901 Help: LISC repair application

PLEASE COMPLETE APPLICATION IN FULL AND SUBMIT ALL REQUIRED DOCUMENTATION AS SHOWN ON CHECKLIST
Memphis Homeowner Empowerment Loan (901 HELP) Program

Application for Home Repair Loan
PROPERTY INFORMATION

Single Family HomeCondominium
Condominium

MortgageDuplexFree and ClearRoof
I have lived at this address for
years
years
months

HELOCHVACLand ContractPlumbingElectrical
Do you have homeowners insurance?

Porch/MasonryYesAccessibility ImprovementsN/AFoundationDoors/WindowsN/AStanding Water/SewageUnsureBathroom/KitchenLead Paint Hazards
Are City property taxes current?
Yes

YesYesYesYesYes
Yes

NoNoNoNoNoNo
If no, are you on a payment plan?

Are County property taxes current?

If no, are you on a payment plan?
City
City
State
Zip
# in Household
APPLICANT INFORMATION
Telephone Number
Telephone Number
Alternate Telephone Number
Alternate Telephone Number
Email Address
example@example.com
Single
Single
Married Divorced
Widowed
CO-APPLICANT INFORMATION
Social Security Number
Telephone Number
Telephone Number
Alternate Telephone Number
Alternate Telephone Number
How did you hear about this program?
How did you hear about this program?
Have you previously received a home repair loan/grant through the City of Memphis Division of Housing & Community
NO ☐ YES If yes, year
Amount
HOUSING PAYMENTS (Complete if Mortgage or Land Contract Present)
Balance of Mortgage or Land Contract
Payments Made To
Monthly Mortgage Payment/Land Contract Amount
Conflict of Interest
Date Application Received By United Housing, Inc.

Approval / Denial Date (circle one)
ANNUAL GROSS HOUSEHOLD INCOME VERIFICATION CHECKLIST
Please complete an income verification form for each household member 18 years of age and older. Please indicate the
total gross monthly income from all sources:
Source of Income
Amount Received Monthly
Applicant
Co-Applicant
Employment (Gross Wages and Salary)

Social Security or SSI Benefits

Payments from Trusts, Annuities, or Inheritance

Retirement Accounts, Funds or Pensions

Savings Account or Checking Account

Other (Parents/Relatives, Education Grant or Scholarship, Lottery

Winnings, Inheritance, Insurance, Interest/Dividends etc
Total
DECLARATIONS
APPLICANT YESNO

Are you a party to a lawsuit?

	APPLICANT YESNO	-	CO-APPLICANT YESNO	-
Are there outstanding judgements against you?
Have you declared bankruptcy in the past 7 years?
Have you had any property foreclosed or given title or deed in lieu within 7 years?
Are you presently delinquent on any federal or state debt student loan, income tax,
etc?
Is this property in probate?

INFORMATION FOR GOVERNMENT MONITORING PURPOSES
The following information is requested by the U.S. Department of Housing and Urban Development (HUD) for certain types of loans related to a dwelling in order to monitor the lender’s compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information but are encouraged to do so. The law provides that a lender may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual observation and surname if you have this application in person. If you do not wish to furnish the information, please check the box below.
Applicant:
I do not wish to furnish this information

Applicant:Co-Applicant:
Co-Applicant:
I do not wish to furnish this information
Ethnicity

Hispanic or LatinoNot Hispanic or Latino Ethnicity:Hispanic or LatinoNot Hispanic or Latino
Not Hispanic or Latino Ethnicity:
Racial group (You may voluntarily select one or more)

Black/African American
Racial group (You may voluntarily select one or more)

Asian
Racial group (You may voluntarily select one or more)

American Indian/Alaskan Native
Racial group (You may voluntarily select one or more)

Black/African American
Racial group (You may voluntarily select one or more)

Asian
Racial group (You may voluntarily select one or more)

American Indian/Alaskan Native
Racial group (You may voluntarily select one or more)

White
Black/African American
Black/African American
Asian
Asian
American Indian/Alaskan Native
American Indian/Alaskan Native
White
White

Native Hawaiian/Other Pacific IslanderNative Hawaiian/Other Pacific IslanderWhiteOther Multi-Racial
White
Check all that apply
Check all that apply

Female Head of Household
Check all that apply

Disabled
Check all that apply

Child Under 6
Check all that apply

Veteran
Check all that apply
Check all that apply

Female Head of Household
Check all that apply

Disabled
Check all that apply

Child under 6
Check all that apply

Veteran
Female Head of Household
Female Head of Household
Disabled
Disabled
Child Under 6
Child under 6
Veteran
Veteran
Conflict of Interest Are you or an immediate family member or a business associate now or any time in the past 12 months of an employee, agent, consultant, contractor, elected or appointed official of the City of Memphis (CITY), Local Initiatives Support
NO

Corporation (LISC), or United Housing, Inc. (UHI)?YES
Authorization to Release Information The Applicant(s) gives permission to United Housing Inc. (UHI) to release the Memphis Homeowner Empowerment Loan Program Application and supporting documentation to Shelby County/CITY/LISC Memphis for the purposes of: 1) Obtaining a credit report in my name; 2) Verifying my income, asset and employment information; and 3) Verifying any and all other information necessary to establish the Applicant(s) eligibility to receive assistance through the Memphis Homeowner Empowerment Loan Program or other applicable programs. The Applicant(s) understand that the information obtained will remain confidential and will be used solely for the purpose of determining eligibility to receive home repair assistance.

Notice of Non-Discrimination The CITY/LISC/UHI does not discriminate on the basis of race, color, creed, national origin, age, handicap, sex or sexual orientation, marital status and familial status. Complaints may be filed with Patricia Lane, City of Memphis, Division of Housing and Community Development, 170 N Main St, Memphis, TN 38103.

Income and Credit Verification The Applicant(s) authorizes LISC/UHI to make inquiries to verify the accuracy of the statements made and to determine creditworthiness of the applicant. The Applicant(s) authorize LISC/UHI to obtain a consumer credit report through a credit reporting company chosen by UHI. The Applicant(s) understand and agree that LISC/ UHI intended to use this consumer credit reportfor purposes of evaluating my/our financial readiness to secure a Low-Interest Home Repair Loan. The Applicant(s) understand that this credit report will be retained on file at UHI’s offices and that the information will not be disclosed to anyone without my prior written consent.

I understand that if any falsification on this form results in the amount of my home repair loan being ruled as an ineligible cost by the U.S. Department of Housing and Urban Development, I agree to pay the CITY/LISC immediately upon demand, the amount of any such ineligible cost.
Penalty for False or Fraudulent Statement U.S.C. Title 18, Sec. 1001, provides: “Whosever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies or make any false, contain any false, fictitious or fraudulent statements or representation, makes or uses any false writing response or document 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 five years, or both.” The undersigned certifies under penalty of law that all statements made in this application form and supporting documents are true and accurate, correct and complete. If any of the information provided by the Applicant(s) is untrue, inaccurate or incomplete, regardless of when this is discovered by the CITY/LISC, the CITY may, in its sole discretion, immediately terminate the Applicant(s) participation in the Memphis Homeowner Empowerment Loan Program Application without liability.

Clear
Penalty for False or Fraudulent Statement U.S.C. Title 18, Sec. 1001, provides: “Whosever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies or make any false, contain any false, fictitious or fraudulent statements or representation, makes or uses any false writing response or document 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 five years, or both.” The undersigned certifies under penalty of law that all statements made in this application form and supporting documents are true and accurate, correct and complete. If any of the information provided by the Applicant(s) is untrue, inaccurate or incomplete, regardless of when this is discovered by the CITY/LISC, the CITY may, in its sole discretion, immediately terminate the Applicant(s) participation in the Memphis Homeowner Empowerment Loan Program Application without liability.

Clear
Applicant’s Signature
Co-Applicant’s Signature

PLEASE COMPLETE FOR ALL HOUSEHOLD OCCUPANTS INCLUDING ALL CHILDREN IN THE HOME

	-	-	-
Visiting Child Name

Is this person Tested pregnant?

	Occupant Name	Date of Birth	Income	Full time Student?

Blood Lead Level
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N

Visiting Child Name

	-	-	-	-

Visiting Child Name

	-	-	-	-

Visiting Child Name

	-	-	-	-

Visiting Child Name

	-	-	-	-

Visiting Child Name

	-	-	-	-

Visiting Child Name
How long does the child visit?

Hours

	-	day?	week?	year?

Hours
DOCUMENTATION CHECKLIST
Once you have completed the application, and gathered the required documentation as described on the documentation checklist, submit to United Housing (UHI You can reach UHI at 901-272-1122 or LISC@uhinc.org.
- Current driver’s license or State ID card
- Passport
• United States of America birth certificate • Naturalization papers • Alien registration card/Green card

Photo identification for each member of the household 18 and overProof of citizenship or resident alien status documentsMust show ownership for at least twelve (12) months at the time of application
- Recorded Deed, Warranty Deed, Quit Claim Deed or Land Contract (Warranty Deeds must accompany all recorded Quit Claim Deeds)
- Death and Marriage Certificates must be provided, if applicable
- Probate documents or Divorce Decree must be provided, if applicable.
- Copy of your divorce decree or certified court documents if your former spouse is listed on the
deed/tax record.

Copy of current, paid property tax bill (city or county) or
- Approved payment plan with the Shelby County Trustee’s Office and/or the City of Memphis Treasurer, with evidence that the payment plan is currently up-to-date in accordance with the agreed upon terms of the plan
class mail addressed and received within last 2 weeks

Copy of current utility bill or merchant’s statement Credit card bills, delivery notices or other firstCurrent Mortgage Statement, if applicableCopy of current homeowner’s insurance or a homeowner’s insurance quoteProof of Income and signed income affidavit submit for each member of the household 18 years and
over) (Submit all applicable documents) o Copy of 2 most recent months’ paycheck stubs o 2 years federal tax returns or transcripts o 2 years W-2s o 2 months bank statements o Other items such as Social Security Award Letters, Pension Statements, TN DHS Benefit Letter, etc. OR o Zero Income Affidavit signed, dated and notarized for each non-working householder over 18 years o Self-employed applicants must submit: Two years tax returns with Schedule C showing amount earned Two months bank statements A notarized profit & loss statement for 12 months
Should be Empty:

PLEASE COMPLETE APPLICATION IN FULL AND SUBMIT ALL REQUIRED DOCUMENTATION AS SHOWN ON CHECKLIST

APPLICANT INFORMATION

CO-APPLICANT INFORMATION

HOUSING PAYMENTS (Complete if Mortgage or Land Contract Present)

ANNUAL GROSS HOUSEHOLD INCOME VERIFICATION CHECKLIST

Amount Received Monthly

DECLARATIONS

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

Applicant:

Co-Applicant:

DOCUMENTATION CHECKLIST