96 Prince Charles Drive

Toms River, NJ  08757




(Housing for Older People Act)


The Housing for Older Person Act was signed into law on December 28, 1995 by President Clinton.  The HOPA provides housing for older persons and is intended for occupancy by at least one person 55 years of age or older per unit.  It requires that periodically information must be collected and verified with the age of all residents.  Under NJ Law, a letter regarding age is required to be filed with the deed.


It is mandatory that you complete this survey and return to the Association office immediately.




H       Homeowner           Renter (Check One)                                         BADGE#_____________


Please print:


___________________________________________     ______________________________________

Homeowner/Renter Name (s)                                                           Street Address


_____________________  _____   _________________    ____________________________________

City                                  State      Primary Phone #       Emergency Contact  Phone #

                                                                                                    *Should not be the same as the

                                                                                                               primary phone #

Alternate Address:


_____________________    __________________   ____   _________     ________________________

Street Address                            City                 State   Zip Code          Alternate phone #


Total number of people living in your home. ________ including live in assistants, housekeepers, aides, etc.


Please list below the name (s); age and birthdate of all residents:


                                 NAME                                        AGE                            BIRTHDATE


Person#1____________________________         _________                 __________________


Person#2____________________________         _________                 __________________


Person#3____________________________         _________                 __________________


Person#4____________________________         _________                 __________________


I/We certify this form to be an accurate statement of the number of persons living in my home with their accurate birthdates.  Under penalty of perjury, I/We declare that the above information is true, correct and complete.


____________________________      _____________________________               ________________

Homeowner/Renter Signature       Homeowner/Renter Signature                Date


Filing of this document is required by Federal and State Law.