2. Preliminary Housing Application - Placement on Housing Registry
4. First Name*
5. MI
6. Last Name*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Home Phone*
15. Cell Phone
16. Work Phone
18. Email Address*
20. Rentals or Homeownership

    1. Homeownership
    2. Renting
    3. Both

    Are you interested in rentals or homeownership?
21. Size of Residence Desired
    How many bedrooms and bathrooms would you like to have?
22. Number of people
    How many people will live in the residence?
24. Household Income*

    1. 0 - $55,000
    2. $56,000 - $72,000
    3. $73,000 - $89,000
    4. $90,000 - $130,000
    5. $ 131,000 +

    Based on your most recent tax return, what is your approximate annual household income?
26. Age 55 or Older*

    1. Yes
    2. No
27. US Veteran*

    1. Yes
    2. No
28. Police / Fire / EMS*

    1. Yes
    2. No
30. Town of Southold Affordable Housing Registry
    Please note that placement on the Town of Southold Affordable Housing Registry in no way should be construed as a representation to placement, availability or offering of affordable housing in the Town of Southold. Parties completing this application are doing so under no promise of the same. Applicants specifically understand that no representations, guarantees or warranties of any nature whatsoever have been made in conjunction with this application.
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit Submit and Print

* indicates a required field