HomeMy WebLinkAbout2026-27 HILP Application Packet
HOME IMPROVEMENT LOAN
PROGRAM
(HILP)
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
HOME IMPROVEMENT LOAN PROGRAM
(HILP) FACT SHEET
PURPOSE:
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.
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. Single family dwelling on Department of Hawaiian Home Lands (DHHL), if a master
Agreement between DHHL and the County is in effect.
3. The dwelling must be a completed residence prior to the owner applying.
4. The residence must meet equity underwriting requirements.
5. After repairs, the dwelling must be safe, sanitary and decent.
6. Dwelling may not be located in the Flood Hazard Area unless all flood hazards are
Mitigated under Executive Order 11988, Flood Plan Management.
7. Dwelling must be insured (homeowners insurance).
The applicant and dwelling must meet all program underwriting requirements as
documented in the HILP Standard Operating Procedure (SOP). A copy of the SOP 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
Interest Rates:
Maximum $50,000
3% Simple Interest
15 year term
**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 HOME IMPROVEMENT LOAN PROGRAM?
A. The Home Improvement Loan Program (HILP) 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 May 1, 2026
1 2 3 4 5 6 7 8
$67,760 $77,440 $87,120 $96,800 $104,560 $112,320 $120,080 $127,840
*Income limits are adjusted annually
5. Q. ARE OWNERS OF PROPERTIES WITH RENTAL UNITS ELIGIBLE
FOR A LOAN?
A. 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. Yes. Single family dwellings on Department of Hawai'i Home Lands (DHHL) are eligible if
a master Agreement between DHHL and the County is in effect.
8. Q. WHAT MUST A HOMEOWNER REPAIR AND CORRECT UNDER THE LOAN
PROGRAM?
A. To ensure that the property is safe and sanitary, all deficiencies cited by the County’s HILP
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 $50,000 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 HILP 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.
HOME IMPROVEMENT LOAN
PROGRAM PREFERRED TERMS
The preferred terms shall be as follows:
Preferred Terms: FIFTY PERCENT (50%) 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.
INCOME GUIDELINES
2026 MEDIAN FAMILY INCOME: $98,300
EFFECTIVE: May 1, 2026
HOUSEHOLD SIZE LOW-INCOME LIMITS
1 67,760
2 77,440
3 87,120
4 96,800
5 104,560
6 112,320
7 120,080
8 127,840
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 most recent three months of 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: (will be processed 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
Home Improvement Loan Program (HILP)
1990 Kino‘ole Street, Suite 102
Hilo, Hawai‘i 96720
C. Kimo Alameda, Ph.D.
Mayor
William V. Brilhante, Jr.
Managing Director
Merrick Nishimoto
Deputy Managing Director
Kehaulani M. Costa
Housing Administrator
Keiko M. Mercado
Assistant Housing Administrator
County of Hawai‘i
Office of Housing and Community Development
1990 Kino‘ole Street, Suite 102 • Hilo, Hawai‘i 96720 • (808) 961-8379 • Fax (808) 961-8685
Existing Housing: (808) 959-4642 • Fax (808) 959-9308
Kona: (808) 323-4300 • Fax (808) 323-4301
HOME IMPROVEMENT LOAN PROGRAM APPLICATION (HILP)
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
2
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
3
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:
______________________________________________________________________________
______________________________________________________________________________
4
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: _______
5
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
HOME IMPROVEMENT LOAN PROGRAM
Requesting release of information:
COUNTY OF HAWAIʻI
OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT
1990 Kinoʻole Street, Suite 102
Hilo, Hawaiʻi 96720
Phone: (808) 961-8379
Purpose: In signing this consent form, you are authorizing the
County of Hawaiʻi Office of Housing and Community
Development (OHCD) to request, obtain, and verify information
necessary to determine eligibility and administer assistance under
the Home Improvement Loan Program. This includes, but is not
limited to, verification of income, employment, assets, property
ownership, mortgage information, public benefits, and
contractor-related records.
Uses of Information to be Obtained: Information obtained will
be used solely to determine eligibility for the Home Improvement
Loan Program, verify information provided by the applicant,
process loan documents and payments, and monitor compliance
with program terms.
All information will be kept confidential and used only for
official program purposes in accordance with state and federal
privacy laws.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form.
Failure to Sign Consent Form: Your failure to sign the consent
form may result in delays in processing your application or denial
of assistance through the Home Improvement Loan Program. The
OHCD requires this consent to verify the information needed to
determine your program eligibility.
Sources of Information: The groups or individuals that may
be asked to release information include but are not limited to:
Previous Landlords
Courts and Post Offices
Schools and Colleges
Law Enforcement Agencies
Support and Alimony Providers
Past and Present Employers
Welfare Agencies
State Unemployment Agencies
Social Security Administration
Medical and Child Care Providers
Veterans Administration
Retirement Systems
Banks and Financial Institution
Credit Providers
Credit Bureaus Utility Companies
Mortgage Servicer
Title Companies
Escrow Agencies
Penalties for Misuse of Information:
Any employee or representative of OHCD who discloses
information improperly or without authorization may be subject
to disciplinary action, civil liability, and/or criminal penalties.
Consent: I consent to allow the County of Hawaiʻi OHCD 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 the Home Improvement Loan Program. I understand that received 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 Household Member Date
Spouse Date Other Household Member Date
Other Household Member Date Other Household Member Date
Home Improvement Loan 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:_____________________
Home Improvement Loan 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 Home Improvement Loan 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. 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. Bewarethatwhenlead-
primersmayalsohavebeenused basedpaintisremovedbyscrapingor
onoutsideporches, railings, PrecautionstoTaketoPreventLead- sanding, adustiscreated, whichmay
garages, fireescapesandlamp BasedPaintPoisoning behazardous. Thedustcanenterthe
posts. Whenthepaintchips, bodyeitherbybreathingitorswallowing
flakesorpeelsoff, theremaybea Youcanavoidlead-basedpaint it. Theuseofheatpaintremoverscould
realdangerforbabiesandyoung poisoningbyperformingsomepreventive createavapororfumewhichmaycause
children. Childrenmayeatpaint maintenance. Lookatyourwalls, ceilings, poisoningifinhaledoveralongperiodof
chipsorchewonpaintedrailings, door, doorframesandwindowsills. Are time. Wheneverpossible, theremovalof
windowssillsorotheritemswhen thereplaceswherethepaintispeeling, lead-basedpaintshouldtakeplacewhen
parentsarenotaround. Children flaking, chipping, orpowdering? Ifso, therearenochildrenorpregnantwomen
canalsoingestleadeveniftheydo therearesomethingsyoucando onthepremises. 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