Rental Application

Apartments are Independent Living for Seniors

While R.O.U.S.E. provides maintenance assistance including lawn mowing, snow plowing, snow shoveling, and 24 hour emergency maintenance when necessary, residents perpetuate an independent quality of life. Please note that income requirements apply.

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Senior Housing Development Rental Application

99 Blooming Grove Drive
Troy, New York 12180
Telephone: (518) 283-3435
Fax: (518) 286-2013
TDD relay service: 800-662-1220

R.O.U.S.E. RPC offers low to moderate income housing to senior citizens, age 55 and older if qualified. R.O.U.S.E. RPC communities prohibit pets and have a No Smoking Policy (see attached).

Please check the Senior Housing Community or Communities to which you would like to apply.

Brunswick

Brunswick

1 Bedrm apt.

2 Bedrm apt.

Cottage

Blooming Grove

North Greenbush
1 Bedroom Only

Brookside

West Sand Lake
1 Bedroom Only

Nassau

Nassau
1 Bedroom Only

List all household members who will live in the apartment. Be sure to include any temporarily absent family members.

Household Members

Full name	Relationship	Date of Birth	Social Security #	Actions

There are no Members.

Maximum number of members reached.

Address

Street Address City State ZIP Code

Telephone

E-mail*

Are you a full time student?

Yes

Are you presently, or were you ever, a resident of the Town of

West Sand Lake:

Yes

Nassau:

Yes

Brunswick:

Yes

North Greenbush:

Yes

INCOME INFORMATION

Please indicate each source of income that any member of your household receives or anticipates receiving in the next twelve (12) months as specified below:

(List Gross Amounts)

Employment: Household Member (1)

Employment: Household Member (2)

Employment: Amount Received Monthly

Social Security Income: Household Member (1)

Social Security Income: Household Member (2)

Social Security Income: Amount Received Monthly

Disability: Household Member (1)

Disability: Household Member (2)

Disability: Amount Received Monthly

Unemployment: Household Member (1)

Unemployment: Household Member (2)

Unemployment: Amount Received Monthly

Pension/Annuity: Household Member (1)

Pension/Annuity: Household Member (2)

Pension/Annuity: Amount Received Monthly

Severance Pay: Household Member (1)

Severance Pay: Household Member (2)

Severance Pay: Amount Received Monthly

Workers Compensation: Household Member (1)

Workers Compensation: Household Member (2)

Workers Compensation: Amount Received Monthly

Child Support/Alimony: Household Member (1)

Child Support/Alimony: Household Member (2)

Child Support/Alimony: Amount Received Monthly

Recurring Gifts: Household Member (1)

Recurring Gifts: Household Member (2)

Recurring Gifts: Amount Received Monthly

Rental Income: Household Member (1)

Rental Income: Household Member (2)

Rental Income: Amount Received Monthly

Veteran Benefits: Household Member (1)

Veteran Benefits: Household Member (2)

Veteran Benefits: Amount Received Monthly

Other Income: Household Member (1)

Other Income: Household Member (2)

Other Income: Amount Received Monthly

ASSET INFORMATION

Assets Include: Cash, trust corpus, equity in real estate or capital investments, notes receivable, stocks, bonds, money market accounts, certificates of deposit, IRAs, retirement and pension funds, luxury person property (gems, jewelry, art, coin collections, etc.) You must also include the value of any assets disposed of in the past 24 months at less than fair market value.

Checking Acct: Household Member (1)

Checking Acct: Household Member (2)

Checking Acct: Amount Received Monthly

Checking Acct: Earned Income

Savings Acct: Household Member (1)

Savings Acct: Household Member (2)

Savings Acct: Amount Received Monthly

Savings Acct: Earned Income

Trust Account: Household Member (1)

Trust Account: Household Member (2)

Trust Account: Amount Received Monthly

Trust Account: Earned Income

Stocks/Bonds: Household Member (1)

Stocks/Bonds: Household Member (2)

Stocks/Bonds: Amount Received Monthly

Stocks/Bonds: Earned Income

Treasury Bills: Household Member (1)

Treasury Bills: Household Member (2)

Treasury Bills: Amount Received Monthly

Treasury Bills: Earned Income

CD/Money Markets: Household Member (1)

CD/Money Markets: Household Member (2)

CD/Money Markets: Amount Received Monthly

CD/Money Markets: Earned Income

Annuity/IRA w/o regular withdraw: Household Member (1)

Annuity/IRA w/o regular withdraw: Household Member (2)

Annuity/IRA w/o regular withdraw: Amount Received Monthly

Annuity/IRA w/o regular withdraw: Earned Income

Whole Life Ins.: Household Member (1)

Whole Life Ins.: Household Member (2)

Whole Life Ins.: Amount Received Monthly

Whole Life Ins.: Earned Income

Other Assets: Household Member (1)

Other Assets: Household Member (2)

Other Assets: Amount Received Monthly

Other Assets: Earned Income

Real Estate:

Do you own any property?

Yes

Type of property

Appraised Market Value

Mortgage or outstanding loans balance due

Have you disposed of any assets in the past 2 years - (example: give away money to relatives, set up Irrevocable trust accounts or sold assets for less than fair market value)?

Yes

Describe asset

Date of disposition

MM slash DD slash YYYY

Amount disposed

Do you have any other assets not listed above excluding personal property?

Yes

List

EMERGENCY CONTACTS

Please list three (3) people to contact in case of emergency:

1. Name:

1. Phone:

1. Address:

1. Relationship:

2. Name:

2. Phone:

2. Address:

2. Relationship:

3. Name:

3. Phone:

3. Address:

3. Relationship:

RESIDENCE HISTORY

Current Address:

Do you Rent or Own your home?

Month/year moved in

What is your monthly rent or monthly mortgage?

If utilities are not included, what is your monthly utility cost

Reason for leaving

Landlord

Landlord Address

Previous Address

Street Address City State ZIP Code

Month/year moved in

Moved out

Monthly rent

If utilities were not included, what was your utility cost

Landlord

Reason for leaving

Landlord Address

OTHER INFORMATION

Driver License#

State

Date Exp.

MM slash DD slash YYYY

Driver License#

State

Date Exp.

MM slash DD slash YYYY

Vehicle Make

Year

License Plate#

Color

Vehicle Make

Year

License Plate#

Color

Would any member of your family benefit from a special design accessible unit?

Yes

Will any alterations to the apartment be necessary for a member of your family?

Yes

It is hereby understood that a background check will be conducted and that all information in the application for residency, including statement of finances, background checks and personal interviews, will be treated confidentially. Any misrepresentation or material omission by the applicant may render any agreement for residence void at the option of the owner. Any applicant that is rejected has the right to review, contest and explain the information contained in the application or in the background check and has the right to present evidence of rehabilitation, if the applicant was rejected due to their criminal history. I certify that the information set forth here is complete and correct to the best of my knowledge. I understand that deliberately submitting false information or withholding information constitutes fraud. Federal law specifies fines up to $10,000 and prison terms up to five years for fraud and may be grounds for eviction. Should any statement above be a misrepresentation or not a true statement of facts, the entire deposit will be retained to offset the agent’s cost, time, and effort in the processing of this application. I also understand that this form is only an application for residency and that them submission of this application does not reserve, nor in any way, guarantee a unit.

Applicant Signature*

Date*

MM slash DD slash YYYY

Co-Applicant Signature

Date

MM slash DD slash YYYY

ROUSE RPC Non-Smoking Policy

All ROUSE RPC managed communities, including:
ROUSE at Brunswick Senior Housing
Blooming Grove Senior Housing
Brookside Senior Housing
Nassau Senior Housing

Effective July 1, 2024, a revision to the No Smoking Policy will be implemented for all current and new leases within all ROUSE RPC managed communities. This decision is motivated by the increased risk of fire, rising maintenance costs, escalating insurance expenses, and the well documented health effects associated with secondhand smoke. Smoking will be strictly prohibited in all areas of the property, encompassing buildings, common spaces, apartment units, and within a 25-foot radius of the building(s), including entryways, porches, and patios. Each community will feature a designated outdoor smoking area, clearly marked with a smoking permitted sign, a cigarette receptacle, and a bench for smokers.

Residents are required to ensure that both family members and guests adhere to this policy. The term "smoking" encompasses any act involving inhaling, breathing, burning, or carrying any lighted cigar, cigarette, pipe, or other tobacco product, vaping, as well as the smoking of marijuana including for medicinal use.

It is important to note that the adoption of the No Smoking Policy by the landlord does not make the landlord or any managing agents guarantors of the resident's health or the smoke-free condition of the property.

Residents are accountable for the actions of their household, guests, and visitors. Failure to comply with any conditions outlined in this policy constitutes a material violation of the lease and may result in legal sanctions, including but not limited to termination of tenancy. Additionally, residents may be responsible for potential financial costs associated with the removal of smoke odor or residue from the unit.

Your cooperation in adhering to this No Smoking Policy is greatly appreciated, contributing to the well-being and comfort of the entire community.