CHS-CAP Program

Community Housing Services (CHS) Program & Critical Assistance Program (CAP)

Program Aplication
The Community Housing Services (CHS) Program provides assistance for reinvestment in the city’s existing housing stock and preserving that valuable asset for future generations. The program also serves to revitalize neighborhoods, enhance property values, and make homes safer through rehabilitation efforts. The program is designed to offer housing rehabilitation assistance for low- and moderate-income families that own their own home. More than 2,000 homes have been upgraded and more than $8.6 million has been injected into local houses, building trade employment, and building materials throughout the program’s 36-year history.

The program provides assistance to low- to moderate-income owner-occupied property owners for minor household maintenance items. Eligible items include but are not limited to electrical items, foundation issues, insulation, plumbing issues and house roof assemblies repair/replacement (and attached garage). Roofing of a detached garage is not permitted under this program. This program revitalizes neighborhoods and maintains/increases property values throughout the Moline neighborhoods.

The Critical Assistance Program (CAP) provides assistance to low to moderate income owner occupied property owners for minor household maintenance items. Emergency eligible items include but are not limited to accessibility issues; water line breaks, sewer line breaks and repairs/replacement of inoperative furnaces/boilers. This program revitalizes neighborhoods, maintains/increases property values, and funds emergency repairs for low to moderate income residents.

CITY OF MOLINE

Community Housing Services (CHS) Program,

Critical Assistance Program (CAP)

Contact:

Bettinna Diaz - Bilingual Community Development Program Coordinator at 309.524.2048 if you have any questions.

Program - Checklist

Please return the following items with your application:

□ Full list of all household members with birthdates

□ Proof of Identification/Citizenship (for everyone 18 and over)
- Social Security Cards
- Government Photo I.D.s
□ Proof of Total Household Income (for everyone 18 and over)

□ Latest Tax Returns with all W-2s

□ Check stubs (30 consecutive days – within the last 60 days)
- Zero Income Form (when no income is received for anyone 18 and over)
- Pensions
- Social Security
- Bank Statements (30 days within the last 60 days)
- Other (i.e. babysitting, Avon, etc…)
□ Property Verification
- Current Homeowners Insurance Policy (Declaration page with agent/company, dates, policy amounts & address)
- Current Property Tax Statement
An applicant's total household income must not exceed the current HUD Income Guidelines.

Applicant*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Co-Applicant (if applicable)

First NameLast Name
Co-Applicant's Phone Number (if applicable)
Please enter a valid phone number.
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Is the following current? If so, documentation must be provided in order for the application to be considered complete.
YesNo
Evidence of Current Homeowner's Insurance

Cancelof
YesNo
Property Tax Documentation

Cancelof
YesNoNot applicable
Flood Insurance Documentation

Cancelof
Single-Family Owner-Occupied Properties Only
I/we understand that the assistance given by the City of Moline is strictly for Single Family and Owner-Occupied properties. I/we understand that aid and assistance will come from the Community Development Block Grant Funds (CDBG) in the form of a grant, with a maximum of $14,999.00 for each occurrence. I/we understand that in the event the most responsive and responsible bid exceeds the allowable funding ($14,999.00), I/we will be notified and may pay the difference within ten calendar days of the bid opening; request staff rebid the project (only once) or withdraw their application and be placed back on the waiting list. Additionally, I/we understand this application shall meet the federal household income guidelines limit established each year by Housing and Urban Development (HUD). I/we understand that taxes on the property must be current and be absent of any outstanding adverse encumbrances, judgments or liens. The City will verify ownership through a title search and/or the Rock Island County legal records.*

I understand

Household Members (please list everyone who lives in your home, including yourself)*

Rows	Full Name	Date of Birth	Relationship	Total Monthly Income
1
2
3
4
5
5

Income Verification Checklist

If any of the following apply to you, you must provide documentation in order for your application to be considered complete.
Most current tax returns with all W-2s

Cancelof
Pay stubs for all persons over 18 in the household (last 30 days)

Cancelof
If you do not have a currently have an income to report, please complete the Zero Income Form on the next page.
Recent checking account statements

Cancelof
Recent savings account statements

Cancelof
Current Social Security benefits statement(s) and/or SSI statement(s)

Cancelof
Current Pension benefits statement(s)

Cancelof
Current Unemployment benefits statement

Cancelof
All other income

Cancelof

Zero Income Verification

(Complete only if applicable)
Applicant Name

First NameLast Name
Social Security Number
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby certify that I do not receive income from any other the following sources:
- Wages, salaries, tips, etc.
- Taxable interest
- Dividends
- Taxable refunds, credits or offsets of state and local income tax. There are some exceptions - refer to Form 1040 for instructions.
- Alimony (or separate maintenance payments) received
- Business income (or loss)
- Capital gain (or loss). There are some exceptions - refer to Form 1040 instructions.
- Other gains (or losses) (i.e. assets used in a trade or business that were exchanged or sold)
- Taxable amount of individual retirement account (IRA) distributions. (Includes simplified employee pension [SEP] and savings incentive.)
- Rental real estate, royalties, partnerships, S corporations, trusts, etc.
  Farm income (or loss)
- Unemployment compensation benefits
- Taxable amount of Social Security benefits
- Other income, including prizes and awards; gambling, lottery or raffle winnings; jury duty fees; permanent fund dividends; reimbursements for amounts deducted in previous years; income from the rental of property if not in the business or renting such property; and income from an activity not engaged in for profit.
And, that I have no income of any kind whatsoever at this point in time and do not anticipate income from any source within the next 12 months.
Signature

Clear
Date

MonthDayYear
Date
PENALTY FOR FALSE OR FRAUDULANT STATEMENT: U.S. title 18, Sec. 1001 provides: "Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writing or documents knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both."

Demographic Information (optional)

The following information is optional and will be used solely for reporting purposes. Please check all that describe the owner of the property.
Alaskan Native or American IndianAsian or Pacific IslanderBlack/Non-HispanicHispanicNative Hawaiian/Other Pacific IslanderWhite/Non-Hispanic
Other Multi-Racial:

Applicant's Certification
This applicant certifies that all information in this application and all other information furnished in support of this application are given for the purpose of obtaining a grant or loan under the CHS Program, and are true and complete to the best of the Applicant's knowledge. Verification may be obtained from any source named herein.I understand that under the guidelines of this program, my house will be inspected by the City of Moline to determine the amount of work to be performed, and that the City has final authority.As a condition of receiving financial assistance through the CHS program, I agree to maintain my property in a decent, safe and sanitary condition, in compliance with all codes for the City of Moline.
Signature*

Clear
Date*

MonthDayYear
Date
Co-Applicant's Signature (if applicable)

Clear
Date

MonthDayYear
Date
PENALTY FOR FALSE OR FRAUDULENT STATEMENT: U.S. Title 18, Sec. 1001 provides: "Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, or makes any false, fictitious or fraudulent statements or representations, or makes or use of any false writing or documents knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both."

Authority for Release of Information
Program Administrator (Sponsor) Name: CHS/CAP

Program Administrator (Sponsor) Address: 619 16th Street, Moline, IL 61265

I hereby authorize the above Sponsor to verify my bank accounts, employment records, outstanding debts, including any present or previous mortgages, and to make other inquiries pertaining to my qualification for home maintenance assistance from the CHS/CAP Program administered by the City of Moline. Sponsor may make copies of this letter for distribution to any party with which I have a financial or credit relationship and such party may rely on such copy as if the same were an original.

Privacy Act Notice: All information collected by Sponsor or its assignees shall be use in determining whether I qualify as a prospective recipient of a forgivable loan under the CDBG CHS/CAP Program. Such information will not be disclosed outside Sponsor except as required and permitted by law. I understand that I do not have to provide any such information, but that failure to do so may cause my application for approval as a recipient or borrower to be delayed or rejected.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Co-Applicant's Name (if applicable)

First NameLast Name
Co-Applicant's Signature (if applicable)

Clear
Date

MonthDayYear
Date
Should be Empty:

Community Housing Services (CHS) Program & Critical Assistance Program (CAP)

Zero Income Verification

Eligible Emergency Item Requested

Non-Emergency Eligible Rehabilitation Assistance Request

Demographic Information (optional)

Applicant's Certification

Authority for Release of Information