Heating System, Housing Rehab, Lead Paint Programs Application (FINAL)

Heating System, Housing Rehab, and Lead Paint Safe Somerville Program Application

City of Somerville Office of Strategic Planning and Community Development-Housing Division
About this Application
The City of Somerville is currently accepting applications to participate in the Heating System, Housing Rehab, and Lead Paint Safe Somerville Program ("the Programs"). This form consists of initial questions required for consideration of acceptance into the Programs.

This form is "Step 1" of the application process. Additional documentation will be required tocomplete the application. Your application will not be considered for eligibility unless steps 1and 2 are completed.

Step 1: Please complete this form in its entirety and click "submit." A staff member will contactyou to answer any questions and discuss next steps.

Step 2: Deliver additional required documentation to EITHER:

OSPCD-Housing Division ATTN: Andres Bueno (Lead Paint Safe Somerville), 93 Highland Avenue, Somerville, MA 02143.

OR

OSPCD-Housing Division ATTN: Ken Joyce (Heating System/Housing Rehab Program), 93 Highland Avenue, Somerville, MA 02143.

Please make an appointment to hand-deliver applications and materials by contacting 617-625-6600 ext. 2577. Leave a message with your name, phone number, and preferred drop off time. A staff member will respond.

Step 3: When we receive completed applications and all requested income documentation forall applicable units on the property, we will determine your eligibility and contact you with nextsteps.

Please note:
- All information provided will be treated condentially.
- Once submitted, you will have the option to print this form.
- If multiple units of a property are applying for the program, one application will need to becompleted per unit. All residents of that unit must provide applicable income documentation.
- A staff member will contact you within two (2) business days of receiving this form.
- Income limits are the same for the Heating System, Housing Rehab, and Lead Paint Safe Somerville programs.
- The Heating System program applies to the homeowner's unit only.
- The Lead Paint Safe Somerville and Housing Rehab program applications are based on the income of the occupants of the property. Tenants may qualify; however, tenants must have consent from the property owner to participate.
- Any work that begins before acceptance into the program is not eligible for retroactive funding or reimbursement.
- There are specific restrictions and conditions associated with all of our funding sources. Funding for our programs is limited. Funding will be available based on completeness of the application, City priorities, and income eligibility. For the Lead Paint Safe Somerville program, units with children under the age of six (6) and expectant mothers will be prioritized. Vacant units may also qualify for the program. Please contact 617-625-6600 ext. 2584 to discuss program requirements.
Questions? Contact the Housing Division at 617-625-6600 ext. 2577 or allhousingdivision@somervillema.gov.
First, let's make sure you qualify.

Please enter information for the unit of the property that is seeking funding. Owners, please note: tenants may qualify you for participation in the program. If you have nine or more persons in your unit, please contact program staff for income guidelines at 617-625-6600 ext. 2584 (leave a message).
How many people live in your household? *
What is the gross income of all members of your household? *
Based on your response, it looks like the estimated household income will likely qualify for the program. Please continue filling out this form.

This is not an official acceptance into the program. We will need to review the requested income documentation before an official determination is made.
Based on your response, the estimated household income will likely not qualify you for the program. Please call 617-625-6600 ext. 2584 for more information.

General Information
Today's Date *

Month Day Year
Your name *

First Name Last Name
Are you a tenant, homeowner, or an investor-owner? (Important: If you own the property but are not applying for your personal unit, or if you do not live on the property, please select "investor owner.") *
If you are a tenant, do you have consent from your landlord to participate in the program? *
If you are interested in participating in a program but do not have permission from your landlord and wish to be contacted by a City staff member with next steps, please complete the information below and submit the form. A City staff member will contact you within two (2) business days.
Please select which program you are applying for. Please note: only homeowners can apply to the Heating System Program. *

Heating System Replacement (Homeowners ONLY) Lead Paint Safe Somerville Program Somerville Rehab Program
Tenants cannot qualify fo the heating system program.
Applicants of the Lead Program are required to have received the pamphlet "Protect Your Family From Lead Paint in Your Home." Please click the links below to obtain a copy. Once you have read the pamphlet, please check the box below.
- English
- Spanish
- Arabic
- Russian
- Somali
- Vietnamese
This pamphlet is also available in hard copy at the Housing Environment Office during normal business hours. If you have any questions, please contact 617-625-6600 ext. 2584.
Why are you (most) interested in this program? *

Improving health and safety of occupants Receiving a letter of compliance Receiving a tax credit Creating an affordable housing opportunity Complying with lead laws for children under six
How did you hear about this program? *
Address seeking funding *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Units seeking funding *
Example: Unit#1, #2, and #4
Number of units seeking funding *
Example: 3
Do you also live at the residence? *
Are you applying for your unit? *
Year home built (yyyy) *
Unsure? Applicants can go to the Assessor’s Database to access this information. Please note only homes constructed before 1978 may participate in the Lead Paint Safe Somerville Program.
Is your property held in a trust or an LLC? *
Name of trustee or managing member (if different than above)

First Name Last Name
First owner of property listed on deed *

First Name Last Name
Second owner of property listed on deed

First Name Last Name
Main contact name (if different than above)

First Name Last Name
Spouse's name (if different than above)

First Name Last Name
Mailing address (if different than above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best phone number to reach you *

Area Code Phone Number
Alternate phone number

Area Code Phone Number
Best e-mail to reach you *
Are there any outstanding judgments or liens on the property? *
Please explain.
Have you accessed funding through the City before? *
Please provide contact information for all household occupants below and a City staff member will reach out with instructions on how to apply for the program. (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.) *

Homeowner Application

Additional Required Information

Asset Information
Is any member of your household employed? *
Employment Information: Please complete the table below with part-time and full-time information for all household occupants, including tenants. (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Is any member of your household self-employed? *
Please complete the Self Employment Statement and have it notarized. You may schedule an appointment with City staff to have it notarized at 617-625-6600 ext. 2584. The City can provide a notary. The City can also provide a hard copy of the form if the applicant does not have access to a printer.
Is any member of your household that is over 18 and is not employed? *
Please fill out the No Income Statement and have it notarized. You may schedule an appointment with City staff to have it notarized at 617-625-6600 ext. 2584. The City can provide a notary. The City can also provide a hard copy of the form if the applicant does not have access to a printer.
Does any member of your household receive alimony or child support? *
Please provide proof of any child support received (copy of custody agreement, letter from the Department of Revenue, or other official documentation).
Does any member of your household collect unemployment benefits? *
Does any member of your household receive income from a pension or annuity? *
Does any member of your household receive regular income from anyone not living in the household or any agency? *
Is any member of your household the beneficiary of a Trust? *
Does any member of your household receive income from assets including interest on checking, savings accounts, on dividends from certificates of deposits, stocks, or bonds? *
Estimated value of marketable securities (stocks and bonds) ($)
In the table below please list all checking and savings accounts for all household members. (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
If you do not have a bank account, please complete the No Bank Account Statement and have it notarized. You may call 617-625-6600 ext. 2584 to schedule an appointment to have the form notarized. The City can provide a notary. The City can also provide a hard copy of the statement if you do not have access to a printer.
Fixed Income Information

Please list sources of fixed income for all household occupants below. If you do not receive income from a source below, please leave the table blank.
Does any member of your household receive Aid to Families with Dependent Children (AFDC), Supplemental Security Income (SSI), Emergency Aid to the Elderly, Disabled, and Children (EAEDC), Veterans Affairs (VA) Compensation, or Social Security Benefits? *
Retirement Income (Pension) or Disability Award (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Social Security Income (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Veterans Assistance (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Public Assistance (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Unemployment Award (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Student Information

In the table below, please list household members over 18 considered to be full-time students. If this does not describe anyone in your household, please leave the table blank.
Student Information (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Rental Income Information
Does any member of your household receive income from a rental property? *
Please complete the tables below.
Apartment Information (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Please list other rental income including rent received from garage parking spaces and any other rental property. (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)
Total value of other rental income ($)
Add subtotals of above table.
Occupant Information
Are any household members pregnant with a child that is anticipated to live in the current residence? *
Are there currently any children under six (6) residing in the building? And, are there any children that spend at least three (3) hours a day on two separate days a week and a total of 60 hours per year in one or more units? *
Please complete the table below. (Note: Even if you are only filling in one row, you MUST select "save and add row" to save your response and continue.)

Homeowners: Representations and Certifications

Lead Paint Safe Somerville Program
The undersigned hereby represents and certifies under the pains and penalties of perjury respective to the Property located at: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
A. Conflict of Interest: Is the owner or any member of his or her immediate family or any business associate employed by the City of Somerville? *

Yes No
If "yes," please explain:
B. Declaration of Other Real Estate Owned: Are you an owner or part-owner of any other real estate in the City of Somerville? *

Yes No
If "yes," please list address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
C. Tax Contribution Compliance

The owner is in full compliance with all laws of the Commonwealth of Massachusetts and ordinances of the City of Somerville relating to taxes and to contributions and payments in lieu of contributions.

D. Non-Discrimination Compliance

The undersigned agrees that there will be no discrimination on the basis of race, color, national origin, ancestry, age, sex, religion, disability, sexual orientation, presence of children, marital status, source of income or military status, in the sale, lease, rental use, advertisement or occupancy of the property that is rehabilitated with funds provided by the Somerville Office of Strategic Planning and Community Development ("OSPCD"). Regulations issued by the United States Department of Housing and Urban Development and the Massachusetts Commission Against Discrimination pursuant to Title VII of the Civil Rights Act of 1968 and the Massachusetts General Law, Chapter 151B, Section 4, shall apply.

E. Owners’ Permission to Enter and Inspect

I/We hereby give my/our permission for the employees of the City of Somerville OSPCD to inspect my property including conducting heating system analysis as a condition of applying for assistance through OSPCD Housing Program. Further, I/We relieve the City of Somerville, its employees and/or agents from any and all claims of damages or liability arising from the performance of property inspections by the City of Somerville’s OSPCD.

F. Lead Paint Hazards in Accordance with 24 CFR 35.

I/We owners of the property certify that OSPCD has provided the DISCLOSURE NOTIFICATION pamphlet; Protect Your Family from Lead in Your Home. I/We have been made aware of the hazards of lead that may affect the occupants of the property for which we are seeking assistance. I/We understand that as a condition of receiving assistance, I/we will be required to include Lead Hazard Reduction Activities that employ Safe Work Practices as part of the total rehabilitation project. Further, I/we have been made aware of my/our disclosure, protection and relocation rights and responsibilities.

G. Certification

I/We certify that, under penalty of perjury, all information on this application to the best of my/our knowledge is true. I/We understand that false information given is sufficient grounds for rejection of this application. Furthermore, verification may be obtained from any source herein.

Penalty for False and Fraudulent Statement, U.S.C.

“Title 18, Section 1001, provides: ‘Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies…or makes any 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 statements or entry, shall be fined not more than $10,000 or imprisoned not more than five (5) years or both.’”

Applicant’s Right to Appeal

If you believe that you have been discriminated against regarding any decision made on this application because of race, color, national origin, ancestry, age, sex, religion, disability, sexual orientation, the presence of children, or marital status, you may appeal that decision.

Additionally, if you feel you have been wrongfully denied assistance for any reason, you may appeal that decision. Appeals must be made within 15 days of receiving the denial letter. All appeals must be sent in writing to Housing Director, City of Somerville, OSPCD, 50 Evergreen Avenue, Somerville, MA 02145.
Homeowner: Please sign and date the application. Click and hold inside the box below to add a signature. All persons on the deed will be required to submit their signatures at a future date. *

Clear
Your Name: *

First Name Last Name

Homeowners: Representations and Certifications

Heating System and Rehab Programs
The undersigned hereby represents and certifies under the pains and penalties of perjury respective to the Property located at: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
A. Conflict of Interest: Is the owner or any member of his or her immediate family or any business associate employed by the City of Somerville? *

Yes No
If "yes," please explain:
B. Declaration of Other Real Estate Owned: Are you an owner or part-owner of any other real estate in the City of Somerville? *

Yes No
If "yes," please list address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
For purposes of accessing HUD funding: Are you a legal U.S. resident? *

Yes No
Please check which status applies: *

U.S. Citizen Permanent Resident Qualified Alien under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 ("PRWORA"). Qualified Alien under PRWORA S.431: (1) Alien lawfully admitted for permanent residence under the Immigration and Nationality Act ("INA"), 9 USC 1101 et. seq.: (2) Refugees admitted under S.207 of the INA; (3) Aliens granted asylum under S.208 of the INA; (4) Cubans and Haitian Entrants, as defined in S.501(e) of the Refugee Education Assistance Act of 1980; (5) Aliens granted parole for at least one (1) year under S.212(d)(5) of the INA; (6) Aliens whose deportation is being withheld under (1)S.243(h) of the INA in effect prior to April 1, 1997 or (2)S.241(b)(3) of the INA, as amended; (7) Aliens granted conditional entry under S.203(a)(7) of the INA in effect before April 1, 1980; (8) battered aliens who meet the conditions set forth in S.431(c) of the PRWORA as amended; Victims of a serve form of trafficking in accordance with S.107(b)(1) of Trafficking Victims Protection Act of 2000, P.L. 106-386.
C. Tax Contribution Compliance

The owner is in full compliance with all laws of the Commonwealth of Massachusetts and ordinances of the City of Somerville relating to taxes and to contributions and payments in lieu of contributions.

D. Non-Discrimination Compliance

The undersigned agrees that there will be no discrimination on the basis of race, color, national origin, ancestry, age, sex, religion, disability, sexual orientation, presence of children, marital status, source of income or military status, in the sale, lease, rental use, advertisement or occupancy of the property that is rehabilitated with funds provided by the Somerville Office of Strategic Planning and Community Development (OSPCD). Regulations issued by the United States Department of Housing and Urban Development and the Massachusetts Commission Against Discrimination pursuant to Title VII of the Civil Rights Act of 1968 and the Massachusetts General Law, Chapter 151B, Section 4, shall apply.

E. Owners’ Permission to Enter and Inspect

I/We hereby give my/our permission for the employees of the City of Somerville OSPCD to inspect my property including conducting heating system analysis as a condition of applying for assistance through OSPCD Housing Program. Further, I/We relieve the City of Somerville, its employees and/or agents from any and all claims of damages or liability arising from the performance of property inspections by the City of Somerville OSPCD.

F. Lead Paint Hazards in Accordance with 24 CFR 35.

I/We owners of the property certify that OSPCD has provided the DISCLOSURE NOTIFICATION pamphlet; Protect Your Family from Lead in Your Home. I/We have been made aware of the hazards of lead that may affect the occupants of the property for which we are seeking assistance. I/We understand that as a condition of receiving assistance, I/we will be required to include Lead Hazard Reduction Activities that employ Safe Work Practices as part of the total rehabilitation project. Further, I/we have been made aware of my/our disclosure, protection and relocation rights and responsibilities.

G. Certification

I/We certify that, under penalty of perjury, all information on this application to the best of my/our knowledge is true. I/We understand that false information given is sufficient grounds for rejection of this application. Furthermore, verification may be obtained from any source herein.

Penalty for False and Fraudulent Statement, U.S.C.

“Title 18, Section 1001, provides: ‘Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies…or makes any 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 statements or entry, shall be fined not more than $10,000 or imprisoned not more than five (5) years or both,’”

Applicant’s Right to Appeal

If you believe that you have been discriminated against regarding any decision made on this application because of race, color, national origin, ancestry, age, sex, religion, disability, sexual orientation, the presence of children, or marital status, you may appeal that decision.

Additionally, if you feel you have been wrongfully denied assistance for any reason, you may appeal that decision. Appeals must be made within 15 days of receiving the denial letter. All appeals must be sent in writing to Housing Director, City of Somerville, OSPCD, 50 Evergreen Avenue, Somerville, MA 02145.
Homeowner: Please sign and date the application. Click and hold inside the box below to add a signature. All persons on the deed will be required to submit their signatures at a future date. *

Clear
Your Name: *

First Name Last Name

Please click submit to finalize your application.
Name

First Name Last Name
Should be Empty:

Heating System, Housing Rehab, and Lead Paint Safe Somerville Program Application

About this Application

First, let's make sure you qualify.

General Information

Tenant Application: Additional Required Information

Tenant Certification

GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION

Homeowner Application

Asset Information

Fixed Income Information

Student Information

Rental Income Information

Occupant Information

Homeowners: Representations and Certifications

Homeowners: Representations and Certifications

Tenant Statistical Information

Homeowner Statistical Information

Investor-Owner Application: Additional Information

Representations and Certifications of the Property Owners

Statistical Information