Healthy Homes Department Housing Rehabilitation Program County of Alameda Community Development Agency (CDA)

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1 For CDA use only: application first received: Project ID#: Dear Homeowner: With funding and Programs available, NOW is a great time to have those needed home repairs done! Thank you for your interest in the Housing Rehabilitation Loan Program ( Program ) of the County of Alameda, Community Development Agency (CDA). The Program is funded by various government agencies, and such, requires us to verify your gross family income and property loan to value information to determine your eligibility for the program. We would like to assist you with your needed repairs: Leaky roofs Termite and dry rot damage Low water pressure Sewer problems Electrical wiring problems Repairs to improve accessibility in your home Windows and Doors repairs and replacement Energy Efficiency measures To help us determine your eligibility for grants and loans offered by the Program, please provide the information to: ATTN: Applications Housing Rehabilitation Program Alameda County Healthy Homes Department 2000 Embarcadero, Suite 300 Oakland, CA Important! Provide the following documents (copies) as they apply to you and your home: Copy of your 2 most recent consecutive pay stubs or other current proof of income including, but not limited to, Social Security, Retirement, Pension, General Assistance, Child Support, Unemployment, etc. Last year s Federal Tax Returns, including all attachments and schedules Copy of your 2 most recent bank and financial institution s checking savings statements including, but not limited to, stocks, IRAs, pension accounts, mutual funds, etc. Please include all pages of statements, even if blank. Current mortgage statement and home equity lines of credits, which include the terms, the outstanding balances and monthly payments. Current Homeowner s Insurance policy, which includes the policy number, policy period, amount of coverage and the premium amounts. Please include your agent s name and phone number. Copies of your most recent PG&E and Water, Garbage bills. Page 1 of 8 Pages

2 Upon receipt of the screening information to assist in determining eligibility for the Program, we will obtain a title report to verify ownership of the property, taxes paid and other pertinent property information, and obtain a consumer credit report to verify financial information. Having a less than optimum credit score does not necessarily disqualify you from the Program. We may request additional information. Your cooperation will be greatly appreciated. Should you have any questions or/and require more information, please feel free to call (510) Healthy Homes Department, Housing Rehabilitation Program Owner Occupied Housing Rehabilitation Loan Application Home Repairs Needed: (Please check as appropriate) Roof Termites Dry Rot Plumbing Electrical Peeling Paint Foundation Windows/Doors Other: Applicant(s): Owner s Last Name First Middle Init. Social Security Number Birthdate Co-Owner s Last Name First Middle Init. Social Security Number Birthdate ( ) Address City ZIP Phone Number ( ) Cell Phone # address Page 2 of 8 Pages

3 Demographic data is obtained for statistical purposes only and will not be considered in determining eligibility. Head of Household Male Female Disabled? Yes No Age of Head of Household: Under the age of years and older Ethnicity: Select Only One: Hispanic/Latino Yes No Race: Select one or more: White Black or African American Asian Native Hawaiian or Other Pacific Islander Native American Indian or Alaskan Other Multi-Racial The County of Alameda complies with Title VII of the Civil Rights Act of 1964 and that no person shall, on the grounds of race, creed, color, disability, gender, sexual orientation, national origin, age, religion, Vietnam era Veterans status, political affiliation, or any other non merit factor, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under this Program. Please list all of the people living at this property, including you: Name Age Relationship Monthly Income 1. Owner Please check as it applies: I currently have a mortgage Yes No I currently have a line of credit Yes No I currently have a Living Truest Yes No Page 3 of 8 Pages

4 Income and Employment: All income sources for all persons of the household that are age 18 and over must be stated: Attach additional sheets as necessary. Owner/Head of Household Information Are you employed? Yes No Are you self employed? Yes No If employed, Name of your Employer: Years employed: Your Employer Address: Number of Co-Owner Information: Are you self employed? Yes No Co-owner s Employer: Co-owner s Employer Address: number of Years employed: #1: Other People Living in the Home Information: Are you self employed? Yes No Co-owner s Employer: Co-owner s Employer Address: number of Years employed: Please attach more pages, as necessary Other sources of Household Income (monthly): Social Security $ Disability $ Pension $ VA Benefits $ Unemployment $ Rental Income $ Div/Int $ Alimony $ Child Support $ General Assistance $ ADC $ Other $ Page 4 of 8 Pages

5 MORTGAGE INFORMATION Please check: I currently have a mortgage: Yes No I currently have a line of credit: Yes No First Mortgage: Name of Lending Institution: Address of Lending Institution: Healthy Homes Department Housing Rehabilitation Program Account #: Balance: $ Monthly Payment:$ Second Mortgage: Name of Lending Institution: Address of Lending Institution: Account #: Balance: $ Monthly Payment:$ Are there any revocable living trusts that are available to the family? Yes No Do you own any other real estate? Yes No ACCOUNTS/ASSETS (Checking, Savings, Pension, IRA, stocks, etc.) 1) Name and Address of Financial Institution: Type of Account: Checking Savings Other 2) Name and Address of Financial Institution: Type of Account: Checking Savings Other 3) Name and Address of Financial Institution: Type of Account: Checking Savings Other Page 5 of 8 Pages

6 HOMEOWNER S INSURANCE INFORMATION Name and Address of Insurance Company: Agent s Name: Agent s Phone #: ( ) Policy #: Policy Period from: / / / to / / / CONSENT AND RELEASE OF INFORMATION The Housing Rehabilitation Program, Healthy Homes Department, Community Development Agency (CDA) of the County of Alameda, offers housing rehabilitation financing through the use of Federal and local funding. To assist with this goal, I agree to release information regarding income, credit, mortgages, employment and bank and financing account. I give my express permission to use copies of this consent form in obtaining the required information, including credit reports and title reports, and hereby certify that to the best of my knowledge, all information given in this Application is true and complete. Owner Co-Owner PROGRAM OUTREACH How did you hear about us? Internet Word of Mouth Newspaper City Neighbor Other: (please describe Page 6 of 8 Pages

7 FAIR LENDING NOTICE AND NOTICE OF RIGHT TO FINANCIAL PRIVACY FAIR LENDING NOTICE To: All borrowers for a real property secured loan to purchase, construct, rehabilitate, improve or refinance an owneroccupied one to four-family residence; and all owner-applicants for a real property secured home improvement loan to improve a one to four-family residence (whether or not owner-occupied): The Federal Equal Credit Opportunity act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided that the applicants have the capacity to enter into a binding contract); because all or part of the applicant s income derives from any public assistance program, or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The Federal Agency that administers compliance i=with this law concerning this credit in the U.S. Comptroller of the currency, Consumer Affairs Division, Washington, D.C In addition to your rights under Federal law, you may also have other rights afforded under state law. FOR CALIFORNIA RESIDENTS ONLY: In accordance with California law, the following notice is given to applicants who are resident of California. The California Housing Financial Discrimination Act of 1977 provides in part as follows: 35810, no financial institution shall discriminate in the availability of, or in the provision of, financial assistance for the purpose of purchasing, constructing, rehabilitation improving, or refinancing housing accommodations dues, in whole of in part, to the consideration of conditions, characteristics, or trends in the neighborhood or geographic area surrounding the housing accommodation, unless the financial institution can demonstrate that such consideration in the particular case is requires to avoid an unsafe and unsound business practice No financial institution shall discriminate in the availability of, or in the provision of, financial assistance for the purpose of purchasing, constructing, rehabilitation, improving or refinancing housing accommodations due, in whole of in part, to the consideration of race, color, religion, sex, marital status, national origin, or ancestry No financial institution shall consider the racial, ethnic, religious, or national origin composition of a neighborhood or geographic area surrounding a housing accommodation or whether or not such composition is undergoing change, or is expected to undergo change, in appraising a housing accommodation or in determining ether or not, and under what terms and conditions, to provide financial assistance for the purpose of purchasing, constructing, rehabilitation, improving, or refinancing a housing accommodation. No financial institution shall utilize appraisal practices that are inconsistent with the provision of this part. If you wish to file a complaint, or if you have questions about your rights, contact: Controller of the Currency, Administrator of National Banks, Western District, Consumer Complaint Department, 50 Fremont Street, Suite 3900, San Francisco California NOTICE OF RIGHT TO FINANCIAL PRIVACY: This is notice to you as required by the right to Financial Privacy Act of 1978 that the Department of Housing and Urban Development has a right of access to financial records held by any financial institution in connection with the consideration or administration of the housing rehabilitation loan for which you have applied. Financial records involving your transaction will be available to the Department of Housing and Urban Development without further notice or authorization but will not be disclosed or released to any other entities except as required or permitted by law. Owner Co-Owner Page 7 of 8 Pages

8 Owner-occupied Housing Rehabilitation Program ~ Supplemental Information ~ Property Location: I. Consent to Use Photographs for Promotional Material I/We, the undersigned, hereby authorize the Healthy Homes Department of the Community Development Agency (CDA) of the County of Alameda to use photographs of my property for promotional and educational materials in connection with participation in the Housing Rehabilitation Program. The CDA routinely take photographs of the property in different stages of rehabilitation and remodeling, as part of preparing a work plan for project documentation purposes. Often, these photographs are not shared with anyone outside of the Agency. By signing this application, you are agreeing that the County of Alameda may use the photographs for the purposes of describing and/or promoting Programs within the community, including sharing of such information with other persons and organizations or the public. I/We agree to hold the County of Alameda, its officers, agents and employees harmless from any and all claims for damages resulting from the above described use of such materials which may be brought by or on behalf of the undersigned. Owner s Signature Co- Owner s Signature II. Lead-Based Paint (LBP) Disclosure Alameda County CDA/HHD has provided me with a copy of the following brochure: EPA s Protect Your Family from Lead In Your Home. Owner s Signature Co- Owner s Signature Page 8 of 8 Pages

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