Dear Homeowner: Thank you for your interest in The Opportunity Alliance Home Repair Network. The first step is to determine if you pre-qualify.

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1 Dear Homeowner: Thank you for your interest in The Opportunity Alliance Home Repair Network. The first step is to determine if you pre-qualify. On the subsequent pages, you will find the application for the Home Repair Network. Please complete, sign and return the application package via mail or fax to: The Opportunity Alliance Attn: Home Repair 510 Cumberland Avenue Portland, ME Fax #: (207) Make sure you include copies of the following: Proof of income for all household members (three most current month pay stubs, e.g.) If receiving Social Security, please provide the current year s benefit award letter. Copies of your 3 most recent month s bank statements (summary pages detailing the beginning and ending balances can suffice.) Most recent year s tax returns (previous two years if you are self-employed.) Most recent property tax bill Proof of current homeowners insurance Deed, including Exhibit A (property description) and a copy of the death certificate if anyone on the deed has passed away; or a Bill of Sale if you own a mobile home. Please be sure to list and describe the work that needs to be done to your home on the application that follows. If you have any questions or require assistance, please feel free to contact me at , or me at Thank you. Sincerely, Katie Wilcox Project and Billing Specialist The Housing & Energy Services Program is a program of The Opportunity Alliance. The Opportunity Alliance is a non-profit, multi-service, community action agency committed to transforming our community by helping people in need build better lives.

2 HOME REPAIR APPLICATION Dear Homeowner: Attached you will find the application for home repair. Please fill out all required areas and enclose the documents below. If you should have any questions please feel free to call. PHONE (207) FAX (207) DOCUMENTS THAT MUST BE INCLUDED WITH YOUR COMPLETED APPLICATION 1. PROOF OF INCOME FOR ALL HOUSEHOLD MEMBERS (copy of pay stubs with year to date earnings, social security award letters, or other proof of income) 2. 3 MONTHS OF YOUR MOST RECENT BANK STATEMENTS (checking, savings, CD, money market, stocks, bonds, cash) 3. COPY OF YOUR MOST RECENT TAX RETURN (IRS 10-40) (2 years tax returns if self employed) 4. COPY OF YOUR PROPERTY DEED, OR BILL OF SALE FOR MOBILE HOME 5. COPY OF YOUR MOST RECENT PROPERTY TAX BILL 6. PROOF OF HOME OWNERS INSURANCE 7. SIGNED STATEMENT OF RELEASE (ATTACHED) WE CANNOT PROCESS YOUR APPLICATION WITHOUT ALL OF THE ABOVE Please list the repairs that are needed at your home:

3 I. PROPERTY INFORMATION PROPERTY ADDRESS Number & Street: Town/City: Mailing Address (if different:) Is this a Single Family Home: Yes No Number of Bedrooms: Is your name on Deed: Yes: No: Age of Home/Year Home was Built: Is this a Mobile Home: Yes No Year Mobile Home was Built: Is it in a Park: Yes No If yes, what park: If no, do you own the land: Yes No Have you received any past assistance? (Fix ME, Home Repair, Fuel Assistance etc.) Yes No If Yes, What & When? II. APPLICANT INFORMATION List all owners of the property: NAME DOB SOCIAL SECURITY #_ HOW MANY PEOPLE IN HOUSEHOLD: List all household members: NAME DATE OF BIRTH SOCIAL SECURITY # PHONE (H) PHONE (W) PHONE (C)

4 III. HOUSEHOLD INCOME For the purpose of this program, total household income shall include the combined gross income of all household members, excluding dependents under the age of 18 or dependents attending school on a full-time basis. GROSS MONTHLY INCOME: HOUSEHOLD MEMBER NAME WAGES/SALARY OVERTIME/ COMMISSIONS VA BENEFITS PENSIONS ANNUITIES SOCIAL SECURITY DISABILITY PAYMENTS TANF/GENERAL ASST./OTHER CHILD SUPPORT/ ALIMONY UNEMPLOYMENT PAYMENTS TOTAL TOTAL GROSS ANNUAL HOUSEHOLD INCOME $ (HUD s income limit = 80% of AMI)

5 IV. NOTICE OF INTENT TO OCCUPY I/we, (and ), do not intend to sell, transfer, rent or otherwise vacate my/our current residence located at. I intend to use this residence as my principle residence and not a vacation or second home. Certification: I certify that the information provided in this application is true and correct as of the date set forth opposite my signature on this application and acknowledge my understanding that any intentional or negligent misrepresentation of the information contained in this application may result in civil liability and/or criminal penalties. APPLICANT SIGNATURE DATE X APPLICANT SIGNATURE DATE X V. INFORMATION FOR GOVERNMENT MONITORING PURPOSES The following information is requested by the Federal Government for certain types of loans related to a Dwelling, in order to monitor the Lender s compliance with equal credit opportunity fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a Lender may neither discriminate on the basis of this information, nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations this Lender is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish the below information, please check the box below. (Lender must review the below material to assure that the disclosures satisfy all requirements to which the Lender is subject under applicable state law for the particular type of assistance applied for.) Applicant #1 Applicant #2 I do not wish to furnish this information Ethnicity: Hispanic or Latino I do not wish to furnish this information Hispanic or Latino Race: American Indian or Alaska Native American Indian or Alaska Native Asian Asian Black or African American Black or African American White White Native Hawaiian or Other Pacific Native Hawaiian or Other Pacific Islander Islander Sex: Female Male Female Male

6 STATEMENT OF RELEASE I/We, (Printed name of applicant) (Printed name of Co-applicant) Authorize The Opportunity Alliance to contact any employer, town official, or other agency deemed necessary to obtain information or verification required to complete my request for Housing Repairs. STATEMENT OF RELEASE This Statement of Release shall be valid from the date of my/our signature(s) below. Applicant: Co-Applicant: Date:

7 Form RD Form Approved (Rev.4-02) OMB No AUTHORIZATION TO RELEASE INFORMATION TO: FROM: The Opportunity Alliance Name(s) of Client(s) I have applied for or obtained a loan or grant from the Maine State Housing Authority (MSHA), Rural Development (RD), Department of Economic and Community Development (DECD), and The Opportunity Alliance Community Action Agency (CAA) as part of this process or in considering me for interest credit, payment assistance, or other servicing assistance on such loan, MSHA, DECD, and The Opportunity Alliance may verify information contained in my request for assistance and in other documents required in connection with the request. I authorize you to provide to MSHA, RD, DECD, and The Opportunity Alliance CAA for verification purposes the following applicable information: Past and present employment or income records. Bank account, stock holdings, and any other asset balances. Past and present landlord references Other consumer credit references If the request is for a new loan or grant, I further authorize MSHA, RD, DECD, and The Opportunity Alliance CAA to order a credit consumer report and verify other credit information. I understand that under the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401, et seq., MSHA, RD, DECD, and The Opportunity Alliance CAA is authorized to access my financial records held by financial institutions in connection with the consideration or administration of assistance to me. I also understand that financial records involving my loan and loan application will be available to MHSA, RD, DECD, and The Opportunity Alliance CAA without further notice or authorization, but will Not be disclosed or released by MSHA, RD, DECD, and The Opportunity Alliance CAA to another government agency or department or used for another purpose without my consent except as required or permitted by law. This authorization is valid for the life of the loan. The recipient of this form may rely on the Government s representation that the loan is still in existence. The information MSHA, RD, DECD, and The Opportunity Alliance CAA obtains is only to be used to process my request for a loan or grant, interest credit, payment assistance, or other servicing assistance. I acknowledge that I have received a copy of the notice to Applicant Regarding Privacy Act Information. I understand that if I requested interest credit or payment assistance, this authorization to release information will cover any future requests for such assistance and that I will not be re-notified of the Privacy Act information unless the Privacy Act information has changed concerning use of such information. A copy of this authorization may be accepted as an original. Your prompt reply is appreciated. Signature Date Signature Date According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the collection of information. MSHA, RD, DECD, and The Opportunity Alliance are an Equal Opportunity Lender

8 NOTICE TO APPLICANT REGARDING PRIVACY ACT INFORMATION The Opportunity Alliance collects nonpublic personal information about you from the following sources: Information we receive from you on applications or other forms Information we receive from a consumer reporting agency The Opportunity Alliance may disclose nonpublic personal information about you to the following types of third parties: Financial service providers, such as Maine State Housing Authority (MSHA) York County Community Action Corporation (YCCAC) Cumberland County City of South Portland Maine Department of Economic and Community Development City of Rockland City of Portland United States Department of Agriculture, Rural Development Banks The Opportunity Alliance restricts access to nonpublic personal information about you to those Agencies and employees who need to know that information to provide products or services to you. The Opportunity Alliance maintains physical, electronic and procedural safeguards that comply with federal regulations to guard your nonpublic personal information. Federal lending regulations require that The Opportunity Alliance bring this information to your attention. Your signature below indicates that you are now aware of this information and agree to authorize The Opportunity Alliance to disclose nonpublic personal information about you to those Agencies and employees who need to know in order to provide services or products to you. Applicant Co-Applicant Date Date

9 Demographic Information collected for each Program at The Opportunity Alliance Optional- This form is for tracking purposes only and does not affect your eligibility for Home Repair Gender (Head of Household): Female Male Transgendered Female to Male Transgendered Male to Female Ethnicity: Hispanic, Latino, Spanish Not Hispanic, Latino, Spanish Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White Other: Primary Spoken Language: American Sign Language French Polish Arabic German Russian Chinese Hungarian Spanish English Japanese Somali Farsi Koren Other: Education (Head of Household): Veteran: No School Pre-elementary Some elementary Some high school High school grad GED Some college College degree Graduate degree Post-graduate degree Yes No Household Type / Responsibilities: Single with no children Female single parent family Male single parent family Couple with no children Two-parent Family Grandparent(s) and child(ren) Adult relative (non-grandparent) and child(ren) Foster parent(s) Other caregiver(s) Other: Name: City/Town:

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