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SOUTH BEND LEAD PROTECTION PROGRAM APPLICATION
Primary Applicant Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Check all that apply:
*
Male
Female
Married
Unmarried
Separated
Handicapped
Owner-Occupant
Renter
Second Applicant Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Check all that apply:
Male
Female
Married
Unmarried
Separated
Handicapped
Owner-Occupant
Renter
Does a child under the age of 6 live in or frequently visit the home?
*
Yes
No
How many individuals reside in the home, including applicant(s)?
*
Does the property have a current citation issued by Neighborhood Services and Enforcement?
*
Yes
No
Is it under a demolition order?
*
Yes
No
Are the property taxes current on your home?
*
Yes
No
What year was your home built?
*
How many total rooms are in the home? (Do not include bathrooms)
*
Family Residence
*
Please Select
Single-Family
Duplex
Multi-Family
Do you have homeowner's Insurance?
*
Yes
No
How did you hear about the Department of Community Investment and the South Bend Indiana Lead Protection Program?
City of South Bend Website
St. Joseph County Health Department
Neighborhood Group
Television
Facebook Ad
Friend/Family
Newspaper
Community Event
Other
Income Eligibility
You must make under the average median income for your household size
Please provide the following documents to complete income verification and your application. Check off what applies to your application.
*
Submit the income information here, if you would prefer to email them, please email them to dbautista-amick@southbendin.gov
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Applicant Demographics
THE FOLLOWING INFORMATION IS FOR GOVERNMENT MONITORING PURPOSES ONLY. (Data is not used to determine eligibility) Please select all that apply.
Ethnicity
Race
The applicant (s) certifies that all information given in this application and all information furnished in support of this application is given for the purpose of obtaining housing rehabilitation assistance through the City of South Bend Indiana Lead Protection Program. Furthermore, all of the information is true and complete to the best of the applicant (s)knowledge. Penalty for false or fraudulent statement U.S.C. Title 18, section 1001 provides: “Whoever in any matter within jurisdiction of any department or agency of the United States knowingly and willfully falsifies or makes false fictitious or fraudulent statements or representations or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined no more than$10,000.00, or imprisoned not more than five (5) years or both.”
APPLICANT’S CERTIFICATION AND AUTHORIZATION
The Undersigned Certify the Following: 1. I/We have applied for a grant from the City of South Bend, Department of Community Investment related to address lead hazards in our home. 2. I/We have completed an application for the purpose of receiving assistance which includes the amount and source of household income, assets and liabilities. 3. I/We understand and agree that the Department of Community Investment will need to secure and verify documents supporting employment and income and funds in order to approve my/our request for assistance. 4. I/We agree to supply the Department of Community Investment all information requested and give them authorization to verify all information contained in my/our application or any other documents required in connection with this program. 5. I/We hereby authorize and instruct the Department of Community Investment to obtain any and all information concerning my/our employment, checking/saving accounts which may be required to assess my/our application for benefits from this grant program. 6. I/We agree that this information may be reproduced or photocopied, and a copy shall be effective consent as the original signed form. 7. Applicant (s) agrees not to allow the premises to be used as a site for any illegal use or sale of drugs or other controlled substances. Any such event by the applicant or members of the applicant’s family or guests will be an event of default under this application causing the City to cease processing or work on the applicant’s home improvement project.
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Signature
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