KOVAR Home Loan

APPLICATION FOR GROUP HOME LOAN
1.A Project Mortgagor (sponsor/borrower):
(Name of Organization)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person*
Telephone*
Alternate Person*
Telephone*
1.B Mortgagor is (Only one is required):
1.B Mortgagor is:*

Non-profit 501 (c) 3Governmental Agency (explain below)
2.A Community Service Board (CSB) providing support:
(Name)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person*
Telephone*
Alternate Person)
Telephone
2.B CSB will provide mortgagor with funds to support project mortgage and related Housing expenses?*

YesNoOther (Explain below)
If the answer to Question 2.B is yes, CSB is to complete parts 12 and 13.
2.C If this loan application is granted, will the facility operated on the property upon which the loan is made be open to all persons with intellectual disabilities without regard to race, color, gender, creed, or national origin?*

YesNoOther (explain below)
3: Project
3A. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
3.B Site control by mortgagor corporation: (check only one)
(Explain)*

owns propertyhas option to buyhas a sales agreementhas lease with option to buyother (explain below)
(Options and agreements to purchase should have a life of at least 120 days with provision to extend for an additional 30 days from date of application submission to KOVAR
4. Development Method: (check only one)
Estimated cost of rehabilitation*

a. Acquisition without rehabilitationb. Acquisition with rehabilitationc. Rehabilitation onlyd. New construction
a. Construction Costs*
5. Loan Requested:
Estimated value of completed project*
Loan amount requested*
(Maximum loan amount cannot exceed 75% of appraised value - maximum of $150,000 for a ten-year loan or a maximum of $250,000 for a fifteen-year loan (subject to change) - of project actual loan amount will be determined by use of Virginia Housing Development Authority (VHDA) underwriting procedures
Show the amount (25% or more) of equity or down payment to be provided.*
Describe the source of equity funds (federal, state or local grants/loans or private donations in the form of cash or property) on a sheet and upload.
6. Housing
Type: (check only one)*

Single family detachedTownhouseMulti-familyCondominium unitsCongregate (living units with community dining room and kitchen)
Fill out the correct item below based on the selected box above
Number of bedrooms if Single Family, Townhouse or Congragate.
Number of apartments if Multi-family or Congregate.
Number of units for Condominiums.
7. Description of the residential service to be offered in the facility: (check only one):*

Group homeSupervised apartment
8. Client Population to be Served:
a. Primary Disability Identification*

Intellectual Disability
b. Age: (check all that apply)*

Children/Adolescents (0-18)Adults (19-64)Elderly (65+)
c. Sex:*

FemaleMaleBoth
d. Number of clients with intellectual disabilities: (enter figures in both spaces)
Number of clients who will be served on an annual basis once the facility’s program is fully operational.
Number of clients who will be served during the first fiscal year of operation normally smaller than the first figure due to start-up/phase-in of the program
9. Description of Program of Services to be Offered Through the Residential Facility:
a. Static Capacity: (enter figures in both spaces)
Number of beds for which the facility will be approved and staffed once it is fully*
Number of beds available during the first fiscal year of operation normally smaller than*
the first figure due to start-up/phase-in of the program

b. Briefly describe the service model which will be used to deliver the type of residential Service checked in item # 7, above. The description should explain how the particular service needs of the client population described in item # 8 will be addressed. (Please use additional sheets if necessary and upload)
c. Licensure: Will this facility be required to be licensed by the Virginia Department of Behavioral Health and Developmental Services (VDBHDS), or other governmental agency, inorder to operate?*

YesNo
If yes above, have you discussed the applicability/suitability of the facility with the Licensure Office?*

YesNo
Name of Licensure Staff member contacted: .*
Date of Contact*

MonthDayYear
Date
Telephone Number: .*

d. Staffing: Complete the following table showing each of the direct service staff projected to be employed in this facility (give job titles, not names):*

	Position/Title	FTE	Sun	Mon	Tues	Wed	Thurs	Fri	Sat
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

e. Implementation: Enter projected schedule or status for all of the following items that apply.
Application date plus number of weeks or estimated dates*

MonthDayYear
Date
Zoning approval*
Consultation with VDBHDS Licensure Office*
Loan closing*
Health Department inspections completed*
Fire Marshall’s certificate*
Building inspection approval*
Occupancy certificate obtained*
Staff hired*
Clients screened*
Clients occupy facility*
f. Project manager's name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person*
Phone Number*
Please enter a valid phone number.
10. Project Operating Budget: Enter all applicable items in both columns for the budget of the program that will deliver services in the facility First Year Annualized
a. Revenues*
b. Expenses*
11. Chief Executive Officer of the Mortgagor Corporation:
Signature

Clear
Title
Name (Typed)
Date

MonthDayYear
Date
a. Name of Program/Service in the CSB’s FY 20____ Program Application/Performance*
Contract which contains the funds necessary to operate this project: . *

This CSB directlyCSB-established private, non-profit corporation name (fill in b1 below):Contract agency name (fill in b2a and b2b below):
b. Program/Service operated by (check one only):
b1. CSB-established private, non-profit corporation name
b2a. CSB-established private, non-profit corporation name
b2b. If a contract agency, describe the nature of the contractual relationship (e.g. for the entire program/service, for services for specific individuals, for purchases of identified beds or services):

c. List the other necessary services and the name of the programs(s) which will provide them: Service Program*

	Service	Program
1.
2.
3.
4.
5.

13. Certifications by the CSB regarding proposed project located at:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
a. I certify that funds are available in our budget to operate this project, and that other necessary emergency, outpatient, day support, case management and transportation services will be available to residents of this project when the site becomes operational.

b. I further certify that, to the best of my knowledge, the mortgagor has the intent and ability to provide the services deemed necessary for the success of the project; that the proposed location and type of housing are suitable for the contemplated residents and that there exists a need in the area of housing for persons with intellectual disabilities; and that the development is economically feasible to the extent that it is projected to have or to receive funds in an amount sufficient to pay for debt service and all of the requisite services deemed necessary for the success of the project.
Name of CSB providing assurances and certifications
Signature of Executive Director or Chairman

Clear
Title
Name (Typed)
Date

MonthDayYear
Date
Signature of Executive Director or Chairman

Clear
Title
Name (Typed)
Date

MonthDayYear
Date
Should be Empty:

APPLICATION FOR GROUP HOME LOAN