Rehab Program Application

Rehab Program Application
Which program are you interested in?
Applicant #1: Name

First NameMiddle NameLast Name
Are you a veteran?
Social Security Number
Age
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Is there anybody who is 18 years or older in your household who is not currently employed?(Note, if the answer is "yes," you will be directed to fill out a No Income Statement after submitting this form).

Applicant #1 Occupation (1)
Employer Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Employment

MonthDayYear
Date
Years in line of business
Applicant #1 Occupation (2)
Employer Name

First NameLast Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Employment

MonthDayYear
Date
Years in line of business

Is there a second person applying for the Rehab Program?
Applicant #2

(Answers are only mandatory if there is a second person applying)
Applicant #2: Name

PrefixFirst NameMiddle NameLast Name
Are you a veteran?
Social Security Number
Age
Date of Birth

MonthDayYear
Date
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Applicant #2 Occupation (1)
Employer Name

First NameLast Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Employment

MonthDayYear
Date
Years in line of business
Applicant #2 Occupation (2)
Employer Name

First NameLast Name
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Employment

MonthDayYear
Date
Years in line of business

Property Information
Owner Occupied
If yes, is the property your principal residence
Single-Family
Multi-Family
# of Units
# of Vacant Units

DESCRIBE REHABILITATION WORK NEEDED ON YOUR PROPERTY:

PROPERTY MORTGAGE INFORMATION: (required only if applying for a loan)
Are you applying for a loan?
Name of Bank
Purchase Price ($)
Original Mortgage Amount ($)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mortgage Payment ($)
Mortgage Balance ($)
Date Purchased

MonthDayYear
Date
Principal & Interest ($)
Taxes ($)
Insurance ($)
Mortgage Insurance ($)

LIST ALL CURRENT ASSETS

Rows	Interest Rate	Amount ($)
Average 6 month balance of Checking Account
Actual balance of Saving Accounts
FSS Escrow Account
Mutual Funds, Bonds & Annuities
Certificates of Deposit
Cash Value of Life Insurance Policies
Retirement and Pension Funds (current cash value)
Value of Stocks
Cash value from Trust
Investments such as jewelry, antiques cars, collections
Inheritances, lottery winnings, capital gains, insurance settlements
Mortgages or deeds held by applicants

Did any member of the household dispose of any assets for less than the fair market value within the past two years?

No (were the assets either given away or sold at less than the allotted market value?)

LIST ALL CURRENT LIABILITIES

Rows	Lender	Monthly Payments ($)	Balance ($)
Car Loan
Personal Loan
Student Loan
Credit Card
Credit Card
Other
Other

THESE QUESTIONS APPLY TO BOTH APPLICANT AND CO-APPLICANT

Rows	Applicant (Yes or No)	Co-Applicant (Yes or No)
Are there any outstanding judgments against you?
Have you been declared bankrupt within the past seven (7) years?
Have you had a property foreclosed upon or given title or deed in lieu thereof within the past seven (7) years?
Are you a party to a lawsuit?
Are you a co-maker or endorser on a note?
Are you a U.S. citizen or resident alien?

INCOME and ASSET DOCUMENTATION CHECKLIST

The following documentation applies to ALL persons who will reside in the household and must be included with your application to determine your income eligibility: Documentation for all sources of income for all household members must be attached to this application.
Are you currently employed?
Most recent 4 (four) consecutive paystubs

Cancelof

Do you currently receive Social Security?
Current Social Security Award Letter

Cancelof

Do you currently receive a pension?
Current Pension Award Letter (indicating monthly gross income for the current year)

Cancelof

Do you have your most recent federal Income Tax forms (1040)?
Complete copy of the applicant’s most recent 3 (three) years federal Income Tax form 1040, with all schedules.

Cancelof

Do you receive veteran benefits?
Veteran Benefits Certificate

Cancelof

Are you self-employed?
Profit & Loss Statement year-to-date (If self-employed)

Cancelof

Do you give or receive Child Support and/or Alimony?
Child Support and/or Alimony Statement (Court statement)

Cancelof

Are you currently unemployed?
Unemployment Documentation (Computer run-off sheet from Unemployment Office)

Cancelof

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.
Are you over the age of 18 years old not receiving any source of income?

Do you receive any other form of income?
Other income (acceptable forms of current income verification)

Cancelof

Do you have bank statements available for your household's bank accounts?
Most recent 3 (three) consecutive months of bank statement for all bank accounts in the household.

Cancelof

REHAB PROGRAM AFFIDAVIT
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.
Applicant 1
Date

MonthDayYear
Date
Applicant 2
Date

MonthDayYear
Date
*Incomplete applications will result in delay in processing

Date

MonthDayYear
Date
ELIGIBILITY RELEASE FORM
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)

DeLead Program

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):
- Any credit bureau, retail merchants association, bank, financial institution, or other credit-extending organization
- Providers of alimony, child support, credit, handicapped assistance, pension/annuities, the U.S. Social Security Administration, the U.S. Department of Veteran’s Affairs, and Welfare agencies
- All income information and employments records
Other
I understand that a photocopy of this form is as valid as the original.
How many adult family members are in your household?
Head of Household - Family Member Head: Signature
Head of Household - Family Member Head: Name

First NameLast Name
Date

MonthDayYear
Date
Other Adult Member - Family Member #2: Signature
Other Adult Member - Family Member #2: Name

First NameLast Name
Date

MonthDayYear
Date
Head of Household - Family Member #3: Signature
Head of Household - Family Member #3: Name

First NameLast Name
Date

MonthDayYear
Date
Other Adult Member - Family Member #4 Signature
Other Adult Member - Family Member #4: Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Rows	Name	D.O.B.	Relationship to Applicant	College Student	Annual Income
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7

Rehab Program Application

Applicant #2

Property Information

PROPERTY MORTGAGE INFORMATION: (required only if applying for a loan)

INCOME and ASSET DOCUMENTATION CHECKLIST

REHAB PROGRAM AFFIDAVIT

ELIGIBILITY RELEASE FORM