( ) I WISH TO MAKE THE FOLLOWING DEVELOPMENTS CHANGES TO MY APPLICATION:

Applicant Name: \underline{\hspace{8cm}} \hfill Client \#: \underline{\hspace{3cm}} \\
(PLEASE PRINT YOUR FIRST AND LAST NAME) \hfill Social Security \#: \underline{\hspace{1cm}} - \underline{\hspace{1cm}} - \underline{\hspace{1cm}}

\subsection*{ELDERLY/DISABLED FEDERAL PROGRAM}

\begin{tabular}{|l|l|l|l|l|}
\hline
Development & Neighborhood & Bedroom Size & Wheelchair Accessible Units That Exist at The Site & Circle Changes Here REMOVE \\
\hline
Armory Street & Jamaica Plain & 0, 1 \& 2 & YES & REMOVE \\
Annapolis & Dorchester & 1 \& 2 & NO & REMOVE \\
Ashmont & Dorchester & 1 \& 2 & NO & REMOVE \\
Ausonia & North End & 1 \& 2 & YES & REMOVE \\
Bellflower & Dorchester & 1 \& 2 & YES & REMOVE \\
Codman Apartments & Dorchester & 0, 1 \& 2 & YES & REMOVE \\
Commonwealth & Brighton & 1 \& 2 & YES & REMOVE \\
Davison Apts. & Hyde Park & 0 \& 1 & NO & REMOVE \\
Eva White Apts. & South End & 0, 1 \& 2 & NO & REMOVE \\
Foley Apts. & South Boston & 1 & NO & REMOVE \\
Frederick Douglass & South End & 0 \& 1 & YES & REMOVE \\
General Warren & Charlestown & 0, 1 \& 2 & NO & REMOVE \\
Groveland & Mattapan & 0 \& 1 & NO & REMOVE \\
Hampton House & South End & 0 \& 1 & YES & REMOVE \\
Hassan Apts. & Mattapan & 0, 1 \& 2 & YES & REMOVE \\
Heritage Apts. & East Boston & 0, 1 \& 2 & YES & REMOVE \\
Holgate Apts. & Roxbury & 1 & NO & REMOVE \\
John J. Carroll & Brighton & 1 \& 2 & NO & REMOVE \\
Lower Mills & Dorchester & 0, 1 \& 2 & YES & REMOVE \\
Malone Apts. & Hyde Park & 1 & NO & REMOVE \\
Meade Apts. & Dorchester & 1 \& 2 & NO & REMOVE \\
Mildred C. Haley Apts. (Bromley) & Jamaica Plain & 1 \& 2 & NO & REMOVE \\
MLK Apts. & Roxbury & 0 \& 1 & NO & REMOVE \\
Pascuicco & Dorchester & 0, 1 \& 2 & YES & REMOVE \\
Patricia White & Brighton & 1 \& 2 & YES & REMOVE \\
Peabody & Dorchester & 1 \& 2 & YES & REMOVE \\
Pond Street & Jamaica Plain & 1 \& 2 & NO & REMOVE \\
Rockland Towers & West Roxbury & 0, 1 \& 2 & YES & REMOVE \\
Roslyn & Roslindale & 1 \& 2 & YES & REMOVE \\
Spring Street & West Roxbury & 1 \& 2 & YES & REMOVE \\
St. Botolph St. & Back Bay & 0, 1 \& 2 & MODIFIED & REMOVE \\
Torre Unidad & South End & 0, 1 \& 2 & YES & REMOVE \\
Walnut Park & Roxbury & 0, 1 \& 2 & YES & REMOVE \\
Washington Manor & South End & 0 \& 1 & YES & REMOVE \\
Washington St. & Brighton & 1 \& 2 & NO & REMOVE \\
West Ninth & South Boston & 1 \& 2 & NO & REMOVE \\
\hline
\end{tabular}

\subsection*{ELDERLY/DISABLED STATE PROGRAM}

\begin{tabular}{|l|l|l|l|l|}
\hline
Development & Neighborhood & Bedroom Size & Wheelchair Accessible Units That Exist at The Site & Circle Changes Here REMOVE \\
\hline
Basilica & Charlestown & 1 & NO & REMOVE \\
Franklin Field Elderly & Dorchester & 1 \& 2 & NO & REMOVE \\
Franklin Field - Grandparenting & Dorchester & 2 & YES & REMOVE \\
Msgr. Powers/"J" St. & South Boston & 0, 1 \& 2 & YES & REMOVE \\
\hline
\end{tabular}

IMPORTANT: (PLEASE READ, AND SIGN)

I UNDERSTAND BY ADDING NEW DEVELOPMENT CHOICES THAT I WILL BE GIVEN A NEW ELIGIBILITY DATE FOR EACH DEVELOPMENT CHOICE ADDED. PLEASE NOTE: ELIGIBILITY DATE IS DETERMINED BY THE DATE RECEIVED AND TIME-STAMPED AT OUR OFFICE.

I have read following, and understand that I will receive a new eligibility date for each new choice I select today.

Applicant Signature: \underline{\hspace{8cm}} \hfill Date: \underline{\hspace{3cm}}

(HEAD OF HOUSEHOLD)

OFFICE USE ONLY

Eligibility Date: \underline{\hspace{4cm}}

Development choice REMOVE form (PH) Rev. 10/3/2017