City of Sugar Hill A n: Kaipo Awana 5039 West Broad Street Sugar Hill, GA 30518

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1 This summer, the World Changers Organiza on, Sugar Hill Housing Authority and City of Sugar Hill, are teaming up for our annual community development program. About 200 youth and young adult volunteers from all over the country have paid their own way to par cipate in a large scale service project pain ng homes, fixing porches, building handicap ramps and doing other minor exterior home repairs over three days for qualified Sugar Hill homeowners. The Sugar Hill Housing Authority generously provides funding for materials. The City provides administra ve support. World Changers brings the volunteer labor. Each work group will have a senior advisor and professional construc on managers will be monitoring all work. The enclosed applica on must be completed and returned to the City as soon as possible for your home to be considered for the program this summer. If you have any ques ons, or need help with the form please contact me directly. Kaipo Awana, Planning Director (770) , Ext Mail or hand deliver your completed applica on to: City of Sugar Hill A n: Kaipo Awana

2 APPLICATION FORM - WORLD CHANGERS HOME REPAIR ASSISTANCE PROGRAM 2015 THE CITY OF SUGAR HILL Applicant: Address: Daytime Phone: Evening Phone: Date of Birth: U.S. Citizen Yes No If you answered yes, check proof of Citizenship: Birth Certificate Passport Naturalization/Citizenship Certificate Legal Resident A# (If legal resident provide alien number) Are you a resident of Sugar Hill and the owner of the property? Yes No How long have you owned this property? Do you have a mortgage on the property? Property Taxes Name on Property Tax Bill: Annual Tax Amount: Are Taxes Current? Yes No Employment Owner Spouse/Co-Owner Present Employer: Address: Phone Number: Position: How Long Names and ages of all persons living in the dwelling:

3 Please list all sources of income for everyone 18 and older. You must submit proof of income for each. Name Type of Income Amount Monthly/Annually General Description of Home Improvements you are requesting: Homeowners Insurance or Fire Insurance Insurance Company: Amount of Coverage: Agent Name: Address: Phone: Policy Number: Expiration Date of Policy Are Premiums current? Yes No AGREEMENT I/We. The undersigned, hereby certify that the above statements are correct and accurate at the time of execution of this application. I/We understand that any persons giving false information will be subject to a prosecution and penalty for perjury. It is hereby acknowledged that a minimum Housing Code inspection is required before I/We receive approval for a repair grant and that additional inspections and photographs may be required to determine cost estimates of eligible repairs. I/We agree to notify the Program in writing of any material change in my/our financial condition or circumstances. I/We will not sell my home for a minimum of 1 year from the date of last service. I/We also authorize the Housing Authority of the City of Sugar Hill, Georgia to confirm the above information by securing verification of income from the issuing sources and/or employers, and verification of ownership from title reports or motor vehicle ownership records. I/We agree to complete and submit a Citizenship Status Affidavit and to authorize the Housing Authority of Sugar Hill, Georgia to confirm my/our immigration status as required by Georgia law. Signature: Date:

4 APPLICATION FORM HOME REPAIR ASSISTANCE PROGRAM THE CITY OF SUGAR HILL Questions? Contact Kaipo Awana at City Hall Only COMPLETED Applications will be Accepted Did you include the following items? GRANT APPLICATION CHECKLIST Application - Completed and signed. S.A.V.E Affidavit Completed, signed and notarized. City staff are available to notarize the form for you. Please wait to sign until the notary public can personally witness your signature. At least one secure and verifiable document, as required by O.C.G.A (e)(1) to accompany SAVE form. Such as a valid driver s license. Copy of most recently filed federal tax return, including all attachments and schedules. Copy of W-2 form or other current proof of income including, but not limited to copies of past two month s pay stubs from all income sources (including checks or award letters for social security, SDI, general assistance, etc.) Copy of written verification of your disability (if applicable) To verify home ownership submit a copy of the Deed or Property Tax Bill. This application will not be processed until all documentation is received. Information is confidential and is submitted for the sole purpose of qualifying for this program.

5 O.C.G.A (e)(2) SAVE Affidavit By executing this affidavit under oath, as an applicant for a City of Sugar Hill, Georgia Business License or Occupation Tax Certificate, Alcohol License, Taxi Permit or other public benefit as referenced in O.C.G.A , from City of Sugar Hill, the undersigned applicant verifies one of the following with respect to my application for a public benefit: 1) I am a United States citizen. 2) I am a legal permanent resident of the United States. 3) I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency. My alien number issued by the Department of Homeland Security or other federal immigration agency is:. The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A (e)(1), with this affidavit. The secure and verifiable document provided with this affidavit can best be classified as:. In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A , and face criminal penalties as allowed by such criminal Statute. Executed in (City), (State). SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF, 20. Signature of Applicant Printed Name of Applicant NOTARY PUBLIC My Commission Expires: