and current status of these deposits from the
source of payment. All written statements from third sources must be signed, dated and notarized.

Initial(s): _________ Initial(s): _________

15. For every household member claiming to have NO ASSETS, I have included a signed, dated, and notarized
affidavit stating that the household member has no assets or accounts of any kind, including checking, savings,
money market, trust, 401k, retirement, IRA, stocks, or any other type of account. If the household or household
member has assets of any kind, they have followed the directions given in the two questions above.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

16. Divested/Closed Assets: For every household member who no longer owns an asset that generated income on the
most recent tax return or has closed an asset/account within the past 12 months (e.g., if a bank account was closed),
I have attached a letter from the bank/institution that holds the account stating that the account is closed OR the
final bank statement explicitly indicating that the account was closed (just showing a zero balance is not sufficient).
And for every household member who divested themselves of an asset for less than full and fair present cash value
of the asset within two years prior to this application, I have listed the full and fair cash value of the asset at the
time of its disposition in the Asset Table AND provided the last statement for that asset showing its full market
value AND attached a signed letter by the household member detailing the transaction in which they divested
themselves of the asset.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

15
17. REAL ESTATE: If I currently own property, I have attached documentation supporting the value of the property
(such as a recent broker’s opinion of the property or tax assessment or value as stated on a divorce decree or
settlement statement) AND documentation showing my debt on the property (such as mortgage statements or
foreclosure notices). I understand that if I have sold a home in the last calendar year in which taxes were filed, I
must include the Closing Disclosure Form (formerly the HUD-1 form) Settlement statement for that sale or a copy
of the deed that was recorded with the Registry of Deeds. I understand that I cannot live in an affordable unit and
own another home and, if my current home is under Purchase and Sale Agreement or being lost/sold through
divorce, I may be entered onto a Waiting List for an affordable unit, but the home must be sold and a Closing
Disclosure Form (formerly the HUD-1 form) Settlement statement provided or the recorded deed provided prior
to move-in or I will lose my position on the Waiting List.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

TAX DOCUMENTATION:

18. I have attached all W-2s, 1099s and all other tax documentation for all sources of income and assets. I understand
that W-2s are the tax documents that are given by employers to show wages, salaries and tips and 1099s are the tax
documents that are given by other sources of income (ex: interest on savings accounts, income from retirement
accounts, income from unemployment etc). These are the tax documents used so that 1040 taxes can properly be
filed as detailed in the next question below. (You will have a W-2 for every job worked in the most recent year you filed
taxes. Please be sure that the wages in the W-2s you submit add up to the wages you filed on your 1040 tax form. If you are
not currently working at any of the jobs for which you have received a W-2, please see Question 2: “Earnings
(Former Employment)” on the first page of Section 2 for directions.)

 N/A
 Yes
Initial(s): _________ Initial(s): _________

19. 1040 Tax Transcripts: I have attached a computerized print out of the most recent federal income tax returns (i.e.
1040 tax transcripts) including any and all schedules, attachments and amendments for every household member
18 years or older. Every page of the tax transcript must be sent (including, if applicable, Schedules A, B, C etc ). I
understand I can obtain these transcripts from the tax professional who filed my taxes last year or I can download
these transcripts immediately for free by going to [Link]/Individuals/Get-Transcript or by calling the IRS at
1.800.829.1040 and they will mail or fax the transcripts in 7-10 days. For every household member who has not
filed in the most recent tax year, I have attached a statement from the IRS showing “No Filing” for that household
member for the most recent tax year. I understand I can call 1.800.829.1040 and the IRS will mail it or fax it to me
in 7-10 days. I understand I can download these statements of no filing for the applicable year immediately for free
by going to [Link]/Individuals/Get-Transcript or by calling the IRS at 1.800.829.1040 and they will mail or
fax the statements in 7-10 days. I understand that when I visit [Link]/Individuals/Get-Transcript I will need
to sign up for an account by providing an email address where the IRS can email me a verification code that can
then be used to access my records, that I will need to answer a few security questions, and then my tax transcripts
or statements of “No Filing” for the past 5 years will be available.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

16
FINAL CERTIFICATION OF HOUSEHOLD INCOME:

20. I certify that my combined Gross Annual Household Income is $_______________________________

(total on the bottom of the Income Table)

Initial(s): _________ Initial(s): _________

21. My Gross Annual Household Income listed above is greater than the Allowable Income Limits for our household
size as specified on the cover page of this Program Application and I have therefore attached a signed and dated
statement detailing why my income listed above does not reflect my income over the next 12 months AND have
attached supporting documentation.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

22. Planned Changes in Income: There are planned changes in my household income over the next 12 months and I
have therefore attached verification of these planned changes in income.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

17
PREFERENCES:

23. Household Type: On page 4 for Household Type I or II, I stated that we have two household members who cannot
be required to share a bedroom as a consequence of sharing would be a severe adverse impact on his or her mental
or physical health and have attached supporting documentation. Supporting documentation can be verification from
a doctor or other medical professional.

 N/A
 Yes
Initial(s): _________ Initial(s): _________

24. Disabled Accessible Unit preference: I certify that I am in need of an accessible unit AND I have attached
supporting documentation. The supporting documentation must specify that I am in need of the features specific
to disabled-accessible housing. Supporting documentation can be verification from a doctor or other medical
professional, a peer support group, a non-medical service agency, or a reliable third party who is in a position to
know about the individual’s disability. Need of an accessible unit is defined as persons with a physical disability
that meet standards established by the Department of Housing and Community Development and state laws for
disabled housing.

 N/A
 Not Interested
 Yes
Initial(s): _________ Initial(s): _________

18
 You must now read, sign and date the
following page. And please do not staple
your supporting documentation when
submitting it.

19
 Please read each item below carefully before you sign.

1. I hereby declare under pain and penalty of perjury that the information provided on every page of this application is true
and correct. I understand that if any sources of income or assets are not disclosed on this application, or any information
provided herein is not true and accurate, this application may be removed immediately from further consideration and I
will no longer be allowed to reserve a unit.
2. I understand that this application will be incomplete if I do not sign and date this page and initial at all indicated points in the
application and that the failure to timely and/or fully supply information in accordance with the application may result in the
the denial of my application and loss of position on all Waiting Lists.
3. The undersigned certify that none of the people listed in this application, or their families, have a financial interest in the
development and none of the people listed in this application can be considered a Related Party by the affordable housing
guidelines that govern this property.

4. The undersigned certify that the affordable unit will be undersigned’s principal residence and the undersigned cannot own a
home elsewhere or in trust while living in an affordable unit.
5. I understand that while previous years’ tax transcripts and documentation are required, SEB Housing LLC does not use income
reported on the previous years’ tax documentation to calculate current annualized income.
6. I understand that the lease or residency agreement for the units to be occupied through this affordable housing program may
be subject to cancellation if any of the information above is not true and accurate.
7. I understand that this is a preliminary application and the information provided does not guarantee housing. I also understand
this is not the lease application used by the management company where the management company (not SEB Housing) will use
criteria such credit score, tenant history and criminal background screening (in addition to affordable housing eligibility) to
determine eligibility for an affordable unit.

8. I understand that any material change in the income or assets of my household that occurs after the submission of this
application may make me ineligible for affordable housing. I understand that any changes to income or assets that may put my
household into another income tier must be reported to SEB Housing.

9. Co-signers and Guarantors are not permitted unless they are co-tenants who will reside in the unit.
10. I acknowledge that if my email address is provided in this application, SEB Housing, LLC will correspond with me by email
instead of postal mail unless I make a written request otherwise. I understand that any changes to my contact information or
household composition must be reported to SEB Housing.
11. I acknowledge that the determination of eligibility by SEB Housing is based upon the guidelines that govern the Affordable
Housing Program for the development and, as such, barring any confirmed error by SEB Housing in applying the guidelines
and/or calculating income, the decision is final and I further agree to hold harmless SEB Housing from any claim(s) related to
this application.
12. The undersigned give consent to the Town of Sharon, SEB Housing LLC, The Wren, and EOHLC to verify the information
provided in this application. The undersigned authorize the release of information necessary in determining income and assets
from third-party references.

________________________________________________ ___________________
Applicant’s Signature Date

________________________________________________ ___________________
Applicant’s Signature Date

Attach all documentation as directed. Send applications with ALL required documentation as directed on the cover
page. For Questions contact info@[Link] or (617) 782-6900

This development does not discriminate in the selection of applicants on the basis of race, color, national origin, religion, disability, age,
ancestry, children, familial status, genetic information, marital status, public assistance recipiency, religion, sex, sexual orientation,
gender identity and gender expression, veteran/military status, or any other basis prohibited by law.

20
 Section 3

Additional Forms
(if applicable)

These are the forms that you only need to complete if directed to do
so in Section 2

21
 Verification of Terminated Employment
To Be Completed By Applicant:

Applicant/Tenant:

Contact Info of previous employer:

Name of Contact
Company Name
Street Address
City, State, Zip
Tel. # Fax # email

To Be Completed By Previous Employer:

Date of Termination: Last Day Actually Worked:

Total Gross Income paid to employee over the last calendar year employed:
Reason for Termination:  Employee Quit  Other
Do you anticipate rehiring this employee?  Yes  No If yes, when:
Will the employee receive additional paychecks for Workman’s Compensation?  Yes  No
If yes, provide the name and address of the company through which this can be verified:

Total severance pay anticipated for the next 12 months:

Is employee entitled to receive unemployment compensation?  Yes  No

AUTHORIZED SIGNATURE

Print Name: Title:

Signature: Date:
Telephone:
Please Fax form to SEB Housing at (617) 782-4500 or mail to: SEB Housing
Re: The Wren
257 Hillside Ave
Needham, MA 02494
--OFFICE USE ONLY--

Date Sent:
Date Received:
Comments:

22
 SELF EMPLOYMENT / S-CORP INCOME AFFIDAVIT
Please complete this form if a member of your household receives income as a business owner,
independent contractor, sole proprietorship, cash pay, odd jobs, gig economy jobs (like Uber/Lyft) etc.
You MUST complete and submit all applicable sections within this document.
Please submit all supporting documentation along with these forms.

Applicant/Tenant:

Name and Type of Business:

Position Held:

Start Date:

Section 1: Prior Tax Year’s Self-Employment / 1099-MISC / S-Corp (including K-1) Income

Gross Income from Last Tax Year $_____________________________________

Gross Expenses from Last Tax Year $_____________________________________

Net Income from Last Tax Year $_____________________________________

You are required to provide your complete tax returns from the most recent two (2) years of filing, including all
schedules, 1099s, etc.

Please proceed to Section 2.

Section 2: Year to Date Self-Employment / 1099-MISC / S-Corp (including K-1) Income

Gross Income Year to Date $_____________________________________

Gross Expenses from Year to Date $_____________________________________

Net Income from Year to Date $_____________________________________

You are required to complete the Year to Date Profit and Loss Statement in the following pages, and provide
supporting documentation for your year-to-date gross income and expenses, which may include invoices, receipts,
contracts, independent contractor pay stubs or pay statements, written business plans, employment proposals,
business bank account statements, and/or accountant statements for business income, etc. Please provide whatever
documentation is available to verify your income and expenses, all income must be documented.

Check here if you anticipate no changes in your revenue, expenses, or net income
over the next 12 months:

If you checked this box, please provide a signed, dated, and notarized letter to that effect, and skip to section 4 on the
next page.

If you did not check this box, please proceed to section 3 on the next page.

All households, please proceed to the next page.

23
 Section 3: Anticipated Self-Employment / 1099-MISC / S-Corp (including K-1) Income Over the Next
12 Months (Complete this section if you did NOT check the box at the bottom of the previous page)

Anticipated Gross Annual Income $_____________________________________

Anticipated Gross Annual Expenses $_____________________________________

Net Anticipated Annual Income $_____________________________________

You are required to complete the Anticipated Profit and Loss Statement for the Next 12 Months in the following
pages in addition to the Year to Date Profit and Loss Statement previously requested, in addition to providing any and
all supporting documentation for the changes that will take place to your income and/or expenses over the next 12
months.

Please proceed to section 4.

Section 4: Signature and Required Documentation Summary

As a reminder, all households who completed this form must submit:

- Complete IRS 1040 tax returns from the two (2) previous tax years, in addition to all applicable tax documents.
- A completed Year to Date Profit and Loss Statement on the following page.
- Supporting documentation for your year-to-date gross income and expenses, which may include invoices,
receipts, contracts, independent contractor pay stubs or pay statements, written business plans, employment
proposals, business bank account statements, and/or accountant statements for business income, etc. Please
provide whatever documentation is available to verify your income and expenses.

If you completed Section 3, you must additionally submit:

- A completed Anticipated Profit and Loss Statement for the Next 12 Months on the page following the Year to
Date Profit and Loss Statement.
- Supporting documentation for the changes that will take place to your income over the next 12 months.

If you cannot provide your tax returns for the previous calendar year, or did not report your self-
employment / S-Corp income on your tax returns for the previous year, you must additionally
submit:

- A completed Prior Year Profit and Loss Statement, located on the page following the Anticipated Profit and
Loss Statement.
- Supporting documentation for the income you received in the previous calendar year.

All Households must complete the following:

Under penalty of perjury, I certify that the information presented in this form and in the following profit and loss forms is true and
accurate to the best of my knowledge. The undersigned further understand that providing false representation herein constitutes an
act of fraud. False, misleading or incomplete information may result in the termination of a lease agreement or application review.

______________________________________________ __________________________
Applicant Signature Date

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Year to Date Profit and Loss Statement Business Name:

Please fill in month and year → YEARLY

TOTAL
Revenue Source

Total Revenue
Cost of Sales

Total Cost of Sales

Gross Income (Total Revenue
minus Total Cost of Sales)
Expenses

Total Expenses

Net Income (Gross Profit minus

Total Expenses)

25
Anticipated Profit and Loss Statement for the Next 12 Months Business Name:

Please fill in month and year → YEARLY

TOTAL
Revenue Source

Total Income
Cost of Sales

Total Cost of Sales

Gross Income (Total Revenue
minus Total Cost of Sales)
Expenses

Total Expenses

Net Income (Gross Profit minus

Total Expenses)

26
Prior Year Profit and Loss Statement Business Name:

Please fill in month and year → YEARLY

TOTAL
Revenue Source

Total Revenue
Cost of Sales

Total Cost of Sales

Gross Income (Total Revenue
minus Total Cost of Sales)
Expenses

Total Expenses

Net Income (Gross Profit minus

Total Expenses)

27
 Please note the following page is an example of a
completed Profit and Loss Statement. This is intended
only as an example of what a completed Year to Date
Profit and Loss Statement may look like.

28
Year to Date Profit and Loss Statement Example as of 10/2016 Business Name: Example Bicycle Shop LLC
Please fill in month and year (i.e.
Jan Feb March April May June July Aug Sept YEARLY
January 2016) →
2016 2016 2016 2016 2016 2016 2016 2016 2016 N/A N/A N/A TOTAL
Revenue Source
Bike Sales 1500 1500 1500 1500 1500 2000 1500 200 2500 13700
Bike Service 600 700 600 600 600 900 600 0 1000 5600

Total Revenue 2100 2200 2100 2100 2100 2900 2100 200 3500 19300
Cost of Sales
Cost of Goods (Bikes) 700 700 700 700 700 1200 700 100 1500 7000
Cost of Parts (Service) 100 150 100 100 100 300 100 0 350 1300

Total Cost of Sales 800 850 800 800 800 1500 800 100 1850 8300
Gross Income (Total Revenue
1300 1350 1300 1300 1300 1400 1300 100 1650 11000
minus Total Cost of Sales)
Expenses
Payroll expenses 100 100 100 100 100 100 100 100 100 900
Supplies (office and operating) 50 50 50 50 50 50 50 50 50 450
Repairs and maintenance 0 100 0 0 0 0 0 300 0 400
Advertising 20 20 20 20 20 20 20 20 20 180
Car, delivery and travel 50 50 50 50 50 50 50 50 50 450
Accounting and legal 0 0 0 200 0 0 0 0 0 200
Rent 600 600 600 600 600 600 600 600 600 5400
Utilities 40 40 40 40 40 40 40 40 40 360
Website Maintenance 40 40 40 40 40 40 40 40 40 360

Total Expenses 900 1000 900 1100 900 900 900 1200 900 8700

Net Income (Gross Profit minus

400 350 400 200 400 500 400 -1100 750 2300
Total Expenses)

29