Any person over the age of 18 years old not receiving any source of income must complete a NO INCOME STATEMENT.
If you are over the age of 18 years old and not receiving any source of income, you will be redirected to the NO INCOME STATEMENT upon completion of this form.
Each applicant must make the following certifications:
All information on this application is true to the best of his or her knowledge and belief, and;
Verification may be obtained from any source herein, and;
There shall be no displacement of tenants as a result of granting this grant or loan;
That there will be no discrimination based upon age, sex, race, creed, color, national origin, or handicap in the sale, rental, lease, or use of occupancy of the property that is rehabilitated with LHAND grants or loans;
I received copies of the pamphlet “Protect Your Family From Lead In Your Home” and all occupants of pre-1978 housing have received a copy of the pamphlet;
I/WE HEREBY GIVE MY/OUR PERMISSION TO THE LYNN HOUSING AUTHORITY & NEIGHBORHOOD DEVELOPMENT TO OBTYAIN MY/OUR CREDIT INFORMATION. (required only if applying for a loan)
I/WE HEREBY REQUEST THAT AGGRANGEMENT BE MADE FOR AN INSPECTION OF MY/OUR PROPERTY TO IDENTIFY “PUBLIC HEALTH AND SAFETY” VIOLATIONS.
I/We understand that under U.S.C. Title 18 Section 1001, any untruthful or deliberately misleading statements made by me on this application can result in prosecution under federal law, and that I can be fined not more than $10,000.00 and/or imprisoned for not more than five years, if found guilty.
Purpose: Your signature on this Eligibility Release Form, and the signatures of each member of your household who is 18 years of age or older, authorizes the Lynn Housing Authority & Neighborhood Development to obtain information from a third party relative to your eligibility in the:
HOME/CDBG Homebuyer Program
HOME/CDBG Rehabilitation Program(s)
Privacy Act Notice Statement: The Department of Housing and Urban Development (HUD) is requiring the collection of the information derived from this form to determine an applicant’s eligibility in a HOME/CDBG/DeLead Program(s) and the amount of assistance necessary using HOME/CDBG/DeLead funds. This information will be used to establish level of benefit on the HOME/CDBG/DeLead program(s); to protect the Government’s financial interest; and to verify the accuracy of the information furnished. It may be released to appropriate Federal, State, and local agencies when relevant, to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in a delay or rejection of your eligibility approval. The Department is authorized to ask for this information by the National Affordable Housing Act of 1990.
NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, “REQUEST FOR COPY OF TAX FORM” MUST BE PREPARED AND SIGNED SEPARATELY.
Authorization: I authorize the Lynn Housing Authority & Neighborhood Development and HUD to obtain information about me and my household from the following sources, that is pertinent to eligibility for participation in the HOME/CDBG/DeLead Program(s):
I understand that a photocopy of this form is as valid as the original.