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Home My WebLink About2021 RRP Application Form18078rkfw 1 Mitchell D. Roth Mayor Lee E. Lord Managing Director Robert H. Command Deputy Managing Director County of Hawai‘i Office of Housing and Community Development 1990 Kino‘ole Street, Suite 102 • Hilo, Hawai‘i 96720 V/TT (808) 961-8379 • Fax (808) 961-8685 KONA: 74-5044 Ane Keohokalole Highway • Kailua-Kona, Hawai‘i 96740 (808) 323-4300 • Fax (808) 323-4301 Susan K. Kunz Housing Administrator Harry M. Yada Assistant Housing Administrator RESIDENTIAL REPAIR PROGRAM APPLICATION (RRP) Application must be filled out COMPLETELY. Please use BLACK Ink to complete application. If any question does NOT apply, please acknowledge by writing NONE or NOT APPLICABLE. Do not leave any section unanswered. Be reminded that questions asked apply to ALL Household members. Please print or type. PART 1: GENERAL INFORMATION: APPLICANT (Head of Household): _________________________________________ Phone:________________________ Legal Last Name First Name MI CO-APPLICANT (Spouse or Co-Head): _________________________________________ Email:_________________________ Legal Last Name First Name MI Current Address: ____________________________________________________ Apt. No._______________ City: ___________________ State:________________________ Zip:___________ Yrs. at Residence:___________ Previous address if less than 2 yrs. at above ________________________________________ Yrs. at Residence:___________  Check here if mailing address is the same as current address. Mailing Address: ____________________________________________________ Apt. No.__________ City: _________________________________ State:________________________ Zip:______________ PART 2: HOUSEHOLD MEMBERS: Starting on first line for the Head of Household, please supply the information for all adults and children that will live in the housing unit to be assisted. List the adults first, then children. Enter one of the following codes in the “Relation” box to identify the household relationship of each adult and child listed. H = Head of Household K = Co-Head (Not Married) Y = Youth Under 18 L = Live In Aide S = Spouse (Married) F = Foster Child/ Adult E = Full Time Student Over 18 A = Other Adult Last Name & Sr, Jr, etc. 1 First Name MI Date of Birth Sex Relation H (Head of Household) Single Race (select one or more) [ ] White [ ] Asian [ ] Black or African American [ ] Native Hawaiian or Other Pacific Islander [ ] American Indian / Alaska Native Ethnicity (check one box) [ ] Hispanic or Latino [ ] Not Hispanic or Latino Multi Race (select one or more) [ ] Asian and White [ ] Other Multi-Racial [ ] Black or African American and White [ ] American Indian / Alaska Native and White [ ] American Indian / Alaska Native and Black Last Name & Sr, Jr, etc. 2 First Name MI Date of Birth Sex Relation 8078rkfw Race (select one or more) [ ] White [ ] Asian [ ] Black or African American [ ] Native Hawaiian or Other Pacific Islander [ ] American Indian / Alaska Native Ethnicity (check one box) [ ] Hispanic or Latino [ ] Not Hispanic or Latino Name & Sr, Jr, etc. 3 First Name MI Date of Birth Sex Relation Race (select one or more) [ ] White [ ] Asian [ ] Black or African American [ ] Native Hawaiian or Other Pacific Islander [ ] American Indian / Alaska Native Ethnicity (check one box) [ ] Hispanic or Latino [ ] Not Hispanic or Latino Last Name & Sr, Jr, etc. 4 First Name MI Date of Birth Sex Relation Race (select one or more) [ ] White [ ] Asian [ ] Black or African American [ ] Native Hawaiian or Other Pacific Islander [ ] American Indian / Alaska Native Ethnicity (check one box) [ ] Hispanic or Latino [ ] Not Hispanic or Latino Last Name & Sr, Jr, etc. 5 First Name MI Date of Birth Sex Relation Race (select one ore more) [ ] White [ ] Asian [ ] Black or African American [ ] Native Hawaiian or Other Pacific Islander [ ] American Indian / Alaska Native Ethnicity (check one box) [ ] Hispanic or Latino [ ] Not Hispanic or Latino Last Name & Sr, Jr, etc. 6 First Name MI Date of Birth Sex Relation Race (select one or more) [ ] White [ ] Asian [ ] Black or African American [ ] Native Hawaiian or Other Pacific Islander [ ] American Indian / Alaska Native Ethnicity (check one box) [ ] Hispanic or Latino [ ] Not Hispanic or Latino PART 3: ASSET INFORMATION: Please list any checking, savings, stocks, bonds, annuities, savings bonds, credit union shares, trust accounts, retirement contributions, pension contributions, IRAs, certificates of deposit or other assets for everyone in your household. Also include assets that are held jointly with another person and include the joint holder’s name. Family Member Name Bank/Credit Union/Financial Institution Type of Account Account Number Estimated Current Balance PART 4: REAL ESTATE INFORMATION: Please list all real estate owned for everyone for in your household. Family Member Name Tax Map Key Number Current Assessed Value Mortgage Balance Monthly Payment Mortgage Loan No. Mortgagee Name and Address PART 5: LIABILITIES: Please list total monthly debt owed; credit cards, car loans, personal loans, etc. except previously listed mortgages. Family Member Name Account Type Balance Monthly Payment Account No. Creditor Name and Address 8078rkfw PART 6: TOTAL INCOME RECEIVED BY FAMILY MEMBERS APPLICANT (Head of Household): Current Employment Employer: _____________________________________________________________________________________ Position Held: ______________________________________________ Years of Employment:____________________ Employer Address: _____________________________________________________________________________________ Phone: _____________________________________________ Gross Monthly Income: $_____________________ CO-APPLICANT (Spouse or Co-Head): Current Employment Employer: _____________________________________________________________________________________ Position Held: ______________________________________________ Years of Employment:____________________ Employer Address: _____________________________________________________________________________________ Phone: _____________________________________________ Gross Monthly Income: $_____________________ If the current employment is for less than 2 years, complete the following: Previous Employment Years Employed Last Position Held Monthly Income APPLICANT _____________________________ ____________ _____________ ___________ CO-APPLICANT _____________________________ ____________ _____________ ___________ OTHER GROSS MONTHLY INCOME Please list gross payments (before taxes) made to each family member, for wages, worker’s compensation, social security, SSI, disability, welfare assistance, unemployment benefits, retirement payments, child support, pension, military pay, and business or professional income. Family Member Name Source of Income Address of Source Gross Monthly Amount YES NO [ ] [ ] Did you file a Federal Income Tax Return for the last full calendar year? YES NO [ ] [ ] Did you file a State Income Tax Return for the last full calendar year? YES NO [ ] [ ] Has anyone in your household applied for any benefit or money which is in the process of being approved? If YES, please indicate what household member and for what benefit: ______________________________________________________________________________ ______________________________________________________________________________ 8078rkfw PART 7: CHILD CARE PROVIDER ALLOWANCE:  Check here if the following does not apply to your household. Un-reimbursed Child Care Expense If you pay ( and are not reimbursed) for a care provider to care for a child under the age of 13 who is a member of your family so that an adult member of your family may work or attend classes, enter the first name of the person who works or attends classes here ____________________________, and provide the following information: Name and Address of Care Provider for Verification: Name: _______________________________________ Address:__________________________________________ City: ________________________ State: _________ Zip_______________ Telephone:______________________ Date Child Care Began: ______________________________ Average Hours Per Week: ______________________ Total Child Care Cost: _________________________ Amount you Pay ($):_________________________ (circle one) per hour per week per bi-weekly per month Amount Reimbursed by an individual/ organization: $ ____________________ Name and Address of Organization: __________________________________________________________________ PART 8: DISABILITY ASSISTANCE EXPENSE:  Check here if the following does not apply to your household. Un-reimbursed Disability Assistance Expense If you pay (and are not reimbursed) for care or equipment for a disabled member of your family so that either the disabled member or another member of your family may work, enter the first name of the person who works here ____________________________, and provide the following information: Name and Address of Care or Equipment Provider for Verification: Name: _______________________________________ Address:__________________________________________ City: ________________________ State: _________ Zip_______________ Telephone:______________________ PART 9: MEDICAL EXPENSE ALLOWANCE: Complete only if the Head of Household, Spouse, or Co-Head is disabled or age 62 or older.  Check here if the following does not apply to your household. If you wish to claim an allowance for medical insurance premiums, medical, dental or optical expenses, or prescription or over-the-counter drug expenses, please provide the first name of any family member claiming each expense and the name and address of the provider of the service or product. YES NO [ ] [ ] Do you have Medicare (Social Security)? If YES, Monthly Premium Amount: $ _________ [ ] [ ] Do you have Medicaid (Welfare)? [ ] [ ] Do you have other Medical Insurance? If YES, Monthly Premium Amount: $ _________ [ ] [ ] Are you paying on any medical bills? If YES, Monthly Premium Amount: $ _________ Balance Amount: $ _________ Family Member First Name : ____________________ Expense Claimed: $ __________________________ Provider: ____________________________________ Address: ____________________________________ City: _______________ State: _______ Zip: _______ Family Member First Name : ____________________ Expense Claimed: $ __________________________ Provider: ____________________________________ Address: ____________________________________ City: _______________ State: _______ Zip: _______ 8078rkfw PART 10: REPAIR WORK NEEDED: Give a brief description of the repair work needed: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ PART 11: APPLICANT’S CERTIFICATION GIVING TRUE AND COMPLETE INFORMATION I (We), the undersigned, certify that all of the information provided in this application is true and correct to the best of my (our) knowledge and is submitted for the purpose of the Residential Repair Program. I/We understand that the above information is being collected to determine my (our) eligibility and is submitted for the purpose of obtaining a County rehabilitation loan. I (We) authorize the County of Hawai`i to verify all information contained herein and agree that this application and related verification and statements shall remain the property of the County of Hawai`i. ___________________________________________ _____________________________ (Signature of Applicant) Date ___________________________________________ _____________________________ (Signature of Other Household Adult Member) Date ___________________________________________ _____________________________ (Signature of Other Household Adult Member) Date ___________________________________________ _____________________________ (Signature of Other Household Adult Member) Date