City of Ada SCDP Homeowner Application

Small Cities Development Program
HOMEOWNER APPLICATION
CITY OF ADA

Northwest Minnesota Multi-County HRA
PO Box 128 | Mentor, MN 56736 | Phone: 218-309-0057

The information on this application will be used to determine your eligibility for a Rehabiliation Loan. All fields must be completed.
APPLICANT INFORMATION
Full Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Birth Date
Social Security Number*
Social Security Number
Marital Status*

MarriedSingleDivorcedSeparatedWidowed
Race*

WhiteBlack/African AmericanAsianAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander
Address*

Street

Apt/Unit

CityState

Zip Code
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
Do you have a co-applicant to add to the application?*

YesNo
CO-APPLICANT INFORMATION
Full Name*

First NameMiddle InitialLast Name
Birth Date*

MonthDayYear
Birth Date
Social Security Number*
Social Security Number
Marital Status*

MarriedSingleDivorcedSeparatedWidowed
Race*

WhiteBlack/African AmericanAsianAmerican Indian/Alaska NativeNative Hawaiian/Other Pacific Islander
Address*

Street

Apt/Unit

CityState

Zip Code
Home Number
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Work Number
Please enter a valid phone number.
Email
example@example.com
OTHER HOUSEHOLD OCCUPANTS

Please provide the following information for each member of the household NOT listed as the applicant or co-applicant
How many other household occupants, not including the applicant and co-applicant, do you have to add to the application?*

None31425
Household Member #1
Name*

First NameLast Name
Birth Date*

MonthDayYear
Birth Date
Race*
Household Member #2
Name*

First NameLast Name
Birth Date*

MonthDayYear
Birth Date
Race*
Household Member #3
Name*

First NameLast Name
Birth Date*

MonthDayYear
Birth Date
Race*
Household Member #4
Name*

First NameLast Name
Birth Date*

MonthDayYear
Birth Date
Race*
Household Member #5
Name*

First NameLast Name
Birth Date*

MonthDayYear
Birth Date
Race*
INCOME INFORMATION

"Income" means any amount received from the following sources by ANY member of the household age 18 or over.
Does anyone in the household receive Public Assistance including: MFIP, SSI, GA, Child Support, and Unemployment Compensation?*

YesNo
Does anyone in the household earned a salary including: wages, commissions, bonuses, tips, and overtime pay?*

YesNo
Does anyone in the household receive estate or trust income?*

YesNo
Does anyone in the household receive rental income?*

YesNo
Does anyone in the household receive gains from the sale of property or securities?*

YesNo
Does anyone in the household receive income from pensions or annuities including: PERA, Social Security, and Railroad Retirement?*

YesNo
Does anyone in the household receive income from business profit (for self-employed individuals, including farmers)?*

YesNo
Does anyone in the household receive income from interest and dividends?*

YesNo
Does anyone in the household receive contract for deed payments?*

YesNo
Does anyone in the household receive child support or alimony?*

YesNo
Applicant's Employer is:
Co-Applicant's Employer is:
How many incomes do you have to list?*

None31425
INCOME #1
Name of Household Member*
Annual Income Amount*
Source of Income*
**Attach proof/copies of income at the end of application
INCOME #2
Name of Household Member*
Annual Income Amount*
Source of Income*
**Attach proof/copies of income at the end of application
INCOME #3
Name of Household Member*
Annual Income Amount*
Source of Income*
**Attach proof/copies of income at the end of application
INCOME #4
Name of Household Member*
Annual Income Amount*
Source of Income*
**Attach proof/copies of income at the end of application
INCOME #5
Name of Household Member*
Annual Income Amount*
Source of Income*
**Attach proof/copies of income at the end of application
PROPERTY INFORMATION
Do you have an outstanding mortgage on the property?*

YesNo
What is the outstanding principal on the mortgage?*
Do you have any outstanding Contracts for Deed on the property?*

YesNo
What is the outstanding principal on the contract?*
Do you have a life estate deed?*

YesNo
What type of house is it?*

Single Family HouseDuplex
How many years have you lived in the house?*
What year was the house built?*
What is the current estimated value (from your most recent property tax statement) of the property to be improved?*
Do you have homeowner's insurance?*

YesNo
Are there unpaid property taxes on this property?*

YesNo
Before continuing, please click the following links and read through the information:
- Fair Housing Act of 1966
- Protect Your Family From Lead in Your Home
Please read and check each box by the following statements
I have read and understand the information in the publication "PROTECT YOUR FAMILY FROM LEAD IN YOUR HOME" linked on the online application. I also understand that I had the option to download the files at the end of the application and can request a copy be mailed to me at any time.
I have read and understand the information in the publication "FAIR HOUSING ACT OF 1966" linked on the online application. I also understand that I had the option to download the files at the end of the application and can request a copy to be mailed to me at any time.
I certify subject to penalty under law that the information provided on this application is true and correct to the best of my knowledge and belief, and that the provisions stated above are accepts and agreed to.
I understand that I will make the final selection of improvements to be made with the grant proceeds; that the contract for the improvements will be solely between the contractor selected and me; and that neither the city nor the administering entity will be liable for any inadequate performance of the improvements by my contract.
I am authorizing the photographing of my property.
An authorized representative of the Small Cities Development Program shall have the right to inspect the property to be improved at any time from the date of the loan, upon giving due notice to the owner or occupants.
I understand that all names and financial information on this application are considered private data on individuals and are subject to privacy of the information provisions, as stated under Minnesota Statue 462A.065.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Co-Applicant's Signature*

Clear
Date*

MonthDayYear
Date
WARNING: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willingfully makes or uses a document or writing containing any false, fictious statement or entry, in any matter within the jurisdiction of any department or agency of the United States shall be fined no more than $10,000 or imprisoned for not more than five (5) years, or both.
File Upload

The following items MUST be submitted with the application. You can either submit them below or email them to kristi@nwmnhra.org.
Last three (3) paystubs/last filed income tax

Cancelof
Proof of any other income listed

Cancelof
Copy of insurance declaration page

Cancelof
Copy of mortgage or satisfied mortgage document

Cancelof
Proof of current property taxes & copy of property tax statement

Cancelof
Should be Empty:

APPLICANT INFORMATION

CO-APPLICANT INFORMATION

OTHER HOUSEHOLD OCCUPANTS

INCOME INFORMATION

PROPERTY INFORMATION

Please read and check each box by the following statements

File Upload