HomeMy WebLinkAbout2017 RRP Application Packet 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 Kimble Street, Suite 105
Hilo, Hawai'i 96720-5293
V/TTY: (808) 959-4642
Fax: (808) 959-9308
COUNTY OF HAWAI'I
OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT
1990 Kino'oie Street, Suite 105
HILO, HAWAII 96720-5293
V/TTY: (808) 959-4642
FAX: (808) 959-9308
RESIDENTIAL REPAIR PROGRAM (RRP)
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.
PROGRAM FUNDING:
U.S. Department of Housing and Urban Development(HUD) Community Development
Block Grant Program.
APPLICATION FEE:
1. There is a $50.00 processing fee.
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.qov/office-of-housinq 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 a incomplete structure or unfinished improvements
• Construction on an unpermitted structure
COUNTY OF HAWAII
OFFICE OF HOUSING AND COMMUNTIY DEVELOPMET
RESIDENTIAL REPAIR PROGRAM(RRP)
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.
, 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 Hawaii 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 March 29,2016)
1 2 3 4 5 6 7 8
$39,000 $44,600 $50,150 $55,700 $60,200 $64,650 $69,100 $73,550
"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. The County of Hawai'i Office of Housing and Community Development, 1990 Kino'ole
Street, Suite 105 Hilo, The phone number is 959-4642.
The term of the LOAN maybe extended at the end of 15years 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.
2016 MEDIAN FAMILY INCOME: $57,600
EFFECTIVE„ March 29,2016
INCOME GUIDELINES
HOUSEHOLD LOW-INCOME
SIZE LIMITS
1 39,000
2 44,600
3 50,150
4 55,700
5 60,200
6 64,650
7 69,100
8 73,550
FAMILY SIZE ADJUSTMENT:
Four 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.
COUNTY OF HAWAI'I
OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT
RESIDENTIAL REPAIR PROGRAM
INSTRUCTIONS FOR COMPLETING THE APPLICATION FORM:
- Type or print information using black ink.
- Sign and date the application.
- Fill in all applicable information.
- Sign and date Authorization for the Release of Information
DOCUMENTS TO BE SUBMITTED WITH THE APPLICATION:
- Copy of three (3) months of most recent employment pay stubs for all household
members.
- Copy of most recent documentation of any other income for all household members(such
as: Social Security, Disability, Pension, Public Assistance, Life Insurance Payments,
Living Allowances, etc.)
- Copy of six(6)months of statements for checking accounts,the most recent bank statement
for savings accounts and any other assets for all household members (Such as: IRA,
Mutual Funds, Annuities, Stocks, Bonds, etc.)
- Copy of Deed.
- Copy of most recent Real Property Tax Assessment.
- Copy of most recent Mortgage Statement
- Copy of current homeowners' insurance policy.
- Copy of most recent Federal Income Tax Return.
- Copy of most recent State Income Tax Return.
If you did not file a Federal and/or State Income Tax Return, complete the attached
Certification of Non-Filing of Federal and/or State Income Tax Return, have it notarized and
submit it with the completed application.
- Personal check, cashier's check or money order for $50.00 payable to "Director of
Finance".
RETURN THE APPLICATION BY MAIL OR IN PERSON TO:
County of Hawai'i
Office of Housing and Community Development
1990 Kino'ole Street, Suite 105
Hilo, Hawai'i 96720-5293
If you need any other information or assistance regarding the application, please feel free to contact
our office at (808) 959-4642.
;+ /Tr or Nom.
Harry Kim ' •]ut '�' Neil S.Gyotoku
Mater
• Housing Administrator
Lance M..Nnmi
County of Hawaii Assistant Housing
Office of Housing and Community Development Administrator
1990 Kino'ole Street,Suite 105•Hilo,Hawaii 96720
VITT(808)959-4642•Fax(808)959-9308
KONA: 74-5044 Ane Keohokalole Highway • Kailua-Kona,Hawaii 96740
(808)323-4300 • Fax(808)323-4301
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 I: GENERAL INFORMATION:
APPLICANT
(Head of Household): Phone
Legal M
Last Name First
Name M111
CO-APPLICANT
(Spouse or Co-Head) _... Oilier Phone:waa
I egal Last Name First Name MI
Current Address.' Apt.No....,,...�
try: tateC
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:mm
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 ofeach adult and child
listed. II Head of Household K Co-Head(Not Married) Y Youth Under l8 L Live In Aide
S Spouse(Married) F Foster Child/Adult E w Full Time Student Over 18 A Other Adult
Last Name&Sr,Jr„etc. First Name Ml Date of Birth Sex Relation
1 H tHeasd sof Ho u s e he U Ilk
Single Race(select one or more) Ithnicity(check one box)
[ ] White [ ] Asian [ ]Black or African American ]; '[ Hispanic or Latino
[ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino
[ ] American Indian!Alaska Native
Multi Race(select one or more)
[ ] Asian and White [ ]Other Mulu.Racial
[ ] Black or African Amencan and White
[ ] American Indian t Alaska Native and White
[ ] American Indian Alaska Native and Black
EQUAL HOUSING OPPORTUNITY
'HAWArI COUNTY IS AN EQUAL OPPORTUNITY
PROVIDER AND EMPLOYER'
„ .O'9r'bia
Last Name&Sr,Jr,etc. First Name MI Date of Birth Sex Relation
2
Race(select one or more) Ethnicity(check one box)
[ ] White [ ] Asian [ ]Black or African American [ ] Hispanic or Latino
[ ] Native Hawaiian or Other Pacific Islander [ ] Not I lispanic or Latino
I } Amencan Indian°Alaska Native
Name&Sr,Jr,etc First Name MI Date of Birth Sex Relation
3
Race(select one or more) Ethnicity(check one box)
[ ] White [ ] Asian [ }Black or African American [ ] Hispanic or Latino
[ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino
[ ] American Indian r Alaska Native
Last Name&Sr,Jr,etc. First Name Ml Date of Birth Sex Relation
4
Race(select one or more) Ethnicity(check one box)
[ ] White [ ] Asian [ ]Black or African Amencan [ ] Hispanic or Latino
[ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino
[ ] American Indian%Alaska Native
Last Name&Sr,Jr,etc. First Name MI Date of Birth Sex Relation
5
Race(select one ore more) Ethnicity(check one box)
[ ] White [ ] Asian [ ]Black or African American [ ] I lispamc or Latino
[ ] Native Hawaiian or Other Pacific Islander [ ] Not Hispanic or Latino
[ ] American Indian/Alaska Native
Last Name&Sr,Jr,etc. first Name MI Date of Birth Sex Relation
6
Race(select one or more) Ethnicity(check one box)
[ ] White [ ] Asian [ ]Black or African Amencan 9 } Ilrspanir_or Latino
f ] Native Hawaiian or Other Pacific Islander [ '[ Nit I lrspanic or Latino
[ ] Amencan Indian'Alaska Native
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 Bank/Credit Union/Financial Type of Account Estimated
Name Institution Account Number Current Balance
PART 4: REAL ESTATE INFORMATION: Please list all real estate owned for everyone for in your household.
Family Member Tax Map Key Current Mortgage Monthly Mortgage Mortgagee Name
Name Number Assessed Value Balance Payment Loan No. and Address
A
PART 5: LIABILITIES: Please list total monthly debt owed;credit cards,car loans,personal loans,etc,except previously
listed mortgages.
Family Member Account Type Balance Monthly Account No. Creditor Name
Name Payment and Address
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: 5
CO-APPLICANT(Spouse or Co-Head).
Current Employment
Employer:
Position Held;, Years of Employment
Employer Address:
Phone- Gross Monthly Income 5
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 CROSS 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 orprofessional 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:
PART 7: CHILD CARE PROVIDER ALLOWANCE:
I 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:
DateChildn:. Average Hours 13ega ............................................�.............. .._...................................................................... g 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:
Li 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
[ J [ ] Do you have Medicare(Social Security)? If YES,Monthly Premium Amount:$
[ I [ ] 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: Family Member First Name:
Expense Claimed: S Expense Claimed: S
Provider: Provider:
Address: Address:
City: State: Zip: City: State: Zip:
PART 10: REPAIR WORK NEEDED:
Give a brief description of the repair work needed;
PART I I: APPLICANT'S CERTIFICATION
GIVING TRUE AND COMPLETE INFORMATION
I(We), the undersigned, cert]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 Hanoi'i.
(Si nature of A licant}.. .....................
Date
to
(Signature of Other Household Adult Member) Date
ae
(Signature of Other Household Adult Member) Date o
(Signature of Other Household Adult Member) Date
Authorization for the Release of Information
PHA. Requesting release of informationz
County of Hawaii
Office of Housing and Community Development
50 Wailuko Drive
Hilo, Hawaivi 96720
808/961-8379
Authority: 42 U.S.C. 1437f and 3535dd) , implemented. at 24 CFP. Failure to Sign Consent Form: Your failure!
982.55l(b) . to sign the consent form may result in the
denial of eligibility or temminatio:n 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.
limitedo to identity and marital. status, employment income,
welfare income, assets, residences angrental activity, Medical
or Child Care Allowances, Credit and Criminal Activity. HUD and. Sources of Information: The groups or
the MA. need this information to verify your eligibility for individuals that may be asked to release
aasisted 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 i:n 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 PHAs1
information it obtains in accordance with the Privacy Act or 1974., Courts and. Post Offices
5 U.S.C. 552a. BUD 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
determinind housind assistance, The HA io also required to proteot Welfare Agencies
the information it obtains in accordance with any applicable State State Unemployment! Agencies
privacy law. HUD and HA, employees m' 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 memberof your household who Dents and other Financial
institution.
is 19 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 19 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 ' ted housing programs. I understand that HA. that receive information under this
consent form cannot use it to deny, reduce or terminate ' tance 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;
oc, .
Head of HO us eth.o id ' Co c e 0 h t F1vn i..(Y('ttFti.he r Q V 0 i ;!,1,4 e 15
t......................................................................................................................................................................................................................................................................................._
11.M"t-e
14101131E Other Fa mily Re rAN'tt over ,6,,, gr Date
WiTchl: 111-1; 11Fi; iV12117e Other Family Mombet love17go 18 . ..........................................................................................
Date
Penalties for Misusing this Consent:
HUD, the HA, and any owner dor any employee of RIM, the HA, or the owner) may be subject topenalties 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 whoknowingly
or willfully request, obtains or discloses any information under false pretenses concerning an applicant or
participant may be subject to a misdemeanorand finednot 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
mal be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the
unauthorized disclosure or improper use.
2/21104 Original is retained, by the requesting. organization.
62)8thia
Residential Emergency Repair Program
Certification of Non-Filing of Federal Income Tax Return
Name:
Name:
Address:
STATE OF HAWAII )
SS:
COUNTY OF HAWAII )
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 Hawaii
My commission expires:
Residential Emergency Repair Program
Certification of Non-Filing of State Income Tax Return
Name:
Name:
Address:
STATE OF HAWAII )
SS:
COUNTY OF HAWAII )
The undersigned hereby certify that the borrower(s), pursuant to the laws and regulations as
established by the State of Hawaii 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 Kino'ole Street, Suite 105
Hilo, Hawaii 96720
(808) 959-4642
Application No.
RESIDENTIAL EMERGENCY REPAIR PROGRAM
VERIFICATION OF MORTGAGE
OR DEED OF TRUST
The client identified below has applied for a housing rehabilitation loan from the Office of Housing
and Community Development(OHCD). The applicant has authorized the OHCD 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
the OHCD and the U.S. Department of Housing and Urban Development. Please furnish the
information requested below and return this form using the stamped, addressed envelop provided. If
you have any questions please feel free to contact our office. Thank you for your cooperation.
County of Hawai'i
Office of Housing and Community Development
1990 Kino'ole Street, Suite 105
Hilo, Hawaii 96720
808,1959-4642
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
1 p
Notification
G
Watch Out For Lead-Based Poisoning t
This property was constructed before 1978. There is a possibility it contains lead-based paint. Please read the following • i;
information concerning lead-based poisoning. i
Pr
,
Sources of Lead Based Paint agency to which you or your landlord scraping or brushing the loose paint
is applying for rehabilitation assistance from the surface,then repainted with
The interiors of older homes and so the necessary steps can be taken to two(2)costs of non-leaded paint. 4.
apartments often have layers of Test your unit for lead-based paint Instead of scraping and repainting,the
lead-based paint on wails,ceilings hazards. If your unit does have lead- surface may be covered with other
window silts,doors and door based paint,you may be eligible for materiel such as wall board,gypsum,
frames. Lead-based paint and assistance to abate the hazard. or paneling. Beware that when lead-
primers may also have been used based paint is removed by scraping or
on outside porches,railings, Precautions to Take to Prevent Lead- sanding,a dust is created,which may ,
garages,fire escapes and lamp Based Paint Poisoning be hazardous. The dust can enter the
posts. When the paint chips, body either by breathing it or swallowing
flakes or peels off,there may be a You can avoid lead-based paint it. The use of heat paint removers could
real danger for babies and young poisoning by performing some preventive create a vapor or fume which may cause
children. Children may cal paint maintenance. Look at your walls,ceilings, poisoning if inhaled over a long period of
chips or chew on painted railings, door,door frames and window sills. Arc time. Whenever possible,the removal of
windows sills or other items when there places where the paint is peeling, lead-based paint should take place when
parents are not around. Children flaking,chipping,or powdering? If so, there arc no children or pregnant women
can also ingest lead even if they do there are some things you can do on the premises. Simply painting over
not specifically eat paint chips or immediately to protect your child: defective lead-based paint surfaces does 0
dust particles containing lead,they not eliminate the hazard. Remember that
may get these particles on their (a) Cover all furniture and appliances; you as an adult play a major role in the &
hands,put their ltands into their prevention of lead poisoning, Your actions
mouths,and ingest a dangerous (b) Get a broom of stiff brush and remove and awareness about the lead problem can
amount of lead. all loose pieces of paint from walls,woodwork, make a big difference. I
window wells and ceilings,
I fazards of Lead-Based Paint tenant and Homebuyer Responsibilities
(c) Sweep up ail pieces of paint and plaster
Lead poisoning is dangerous- and put them in a paper bag or wrap theta in You should immediately notify the
especially to children under the age news-paper. Put these packages in the trash management office of the agency through
of seven(7). It can eventually cause can. DO NOT BURN THEM. which you are purchasing your home if the
mental retardation,blindness and unit has flaking,chipping,powdering or
even death. (d) Do not leave paint chips on the floor in peeling paint,water leaks fiom plumbing,
window wells. Damp map floors and windows or a defective roof. You should operate
Symptoms of Lead-based Paint sills in and around the work area to remove all with that office's effort to repair the unite
Poisoning dust and paint particles. Keeping these areas
clear of paint chips,dust and dirt is easy and
Has your child been especially ver important;and [_)I have received a copy of the
cranky or irritable? Is he or she Notice entitled"Watch Out for Lead
eating normally? Does your child (e) Do not allow loose paint to remain within Paint Poisoning"
have stomachaches and vomiting, your children's reach since children may pick
Does he or she complain about loose paint oft'the lower part of the walls
headaches? Is your child unwilling Date
to play? These may be signs of lead Homeowner Maintenance and Treatment of
poisoning. Many times though,there Lead-Based Paint Hazards
arc no symptoms at all. Because there Print Full Name
are no symptoms does not mean that As a homeowner,you should take the necessary
you should not be concerned if you steps to keep your home in good shape. Water
believe your child has been exposed to leaks from faulty plumbing,defective roofs and Signature
lead-based paint. exterior holes or breaks may admit rain and
dampness into the interior of your home These
Advisability mid Availability of Blood conditions damage walls and ceilings and cause
Lead Level Screening paint to peel,crack or flake. These conditions
should be corrected immediately. Before
If you suspect that your child has
eaten chips of paint or someone told
you this,you should take your child to
the doctor or clinic for testing. If the
test shows that your child has an
elevated blood level,treatment is
available. Contact your doctor or local
health department for help or more
information. Lead screening and
treatment are available through the
Medicaid Program for those who arc
eligible. If your child is identified as
having an elevated blood lead level,
you should immediately notify the
Community Development or other