Special Needs Housing Rehabilitation Instructions and Checklist

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1 County of Volusia Special Needs Housing Rehabilitation Instructions and Checklist The Special Needs Housing Rehabilitation instructions and checklist are designed to assist in the application process. All applications will be reviewed to determine ownership (internal search), income eligibility and type of accessibility/repair requested. will determine eligibility o All eligible applicants will be placed on a waiting list. Participants will be selected from a waiting list based on household income and the priorities as further defined in the LHAP. Page 1 Application Forms I. Household Definition Instructions Input household special needs and/or developmental information II. Assistance/Modifications Needed Check all necessary repairs or modifications needed III. Household Composition Input household members information Page 2 IV. Contact Information V. Household Employment Information Input current contact information Input applicant and/or co-applicant employment information VI. Monthly Income Input total monthly household income VII. Assets Input all household banking information Page 3 Signature page Application must be signed by applicant and coapplicant/other (as applicable) Demographic Information Check applicant s demographic information Release of Information form Signed by all household members 18 years or older Certification form Completed by all household members See next page for checklist of supporting documentation required Instructions & Checklist PG 1

2 County of Volusia Special Needs Housing Rehabilitation Instructions and Checklist Required Documentation Comments Government issued picture ID For all household members 18 years or older Social security card For all household members Birth certificate For all household members 17 years and younger Divorce Decree or Final Dissolution of Marriage For all applicable members of household Child Support Documentation Copy of benefit letter(s) Verification of Property Ownership Homeowner Insurance Policy Documentation of special needs or developmental disability For all applicable members of household (Examples: Recorded support orders, Department of Revenue and Clerk of Court print out.) Dated within last 60 days. For all applicable members of household (Examples: Social Security, SSI, Disability, VA, Retirement, Pension, etc Forms not acceptable Proof of legal ownership of property (Example: Warranty Deed, Quit Claim Deed) Declaration page showing current policy period and amount of dwelling coverage Regarding household member(s) with special needs or developmental disability. Instructions & Checklist PG 2

3 County of Volusia Special Needs Housing Rehabilitation Application This program is designed to assist eligible households of persons with special needs as defined in s , Florida Statutes, with a priority for persons with developmental disabilities as defined in s , Florida Statutes. I. My household meets the definition of: Special needs: An adult person requiring independent living services in order to maintain housing or develop independent living skills and who has a disabling condition A young adult formerly in foster care who is eligible for services under s (5) A survivor of domestic violence as defined in s A person receiving benefits under the Social Security Disability Insurance (SSDI) program or the Supplemental Security Income (SSI) program or from veteran s disability benefits. Developmental disability: A person with a disorder or syndrome that is attributable to intellectual disability, cerebral palsy, autism, spina bifida, or Prader-Willi syndrome; that manifests before the age of 18; and that constitutes a substantial handicap that can reasonably be expected to continue indefinitely. II. I believe the following improvements are needed at my home: Home modifications, including technological enhancements and devices: Septic Water/Well Electric Plumbing Roof Foundation Windows Door(s) Kitchen Bedroom(s) Bathroom(s) Ceilings/Floors Air Conditioner Heater Other: Application PG 1

4 III. Household Composition: (List all persons who reside in home.) HOUSEHOLD MEMBERS (LEGAL NAME AS IT APPEARS ON SOCIAL SECURITY CARD) D.O.B. RELATIONSHIP TO APPLICANT SOCIAL SECURITY NUMBER MARRIED (M) WIDOWED(W) NEVER MARRIED (N) DIVORCED(D) Applicant Coapplicant/Other IV. Contact Information: Home City: State: Zip: Mailing City: State: Zip: Telephone Numbers: Home Work Cell V. Household Employment Information: (If not employed, please indicate by N/A). Applicant Co-Applicant / Other Employer Employer VI. Monthly Income: You must disclose all income. Source Applicant Co-Applicant Other Employment (including OT, etc) $ $ $ Social Security $ $ $ V.A. Pension $ $ $ Retirement Pension $ $ $ Real Estate Income (gross) $ $ $ Welfare (Cash assistance) $ $ $ Income from Others $ $ $ Child Support/Alimony $ $ $ Other Source $ $ $ Totals $ $ $ Grand total income $ X 12 MONTHS = $ Application PG 2

5 VII. Assets: You must provide documentation supporting balances of all accounts. Asset Type Applicant Co-Applicant Other Checking Account Savings Account 401(K)/Pension Marketable Securities Additional Property Other IMPORTANT: READ BEFORE SIGNING Written Statement Regarding the Collection and Use of Social Security Numbers This statement is being provided to you pursuant to Section (5), Florida Statutes. The division is required by 24 CFR to collect the social security number(s) of applicant(s) and their household members, if any. Social security numbers are unique numeric identifiers that are used by this office to identify, verify, track and search information in conjunction with an applicant s application for assistance. may disclose social security numbers to another agency or governmental entity if it is necessary for the receiving agency or governmental agency to perform its duties and responsibilities. The intent of this application is only to pre-qualify the applicant(s). It does not guarantee acceptance or approval. Therefore no commitment is made on the part of either party. I/ We hereby certify that all information furnished in this application is true and correct and is given for the purpose of obtaining housing assistance depending on my/our financial ability. Further, I/ We authorize any employee of County of Volusia to verify any statement that I/We have made on this application obtained from any source named herein. PENALTY FOR FALSE OR FRAUDULENT STATEMENT, U.S.C. TITLE 18, SEC provides: Whoever, in any matter within the jurisdiction of any agency of the United States knowingly and willingly falsifies... or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000, imprisoned for not more than 5 years, or both. Signature: Date: Signature: Date: Household Demographic It is the policy of the County of Volusia to provide fair housing opportunities to all persons and to ensure that there is no discrimination in the provision of housing benefits against any person on the grounds of race, color, national origin, religion, gender, familial status or disability. The following questions are for the purpose of tracking the housing benefits of this project and will be summarized for reporting purposes. Race (check one): White African American Asian American Indian or Alaska Native Hispanic Ethnicity: Yes No Native Hawaiian or Other Pacific Islander Other Multi-Racial Application PG 3

6 For Office Only Housing Specialist: Date: Affordable Housing Coordinator: Date: Ranking Information: Income (per AMI): Special Needs Waiting list date: Developmental Disability Application PG 4

7 County of Volusia White-out prohibited Special Needs Housing Rehabilitation Release of Information Form The undersigned hereby authorizes you to release without liability any information regarding employment, credit, income, and/or assets to the County of Volusia division Housing & Grants Administration for purposes of verifying information provided as part of the owner s application for housing assistance. Information Covered I understand that previous or current information may be needed. Verification and inquiries that may be requested include, but are not limited to: personal identification; employment, credit, income, and assets; medical or child care allowances. I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for the housing assistance. Groups or Individuals That May Be Asked The groups or individuals that may be asked to release the above information include, but are not limited to: Past and Present Employers Welfare Agencies Veterans Administration Credit Reporting Agencies Unemployment Agencies Social Security Administration IRS Support and Alimony Providers Retirement Systems Previous Landlords (including Public Housing Agencies) Banks and Financial Institutions Conditions I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will stay in effect for a year and one month from the date it is signed. I understand I have a right to review this file and correct any information that I can provide that may be incorrect. Signature of Adult Date Signature of Adult Date Print Name Print Name Release of Information PG 1

8 County of Volusia Housing Income and Asset Certification Form 1) I am employed. Yes No a) If yes, my employers information is: Phone/fax: I have more than one employer; please see next page 2) I am named on at least one bank or financial institution account. Yes No a) If yes, my account information is: Account #: I have more than one account; please see next page 3) I am enrolled full-time in school and a copy of my class schedule is attached. Yes No I,, social security number ending xxx-xx-, hereby certify that the above information is true and correct to the best of my knowledge. I understand that any incorrect, incomplete, or fraudulent information may result in denial of the associated request for assistance. Should any changes occur to this information from the date of this document until my application is closed I understand I will need to notify the Housing Specialist in writing within five calendar days of the change and that these changes may require that my application for assistance be re-reviewed. Signature Date The foregoing instrument was acknowledged before me on by who is personally known to me (or) produced the following identification. Signature Print Name of Signer Certification Form PG 1

9 County of Volusia Housing Income and Asset Certification Form Social Security Number Ending xxx-xx- Employer: Bank and/or Financial Institution: Certification Form PG 2