URGENT HOME REPAIRS PROGRAM: APPLICATION FOR ASSISTANCE

Required Documentation:

1. Identification of Applicant (e.g. Driver's License, Social Security Card)

2. Proof of Income for All Recipients (e.g. pay stubs; Social Security, pension or retirement statements)

3. Proof of Property Ownership (a copy of recorded deed)

4. Proof of Residency (e.g. utility bill or State issued ID with address)

Who is completing the application?

Homeowner ApplicationTenant/Landlord

Occupant Name

PrefixFirst NameMiddle InitialLast Name

Head of Household Social Security #

Sex

MaleFemalePrefer Not to Say

Marital Status

SingleMarriedDivorcedWidowed

Race

Property Address

Mailing Address (if different from property address)

Year House was Built

Telephone #

Email Address

example@example.com

Total Number of People in Household

Occupant Income

	Name	Age	Relationship to HOH	Disabled?Yes/ No	Income	Source of Income
Head of Household
Resident 1
Resident 2
Resident 3
Resident 4
Resident 5

Do children less than 6 years old live/spend substantial time in the house?

YesNo

Total Household Income

I verify this income is correct

Identify Tornado Repair Assistance Received

	Received	Amount	Purpose
FEMA
USDA
SBA
Non- Profit
Other

Did an insurance claim pay for tornado damage on this property?

YesNo

If Yes, Explain.

Are there any pending requests, applications, or claims with FEMA, SBA, USDA, Non-profits, others, or insurance?

YesNo

If yes, please explain.

Please Upload Required Documentation

Certification:

1. I certify that the information I have provided is true and correct to the best of my knowledge. I hereby give my consent for the Selma Urgent Home Repair Program to verify the information I have given. I understand that I am subject to any applicable Federal or State Laws concerning fraud or knowingly providing false or incomplete information in order to obtain assistance.

2. I understand and agree to be bound and abide by the City of Selma Urgent Home Repairs Program Policies and Procedures. | understand | have the right to file a grievance as described in the Policies if I am dissatisfied with the processing of my application.

3. I hereby grant permission and authorize the City of Selma and its duly appointed agents, inspectors, and contractors to enter my residence to conduct inspections, take pictures, prepare estimates, and make repairs. Further, if I am approved for assistance under this program, I hereby grant permission and authorize the City of Selma to act on my behalf to bid the project, hire a contractor, inspect repairs, make payments and perform other functions as may be necessary to complete the repairs on my property. I hereby release and pledge to hold blameless the City of Selma and its duly appointed agents from any liability arising or eventually arising from the performance of the repair work related to this Program.

Assisted By:

Homeowner Signature

Date

City of Selma Community Development Block Grant Program (CDBG)