Housing Rehabilitation and Emergency Repair Grant Application

Housing Rehabilitation and Emergency Repair Grant Application
Applicant's Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Age*
Co-Applicant's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Number of person(s) in household; including applicant*

Provide name, age, and relationships(s) of all household members: *

Rows	Name	Age	Relationship
Self
2nd Member
3rd Member
4th Member
5th Member

Additional household members

You have the option to upload additional documents that are needed to qualify you below. Please note that we have a long waitlist and you maybe required to submit updated documents again.
Most recent utility bill

Cancelof
Current recorded deed

Cancelof
Receipt of paid property and school tax

Cancelof
Mortgage statement

Cancelof
Proof of homeowners insurance

Cancelof
Drivers license

Cancelof
Last 2 months of income

Cancelof
3 most current bank statements

Cancelof

If there are children in the home, have any of these children been identified as having elevated lead blood levels?*

YesNo
Do you have any current open building permits on your property?*

YesNo
Have you previously done work or renovations on your home?*

YesNo
If yes, have you obtained a CO with your local code enforcement officer to approve and sign off on this work?

YesNo
Date of Work

MonthDayYear
Date
Date of CO

MonthDayYear
Date
Work Performed
All information provided will be kept confidential. All applications received will become the property of North Country Rural Development Coalition (NRDC). I (We) hereby apply for assistance from NRDC. I (We) certify that the above statements are true, accurate, and complete to the best of my (our) knowledge and belief. False statements made knowingly by the applicant will disqualify the applicant from participating in the program. I (We) hereby consent to and authorize NRDC to obtain verification of information required for compliance with the regulations of this program, including income, expenses and employment.
Applicant's Signature *

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Co-Applicant's Signature

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AUTHORIZATION TO SHARE/RELEASE INFORMATION: I am applying for, or seeking to obtain, a loan or grant from North Country Rural Development Coalition. As part of this process, NRDC may share information contained in my request for assistance and the documents required for eligibility in connection with other area agencies for the purpose of collaborating funds. I understand any rights which I (we) may have to the contrary, pursuant to the privacy act, are hereby expressly waived for this purpose.
Applicant's Signature *

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Co-Applicant's Signature

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Should be Empty:

Rows	Agency Name	Grant Type	Amount	Date
First
Second
Third
Fourth

Rows	Name	Source	Gross Amount	Frequency
First
Second
Third
Fourth
Fifth

Housing Rehabilitation and Emergency Repair Grant Application

Statistical Data

Applicant

Co-Applicant