Community Revitalization Fund Program
(Down Payment Assistance Program)

Home Owner Application

To the applicant: The information on this form will be used to determine your eligibility for down payment assistance. Please fill out all information correctly and completely.

Click on the following links and read through the information before completing the next portion of the application.

Protect Your Family from Lead in Your Home

Fair Housing Civil Rights Act of 1966

Please read each of the following statements:

• I am authorizing the photographing of my property
• I hereby certify that I have received the publication "Protect Your Family from Lead in Your Home" and that I have read and understand this information
• I hereby certify that I have received information on the Fair Housing Civil Rights Act of 1966 and that I have read and understad this information

I, the undersigned, certify subject to penalty under law that the above information is true and complete to the best of my knowledge and belief.

Community Revitalization Fund Program Program Questionnaire

I authorize Northwest Minnesota Multi-County HRA to release the information from this application to my lender and members of the Fund Advisory Committee. I certify that the information in this application is complete and accurate to the best of my knowledge and belief.

The $100.00 application fee should be made payable to:
Northwest Minnesota Multi-County HRA

Please remit:

Northwest Minnesota Multi-County HRA
Attn: Katelyn
P.O. Box 128
Mentor, MN 56736

Community Revitalization Fund Program Privacy Act Release Form

• I hereby consent to permit the release of information contained in my grant and/or loan application file to Northwest Minnesota Multi-County Housing and Redevelopment Authority for the propose of determining my eligibility to participate in the Affordable Housing Program.
• I understand that this information will be released only to Northwest Minnesota Multi-County Housing and Redevelopment Authority and members of the loan review committee.
• Any use, other than specified above, or any subsequent release of this information, is expressly forbidden under the Minnesota Date Privacy Act, unless my written consent is obtained.
• I have been informed of my right to refuse to release the information.
• I understand that I may revoke this consent upon written notice to Northwest Minnesota Multi-County Housing and Redevelopment Authority at any time.

Northwest Minnesota Multi-County Housing and Redeveleopmt Authority

PO Box 128 | 205 Garfield Avenue | Mentor, MN 56736
Phone: 218-637-2431 | Fax: 218-637-2433

Dear Loan Applicant,

If approved, your loan payment will automatically be taken out of your bank account each month, so please complete this form and submit a voided check from the account you wish to use. Please be advised that this payment will automatically come out of your bank account at the beginning of each month.

If you have questions, please call our office at 218-637-2431 ext. 1121

I authorize Northwest Multi-County HRA to withdraw my monthly payment from my checking/savings account. This authorization will remain in effect until I notify the HRA, in writing, to cancel it.