901 Help: LISC repair application

Memphis Homeowner Empowerment Loan (901 HELP) Program

Application for Home Repair Loan

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

How did you hear about this loan product?

Property Information

The property I'm applying to repair is a:

Single family homeCondominiumDuplex

I have lived at this address for NUMBER years orNUMBER months.

How is the home financed?

MortgageHELOCLand ContractFree and Clear (owned outright)

Balance of Mortgage

Balance of HELOC

Balance of Land Contract

Payments Made To

Monthly Payment Amount

Do you have homeowners' insurance?

YesNo

Are your city property taxes current?

YesNo

Are you on a payment plan?

YesNo

Are your county property taxes current?

YesNo

Are you on a payment plan?

YesNo

Was your property built before 1978?

YesNoUnsure

How many people reside at this property?

Property address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Repair Information

What repairs are needed at the property? Choose up to three options.

Applicant Information

Name*

First NameLast Name

Social Security Number

Primary Phone Number*

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Who does the alternate phone number belong to?

Email Address*

example@example.com

Marital Status

SingleMarriedDivorcedWidowed

Have you previously received a home repair loan/grant through the City of Memphis Division of Housing & Community Development?

YesNo

In what year did you receive a home repair loan/grant through the City of Memphis Division of Housing & Community Development?

What was the amount of your previous home repair loan/grant through the City of Memphis Division of Housing & Community Development?

Co-Applicant Information

Name

First NameLast Name

Social Security Number

Primary Phone Number

Please enter a valid phone number.

Alternate Phone Number

Please enter a valid phone number.

Who does the alternate phone number belong to?

Email Address

example@example.com

Annual Gross Household Income Verification Checklist

Please complete income verification information for each household member 18 years of age or older.

Sources of Income – Outline the amount received monthly for each adult living in the household from the sources below.

	Applicant	Co-Applicant	Additional Adult Resident	Additional Adult Resident
Employment (Gross Wages and Salary)
Self-Employment
Worker's Compensation
Veteran's Benefits
Disability or Death Benefits
Social Security or SSI Benefits
Public Assistance
Child Support and/or Alimony
Payments from Trusts, Annuities or Inheritance
Retirement Accounts, Funds or Pensions
Rental Income
Savings Account or Checking Account
Stocks/Bonds
Other (Parents/Relatives, Education Grant or Scholarship, Lottery Winnings, Insurance, Interest/Dividends, etc.)

Indicate the total gross monthly income by adding all of the above sources.

Declarations

Please answer each question for both the applicant and co-applicant.

	Applicant	Co-Applicant
Are there any 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 party to any lawsuit?
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.

	Ethnicity	Racial Group	Female Head of Household	Disabled	Child under 6	Veteran	I do not wish to furnish this information.
Applicant
Co-Applicant

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 SupportCorporation (LISC), or United Housing, Inc. (UHI)?

YesNo

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.

Applicant Signature

Date

Co-Applicant Signature

Date

Household Occupant Information

Please complete this table for all full-time household occupants, including all children in the home. There is an additional table for visiting children who do not live in the home full time.

Household Occupants*

	Name	Date of Birth	Income	Full-Time Student	Is this person pregnant?	Has this person been tested for lead?	Date of Lead Test	Blood Lead Level
Occupant 1
Occupant 2
Occupant 3
Occupant 4
Occupant 5
Occupant 6

Visiting Child Information

	Name	Date of Birth	Income	Full-Time Student	Is this person pregnant?	How many hours per day does this child spend in the home?	How many days per week does this child spend in the home?	How many weeks per year does this child spend in the home?
Occupant 1
Occupant 2
Occupant 3
Occupant 4
Occupant 5
Occupant 6

Supporting Documents

You have completed the application and now need to provide documents to support your applciation. The following section will prompt you to submit the following:

Photo identification for each member of the household 18 and over
- Current driver’s license or State ID card
- Passport
Proof of citizenship or resident alien status documents
- United States of America birth certificate
- Naturalization papers
- Alien registration card/Green card
Must 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 and 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
Copy of current utility bill or merchant’s statement (Credit card bills, delivery notices or other first class mail addressed and received within last 2 weeks)
Current Mortgage Statement, if applicable
Copy of current homeowner’s insurance or a homeowner’s insurance quote
Proof of Income or signed income affidavit (submit for each member of the household 18 years and over)
All applicable income documents, including:
- Copy of 2 most recent months’ paycheck stubs
- 2 years federal tax returns or transcripts
- 2 years W-2s
- 2 months bank statements
- Other items such as Social Security Award Letters, Pension Statements, TN DHS Benefit Letter, etc. OR
- Zero Income Affidavit signed, dated and notarized for each non-working householder over 18 years
- 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 monthsAfter you've updated supporting documents, you can submit your application to United Housing (UHI) and LISC by selecting the "submit" button below. You will receive an email copy of your application.

If you do not have access to all of the documents outlined above, have trouble uploading, or need clarification on documentation, proceed with submitting and the UHI team will provide support.

You can reach UHI at 901-272-1122 or LISC@uhinc.org.

Photo identification

You can upload all needed images in this one submission field.

Citizenship documentation