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HomeMy WebLinkAbout2022 APPLICATION PACKET (2) RESIDENTIAL REPAIR PROGRAM (RRP) APPLICATION PACKET List of attachments: Fact Sheet Frequently Asked Questions Preferred Terms Income Guidelines Application Instructions Loan Application Authorization for the Release of Information Certification of Non-Filing of Federal Income Tax Return Certification of Non-Filing of State Income Tax Return Verification of Mortgage or Deed of Trust Notification-Watch Out For Lead-Based Paint Poisoning County of Hawai'i Office of Housing and Community Development 1990 Kino‘ole Street, Suite 102 Hilo, Hawai‘i 96720 V/TTY: (808) 961-8379 Fax: (808) 961-8685 PURPOSE: RESIDENTIAL REPAIR PROGRAM (RRP) FACT SHEET To provide low cost loans to benefit low-and moderate-income homeowners in the County of Hawai'i to repair the dwelling unit that they occupy as their primary residence. PROGRAM FUNDING: U.S. Department of Housing and Urban Development (HUD) Community Development Block Grant Program. APPLICANT QUALIFICATION: 1. Total adjusted gross income of all persons living in the household may not exceed the attached household income limit schedule. (See attached schedule) 2. Applicant must be owner/occupant for at least one year prior to filing a loan application for proposed repairs to the dwelling. A rental unit or a portion of a owner/occupied unit that is used for rental purposes is not eligible for rehabilitation assistance. DWELLING QUALIFICATIONS: 1. Single family dwelling owned in fee simple. 2. The dwelling must be a completed residence prior to the owner applying. 3. The residence must meet equity underwriting requirements. 4. After repairs, the dwelling must be safe, sanitary and decent. 5. Dwelling may not be located in the Flood Hazard Area unless all flood hazards are Mitigated under Executive Order 11988, Flood Plan Management. 6. Dwelling must be insured (homeowners insurance). The applicant and dwelling must meet all program underwriting requirements as documented in the RRP Administrative Rules. A copy of the Rules is available at www.hawaiicounty.gov/office-of-housing or by contacting the Office of Housing and Community Development. LOAN PROGRAM: Loan Amount: Minimum $2,500 15 year term Maximum $25,000 15 year term Interest Rates: 3% Simple Interest **Term and Principal amount of loan will be due and payable upon transfer of ownership of the property, for any reason, such as sale, inheritance, condemnation or foreclosure. ** EXAMPLES OF ELIGIBLE REPAIRS: • Roof repairs • Termite Treatment • Connecting to Sewer System • Updating faulty electrical wiring and or plumbing • Solar water heating EXAMPLES OF INELIGIBLE REPAIRS: • Construction of a New Structure • Completion of an incomplete structure or unfinished improvements • Construction on an unpermitted structure FREQUENTLY ASKED QUESTIONS 1. Q. WHAT IS THE RESIDENTIAL REPAIR PROGRAM? A. The Residential Repair Program (RRP) was established by the County of Hawai'i to make low-interest loans available to eligible property owners who are interested in repairing and improving their primary residence. 2. Q. WHAT KINDS OF REPAIRS OR IMPROVEMENTS CAN BE MADE WITH THE LOAN? A. The LOAN can be used to repair and correct deteriorated and hazardous conditions on the property such as damage caused by termites or wood rot, leaky roof and drain pipes, abatement of lead based paint, faulty electrical wiring and plumbing, hook up to County sewer lines, termite treatment and installation of a solar water heating system. The LOAN can also be used to accommodate the special needs of disabled household members. 3. Q. IS THERE A FEE TO APPLY? A. Yes, there is a $50.00 processing fee. A personal check, cashier’s check or money order must be submitted with the completed application. Pursuant to Section 2-134, as amended, of the Hawai'i County Code, there shall be a fee charged for a returned check due to insufficient funds. If you do not qualify you will be refunded your $50.00 processing fee. 4. Q. WHO IS ELIGIBLE TO APPLY FOR A LOAN? A. Owner-occupants whose total adjusted gross income of all persons living in the household is within the income schedule listed below are eligible. The current maximum income limits for owner-occupants, by number of persons in household, are as follows: INCOME LIMITS* (Effective April 01, 2021) 1 2 3 4 5 6 7 8 $47,950 $54,800 $61,650 $68,500 $74,000 $79,500 $84,950 $90,450 *Income limits are adjusted annually 5. Q. ARE OWNERS OF PROPERTIES WITH RENTAL UNITS ELIGIBLE FOR A LOAN? A. No. Only owner-occupants whose household income is within the income schedule are eligible. 6. Q. ARE SINGLE FAMILY DWELLINGS ON LEASE LAND ELIGIBLE FOR A LOAN? A. No. Only fee simple, owner-occupant dwellings are eligible. 7. Q. ARE SINGLE FAMILY DWELLING ON DEPARTMENT OF HAWAIIAN HOME LANDS ELIGIBLE FOR A LOAN? A. No. Single family dwellings on Department of Hawai'i Home Lands (DHHL) are not eligible. 8. Q. WHAT MUST A HOMEOWNER REPAIR AND CORRECT UNDER THE LOAN PROGRAM? A. To insure that the property is safe and sanitary, all deficiencies cited by the County’s RRP inspector must be repaired and corrected. 9. Q. HOW MUCH MONEY CAN A HOMEOWNER BORROW? A. The minimum LOAN is $2,500 the maximum LOAN is $25,000 for each dwelling unit for owner occupied properties. 10. Q. CAN I APPLY FOR MORE THAN ONE LOAN? A. No. Only one LOAN per household. 11. Q. WHAT KIND OF INTEREST RATE WILL BE BORROWER BE PAYING? A. The interest rate is set at 3%. The LOAN is deferred for 15 years or until first transfer of title. If the homeowner applies for a mortgage loan or a home equity loan, the LOAN amount must be repaid in full. 12. Q. WHAT ARE SOME OF THE SERVICES AVAILABLE TO HOMEOWNERS? A. The County’s RRP inspector will inspect your property. The County will prepare a Priority List of Repairs which will outline the deficiencies cited that must be corrected. 13. Q. HOW IS THE LOAN SECURED? A. LOANS will be secured with a Mortgage and Note on the property. 14. Q. WHERE CAN A HOMEOWNER OBTAIN MORE INFORMATION? A. Phone: (808) 961-8379 / Email: ohcdloans@hawaiicounty.gov ** The term of the LOAN may be extended at the end of 15 years if the borrower remains qualified for such a LOAN. **LOANS are subject to availability of funds. RESIDENTIAL REPAIR PROGRAM PREFERRED TERMS The preferred terms shall be as follows: Preferred Terms: THIRTY PERCENT (30%) of the principal balance of the Loan, may be forgiven as a grant to an Applicant if he/she or any member of the household is a member of any one of the following groups: 1. Elderly person 62 years of age or older. 2. Disabled person as defined by 24 CFR 5.403 when the condition is verified by appropriate diagnostician such as physician, psychiatrist, psychologist, therapist, rehabilitation specialist, or licensed social worker, using the HUD language as the verification format. All legal owners shall be required to sign a Mortgage and Note and a Grant Agreement that spells out the terms and conditions of the Loan and Grant. 2021 MEDIAN FAMILY INCOME: $78,800 EFFECTIVE: April 01, 2021 INCOME GUIDELINES HOUSEHOLD SIZE LOW-INCOME LIMITS 1 47,950 2 54,800 3 61,650 4 68,500 5 74,000 6 79,500 7 84,950 8 90,450 FAMILY SIZE ADJUSTMENT: For each person in excess of eight, 8 percent of the four person base should be added to the eight-person limit. (For example, the nine-person limit equals 140 percent [132 + 8] of the relevant four-person income limit.) All income limits are rounded to the nearest $50 to reduce administrative burden. The following documentation is needed to complete the eligibility process. Documentation is needed from all adult members: Copy of Picture ID’s (for Head and Co Head) Completed Application Signed Authorization forms Verification of ALL income sources • Copy of last two most recent employment pay stubs • Copy of most recent documentation of any other income (such as social Security, Disability, Pension, Financial Public Assistance, Life Insurance Payments, Living Allowances, etc.) Verification of ALL assets/bank accounts • Copy of current statements for checking accounts and savings accounts and any other assets (such as IRA, Mutual Funds, Annuities, Stocks, Bonds, etc.) Verification of Mortgage and Deed • Copy of most recent Mortgage Statement • Copy of Deed Verification of Homeowners Insurance • Copy of current Homeowners insurance policy Copy of most recent Property Tax Assessment Copy of most recent Federal and State Tax Returns (all pages) If you do not file taxes, the following needs to be completed and notarized: Certification of Non-Filing of Federal Income Tax Return Certification of Non-Filing of State Income Tax Return Processing Fee: (ONLY AFTER DETERMINING PROGRAM ELIGIBILITY) Personal check, cashier’s check or money order for $50.00 payable to “Director of Finance”. Should you fail to provide all the necessary documents this could cause a delay in processing your eligibility. RETURN APPLICATION AND DOCUMENTS TO: County of Hawai`i Office of Housing and Community Development Residential Repair Program (RRP) 1990 Kino‘ole Street, Suite 102 Hilo, Hawai‘i 96720 8078rkfw 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 Authorization for the Release of Information PHA Requesting release of information: County of Hawai`i Office of Housing and Community Development 1990 Kino`ole Street, Suite 102 Hilo, Hawai`i 96720 (808)961-8379 Authority: 42 U.S.C. 1437f and 3535(d), implemented at 24 CFR Failure to Sign Consent Form: Your failure 982.551(b). to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of Purpose: In signing this consent form, you are authorizing HUD eligibility or termination of benefits is and the above named HA to request information including but not subject to the HA’s grievance procedures. limited: to identity and marital status, employment income, welfare income, assets, residences and rental activity, Medical or Child Care Allowances, Credit and Criminal Activity. HUD and Sources of Information: The groups or the HA need this information to verify your eligibility for individuals that may be asked to release assisted housing benefits and that these benefits are set at the information include but are not limited to: correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits. Uses of Information to be Obtained: HUD is required to protect the Previous Landlords (including PHAs) information it obtains in accordance with the Privacy Act or 1974, Courts and Post Offices 5 U.S.C. 552a. HUD may disclose information (other than tax return Schools and Colleges information) for certain routine uses, such as to other government Law Enforcement Agencies agencies for law enforcement purposes, to Federal agencies for Support and Alimony Providers employment suitability purposes and to HAs for the purpose of Past and Present Employers determining housing assistance. The HA is also required to protect Welfare Agencies the information it obtains in accordance with any applicable State State Unemployment Agencies privacy law. HUD and HA employees may be subject to penalties for Social Security Administration unauthorized disclosures or improper uses of the information that is Medical and Child Care Providers obtained based on the consent form. Veterans Administration Retirement Systems Who Must Sign the Consent Form: Each member of your household who Banks and Financial Institution is 18 years of age or older must sign the consent form. Additional Credit Providers and Credit Bureaus signatures must be obtained from new adult members joining the Utility Companies household or whenever members of the household become 18 years of age. Consent: I consent to allow HUD or the HA to request and obtain any information from any Federal, State or local agency, organization, business, or individual for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying the information obtained. In addition, I must be given an opportunity to contest those determinations. This consent form expires 15 months after signed. Signatures: ________________________________ _________________ __________________________________ ____________ Head of Household Date Other Family Member over age 18 Date ________________________________ _________________ __________________________________ ____________ Spouse Date Other Family Member over age 18 Date ________________________________ _________________ __________________________________ ____________ Other Family Member over age 18 Date Other Family Member over age 18 Date Penalties for Misusing this Consent: HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this form is restricted to the purposes cited above. Any person who knowingly or willfully request, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more that $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use. 2/2004 Original is retained by the requesting organization. Residential Repair Program Certification of Non-Filing of Federal Income Tax Return Name:_______________________________ Name:_______________________________ Address:_____________________________ _____________________________ STATE OF HAWAI'I ) ) SS: COUNTY OF HAWAI'I ) The undersigned hereby certify that the borrower (s), pursuant to the laws and regulations as established by the United States Internal Revenue Service (IRS), did not file a Federal Income Tax Return for the tax year __________, and that the borrower (s) understand that misrepresentation of information or failure to disclose information will constitute just cause for the County to call the loan immediately due and payable. _________________________________ __ BORROWER _________________________________ __ BORROWER Subscribed and sworn to before me this _______ day of ________________, 20_____ ________________________________________ Notary Public, State of Hawai'i My commission expires:_____________________ Residential Repair Program Certification of Non-Filing of State Income Tax Return Name:_______________________________ Name:_______________________________ Address:_____________________________ ______________________________ STATE OF HAWAI'I ) ) SS: COUNTY OF HAWAI'I ) The undersigned hereby certify that the borrower (s), pursuant to the laws and regulations as established by the State of Hawai'i Department of Taxation, did not file a State Income Tax Return for the tax year __________, and that the borrower (s) understand that misrepresentation of information or failure to disclose information will constitute just cause for the County to call the loan immediately due and payable. _________________________________ __ BORROWER _________________________________ __ BORROWER Subscribed and sworn to before me this _______ day of ________________, 20____. ________________________________________ Notary Public, State of Hawai'i My commission expires:_____________________ COUNTY OF HAWAI'I OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT 1990 Kinoole St #102 Hilo, Hawai'i 96720 (808) 961-8379 Loan #________ VERIFICATION OF MORTGAGE OR DEED OF TRUST The applicant identified below has applied for a Residential Repair Program loan that is provided through the County of Hawai'i. The applicant has authorized the County in writing to obtain verification of the status of existing mortgages on the property from any source named in the application. The requested information in this verification of mortgage is for the confidential use of this agency and the U.S. Department of Housing and Urban Development. We are required to complete our verification process in a short time and appreciate your prompt response. A self-addressed envelop has been included for your convenience. If you have any questions, please feel free to contact our office at the address below. Thank you for your cooperation. PART I. Applicant Information (to be completed by applicant) Name of Applicant ____________________________________________________________ Address of Applicant ____________________________________________________________ ____________________________________________________________ Address of Mortgaged Property ____________________________________________________________ ____________________________________________________________ Mortgage Account Number ____________________________________________________________ PART II Lender Information (To be completed by applicant) Name of Lender ____________________________________________________________ Address of Lender ____________________________________________________________ ____________________________________________________________ Part III Mortgage Information (To be completed by lender) Date of Mortgage ________________ Original Principal Amount $_______________ Total Monthly Payment: ________________ Current Principal Balance $________________ Monthly Payments: Principal and Interest $_________________ Mortgage Insurance $_________________ Real Estate Tax Escrow $_________________ Hazard Insurance Escrow $_________________ Other _______________ $_________________ Total Monthly Payment $_________________ Type of Mortgage: _____ Conventional _____ FHA _____ VA _____ Other ___________________________ Terms: _____ Fixed _____ ARM _____ Other ___________________________________________________ Lien Position: _____ 1st Mortgage _____ 2nd Mortgage _____ Other __________________________________ Are Payments Current? ___ Yes___ No, If No, amount in arrears $__________ and period of arrears ________ Termination fee or prepayment penalty $___________________ Completed By: Name ________________________________ Title ________________________________ Phone # _______________ Signature ________________________________ Date __________________ WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction. Notification WatchOutForLead-BasedPoisoning Thispropertywasconstructedbefore1978. Thereisapossibilityitcontainslead-basedpaint. Pleasereadthefollowing informationconcerninglead-basedpoisoning. Sourcesof LeadBasedPaint agencytowhichyouoryourlandlord scraping orbrushingtheloosepaint isapplyingforrehabilitationassistance fromthesurface, thenrepaintedwith Theinteriorsofolderhomesand sothenecessarystepscanbetakento two (2) costsofnon-leadedpaint. apartmentsoftenhavelayersof Testyourunitforlead-basedpaint Insteadofscrapingandrepainting, the lead-basedpaintonwalls, ceilings hazards. Ifyour unitdoeshavelead- surfacemaybecoveredwithother windowsills, doorsanddoor basedpaint, youmaybeeligiblefor materialsuchaswallboard, gypsum, frames. Lead-basedpaintand assistancetoabatethehazard. orpaneling. 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Simplypaintingover notspecificallyeatpaintchipsor immediatelytoprotectyourchild: defectivelead-basedpaintsurfacesdoes dustparticlescontaininglead, they noteliminatethehazard. Rememberthat maygettheseparticlesontheir ( a ) Coverallfurnitureandappliances; youasanadultplayamajorroleinthe hands, puttheirhandsintotheir preventionofleadpoisoning. Youractions mouths, andingestadangerous ( b ) Getabroomofstiffbrushandremove andawarenessabouttheleadproblemcan amountoflead. allloosepiecesofpaintfromwalls, woodwork, makeabigdifference. windowwellsandceilings; HazardsofLead-BasedPaint TenantandHomebuyer Responsibilities c ) Sweepupallpiecesofpaintandplaster Leadpoisoningisdangerous- andputtheminapaperbagorwrapthemin Youshouldimmediatelynotifythe especiallytochildrenundertheage news-paper. Putthesepackagesinthetrash managementofficeoftheagencythrough ofseven (7). Itcaneventuallycause can. DONOTBURNTHEM. whichyouarepurchasingyourhomeifthe mentalretardation, blindnessand unithasflaking, chipping, powderingor evendeath. ( d ) Donotleavepaintchipsonthefloorin peelingpaint, waterleaksfromplumbing, windowwells. Dampmopfloorsandwindows oradefectiveroof. Youshouldoperate SymptomsofLead-basedPaint sillsinandaroundtheworkareatoremoveall withthatoffice’sefforttorepairtheunit. Poisoning dustandpaintparticles. Keepingtheseareas clearofpaintchips, dustanddirtiseasyand Hasyourchildbeenespecially verimportant; and \[ ___ \] Ihavereceivedacopyof the crankyorirritable? Isheorshe Noticeentitled “WatchOutforLead eatingnormally? Doesyourchild ( e ) Donotallowloosepainttoremainwithin PaintPoisoning” havestomachachesandvomiting. yourchildren’sreachsincechildrenmaypick Doesheorshecomplainabout loosepaintoffthelowerpartofthewalls. _____________________________ headaches? Isyourchildunwilling Date toplay? Thesemaybesignsoflead HomeownerMaintenanceandTreatmentof poisoning. Manytimesthough, there Lead-BasedPaintHazards _____________________________ arenosymptomsatall. Becausethere PrintFullName arenosymptomsdoesnotmeanthat Asahomeowner, youshouldtakethenecessary youshouldnotbeconcernedifyou stepstokeepyourhomeingoodshape. Water _____________________________ believeyourchildhasbeenexposedto leaksfromfaultyplumbing, defectiveroofsand Signature lead-basedpaint. exteriorholesorbreaksmayadmitrainand dampnessintotheinteriorofyourhome. These AdvisabilityandAvailabilityofBlood conditionsdamagewallsandceilingsandcause LeadLevelScreening painttopeel, crackorflake. Theseconditions shouldbecorrectedimmediately. Before Ifyoususpectthatyourchildhas eatenchipsofpaintorsomeonetold youthis, youshouldtakeyourchildto thedoctororclinicfortesting. Ifthe testshowsthatyourchildhasan elevatedbloodlevel, treatmentis available. Contactyourdoctororlocal healthdepartmentforhelpormore information. Leadscreeningand treatmentareavailablethroughthe MedicaidProgramforthosewhoare eligible. Ifyourchildisidentifiedas havinganelevatedbloodleadlevel, youshouldimmediatelynotifythe CommunityDevelopmentorother