HRAP Application

Home Repair and Accessibility Program (HRAP) Application
The Home Repair and Accessibility Program (HRAP) will assist low- and very low-income homeowners with funds for vital health and safety repairs and accessibility improvements. The program, through these activities, aims to preserve existing affordable housing stock, provide investment in disadvantaged communities, improve the health and well-being of occupants, and help low-income and disabled or mobility-impaired individuals remain in their homes.

Eligible homeowners may receive up to $45,000 in assistance for eligible repairs and/or accessibility improvements, while homeowners participating in the Roof Only option may receive up to $21,500. Assistance is provided to homeowners in the form of a 5- or 3-year forgivable loan. Please note, total household income must be at or below 80 percent of the Area Median Income (AMI) to be eligible for the program.

For Rehabilitation and Roof Only projects, all properties must be an existing residential one-unit single-family property that is independent, privately owned, and non-institutional to be used as the owner’s sole residence and not an income property.

For Accessibility projects, all properties must be an existing residential property that is rental or 8 owner-occupied and must have a documented need for accessibility modifications. The owner or the owner’s tenant must be a senior citizen (over 60 years of age) with a physical limitation, or a resident within the home must be a disabled person (with a physical or mental impairment).

To qualify, the property must be held in fee simple title, clear of all contractor and tax liens.

Priority will be given to rehabilitation items addressing health and safety hazards, local code violations, and accessibility needs. This program is not meant to address issues that are solely cosmetic.

Applicant*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

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

Is the following current? If so, documentation must be provided in order for the application to be considered complete.
Current Homeowner's Insurance*

YesNo
Evidence of Current Homeowner's Insurance

Cancelof
Property Tax Paid (shall be current)*

YesNo
Property Tax Documentation

Cancelof
Flood Insurance (if home is in a FEMA-identified Special Flood Hazard Area) if applicable*

YesNoNot applicable
Flood Insurance Documentation

Cancelof

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 (past 2 years)

Cancelof
Pay stubs for all persons over 18 in the household (60 days consecutive within the last 90 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 (60 days consecutive within the last 90 days)

Cancelof
Recent savings account statements (60 days consecutive within the last 90 days)

Cancelof
Current Social Security benefits statement(s), SSI statement(s), and/or SSA 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."

Assistance Requested
Please describe the home repair and/or accessibility issues with which you would like our assistance.*

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.
Demographic Information

Alaskan Native or American IndianAsian or Pacific IslanderBlack/Non-HispanicHispanicNative Hawaiian/Other Pacific IslanderWhite/Non-Hispanic
Other Multi-Racial:

Applicant's Certification
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 Home Rehabilitation and Accessibility Program (HRAP), 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 HRAP, 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
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
Name*

First NameLast Name
Program Administrator (Sponsor) Name: HRAP

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 Home Rehabilitation and Accessibility Program (HRAP) 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 Rehabilitation and Accessibility 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.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Home Repair and Accessibility Program (HRAP) Application

Zero Income Verification

Assistance Requested

Demographic Information (optional)

Applicant's Certification

Authority for Release of Information