Affordable Unit Lottery Application

Darien Commons
Darien, Connecticut
Applications must be delivered by 2:00pm on August 25th, 2022.
DO NOT SEND APPLICATIONS TO THE PROPERTY. SEND APPLICATIONS TO
THE NEEDHAM ADDRESS BELOW.

MAXIMUM Household Income Limits:

$62,600 (1 person), $71,500 (2 people), $80,450 (3 people), $89,400 (4 people)

Rents for the units are: 1BR at $1,522, 2BR at $1,817

Rents do not include any utilities. Parking is available for rent for $175/mo. Pets are allowed.

*Rents for the units available in 2022 are subject to change. If the Statewide Median Income (“SMI”) increases or the utility
allowances decrease, the rent may increase.

Households must make approximately $45,660 to lease a 1BR unit and $54,504 to lease a 2BR unit.
This is not subsidized housing. Rents do not change based on applicant’s income and tenants who do not already have
housing subsidies (like Section 8 vouchers) will be responsible for paying the full rent themselves. Applicants with a
housing subsidy are encouraged to contact the housing agency who issues their housing subsidy to confirm that the rents
are within the agency’s payment standards so as to ensure that they will not be prohibited by the housing agency from
using the housing subsidy at this property. Applicants may only be listed on one application. If an applicant is listed
on multiple applications, only the most recent application will be used. The prior application(s) will be discarded.
Units are planned for occupancy in Summer of 2022.

Directions:
Applications must be submitted as specified by the date at the top of this page. This application 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” to a question that does not apply to you. LEAVE NOTHING BLANK. Send or drop off all applications to:
SEB Housing
Re: Darien Commons
257 Hillside Ave
Needham, MA 02494
Fax: 617.782.4500 Phone: 617.782.6900
Email: [email protected]
If faxing or scanning, be sure to transmit both sides of double sided pages

This development does not discriminate in the selection of applicants on the basis of race, color, national origin, disability, age,
ancestry, children, familial status, genetic information, marital status, public assistance recipiency, religion, sex, sexual orientation,
gender identity, veteran/military status, or any other basis prohibited by law. For TTY Services dial 711. Free translation available
through Certified Languages International. Traducción gratuita disponible. Tradução livre disponível.

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Darien Commons. Please provide all the following contact information for the Head of Household:

Cambria Ahrens
Applicant’s Name:

Address:
10 Willard Rd #156
City: Norwalk State:
CT Zip:
06851
Home Phone:(
6199339159
) Work Phone:( )

Cell Phone:( ) Employer:

ADP
Email address: cambriaahrens @ gmail.com

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: August 2023

Bedroom Size Information: Circle the bedroom sizes for which you are applying. (you may apply for more
than one bedroom size)
 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
HEAD OF RELATIONSHIP TO FULL-TIME STUDENT
NAME AGE HOUSEHOLD OR APPLICANT LISTED AT THE OR WILL BE A FULL-
DEPENDENT TOP OF THIS PAGE TIME STUDENT IN THE
Cambria Ahrens. 26. Head Self. NEXT 12 MONTHS?
Yes No
Liam Ahrens. 4. Dependent. Son.
Yes No
Yes No
Yes No
I certify that my Household Size is (total number of entries in table above) _________.
2
CA
Initial(s): _________
CA
Initial(s): _________

*An Applicant may ONLY be listed on one (1) Application. If the same person is listed on multiple
applications, only the most recently-submitted application will be used. Others will be discarded.

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REASONABLE ACCOMMODATION
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 accessibility or reasonable accommodation requests or changes in a unit or
development 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:

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)

I looked at affordable housing

options. I am a single mom.

RACE: (OPTIONAL)
You are requested to complete the following optional section in order to assist in determining preference. Completing
this section may qualify you for additional lottery pools. (Please check all boxes that apply):
 Alaskan Native and Native American  Asian
 Black or African American  Native Hawaiian or Pacific Islander
 Hispanic or Latino
 White (not of Hispanic origin) Other (please specify)___

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 INSTRUCTIONS FOR COMPLETING THE FOLLOWING INCOME TABLE

Please complete the Income Table on the following two pages. After the lottery, you will be asked to submit 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. Legally married couples shall both be considered part of the household, even if separated. 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”.

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 INCOME
Household Member Current GROSS
Source of Income Monthly Income
Name
Cambria Ahrens Employer (name)
ADP 3600
Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Employer (name)

Text
Self-Employed (contract/job name)
$0
Self-Employed (contract/job name)

Self-Employed (contract/job name)

Child Support/Alimony
$850
Child Support/Alimony

Social Security Income $0

Social Security Income
Social Security Income
Social Security Income

SSDI $0
SSDI

Pension (list source) $0

Pension (list source)
Retirement Funds
$0
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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)

Commission: 200 per month
Other Income (name/source)

Gross Monthly Household Income

(GMHI)
$ 4650 /month

GMHI x 12 = Gross Annual Household Income $

55800/year
Text

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 ASSETS
If a section doesn’t apply, cross out or write NA. After the lottery 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 Chase Bank 2085. Balance $
Balance $
$850
Balance $
Balance $
Savings
Accounts
Na Balance $
Balance $
Balance $
Trust Account
Venmo/Paypal/
Na Balance $
Balance $
Cash-App
NA Balance $
Balance $
Certificates
(or CDs) NA Balance $
Balance $
Savings Bonds Maturity Date:
Maturity Date:
NA Value $
Value $
401k, IRA, Company Name: Value $
Retirement Company Name: Value $
Accounts Company Name:
(Net Cash Value) Company Name: NA Value $
Value $
Interest/
Name: # of Shares: Value
Dividends
Mutual Funds $ $

NA $
$
$
$
$ $
Stocks
NA $
$
$
$
Bonds
NA $
$
$
$
Investment Appraised
Property
NA 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: $

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You must now read, sign and date the
next page.

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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 lease 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. 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.

4. 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.

5. 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.

6. 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.

7. Co-signers and Guarantors are not permitted unless they are co-tenants who will reside in the unit.
8. 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.

9. 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.

10. The undersigned give consent to the Town of Darien, SEB Housing LLC, and the Property or their assigns 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
Cambria Ahrens 01/15/2023
________________________________________________ ___________________
Applicant’s Signature Date

Send applications by the date on the cover page to SEB (DO NOT SEND THEM TO THE PROPERTY, SEND THEM
TO THE NEEDHAM ADDRESS). For Questions contact [email protected] or (617) 782-6900
This development does not discriminate in the selection of applicants on the basis of race, color, national origin, disability,
age, ancestry, children, familial status, genetic information, marital status, public assistance recipiency, religion, sex,
sexual orientation, gender identity, veteran/military status, or any other basis prohibited by law.

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