Application for Emergency/Minor Home Repair Program City of Coeur d'alene, CDBG Entitlement Program

Transcription

1 FOR OFFICE USE ONLY Date Reeived Appliation omplete By Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil The City of Coeur d'alene Emergeny/Minor Repair Program is designed to assist low to moderate inome persons make emergeny/minor repairs or aessibility modifiations to their home. Emergeny repairs are those repairs whih are neessary to safeguard against imminent danger to human life, health or safety, or to protet property from further strutural damage. Appliations are aepted and proessed on a first ome-first served basis. All projets are subjet to an Environmental Review. Please see Page 10 for the Appliation Cheklist whih will assist you in aurately ompleting the appliation along with providing the required supporting doumentation (be sure to return page 10 as part of the ompleted appliation). Inomplete or unsigned appliations will not be proessed. Appliant is Homeowner Yes Appliant's Yes Home is loated within Yes If no to any question, appliant does not qualify. No primary residene No Coeur d'alene City limits No The CDBG Emergeny/Minor Repair program is open to owner-oupants whose total household inome does not exeed the amount for the orresponding household size listed below: Household Size Maximum Inome Household Size Maximum Inome 1 31, , , , , , , , Please ontat Panhandle Area Counil for inome limits for households of 9 or more. The Emergeny/Minor Repair program is intended to provide assistane to eligible homeowners for safe, sanitary and seure living onditions. Ativities whih may be eligible under the CDBG Emergeny/Minor Repair program inlude, but are not limited to repair, replaement or modifiation of: Roof Plumbing Sewer Floor (strutural) Aessibility Improvements for Homes where Disabled Individuals Reside Hot Water Heater Furnae/Heating System Eletrial City Code Violation Non-inome earning assets may not exeed 35,000. Appliants must ertify that the value of all of their "Non-inome earning assets" do not exeed 35,000. Exluding the value of their primary residene, inome earning real estate investments (revenue derived from rental property is ounted under inome), qualified retirement savings (revenue derived from retirements savings is ounted under inome), household furnishings, lothing and ars CDA Entitlement Appliation Page 1

2 Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil APPLICANT'S NAME Date of Birth Soial Seurity No. Phone Number ARE YOU (hek one) Married Divored Separated Single Widowed ADDRESS Zip No. of Years CO-APPLICANT'S NAME Date of Birth Soial Seurity No. Phone Number ARE YOU (hek one) Married Divored Separated Single Widowed Please provide inome information for all Household members 18 years or older. Use Gross Inome unless stated otherwise, verifiation will be required. Soures of Inome Appliant Co-Appliant Employment/Salary Pay Period Other Adult Household Members Other Adult Household Members Monthly Annual Monthly Annual Monthly Annual Monthly Annual Company Telephone Number Interest & Dividends Business Net Inome Rental Net Inome Soial Seurity/SSI Pension/Retirement Child Support/Alimony Unemployment Workers Compensation AFDC, Welfare, et. Inome from Assets Regular Monetary Gifts Other Other TOTAL Total Household size Total Household Inome LMI Yes No Mortgage Lien Holder Own Home Outright Year House was Construted Are taxes urrent? Yes No Page 2

3 Please indiate the type of repair with an explanation of the existing problem. Inlude a brief desription of the work to be done (repair/modifiation) under the CDBG Emergeny/Minor Repair Program. Emergeny repairs are those repairs whih are neessary to safeguard against imminent danger to human life, health or safety, or to protet property from further strutural damage. Other eligible program ativities may inlude handiap aessibility. If additional spae is needed, please attah a separate page. Please label any additional pages with homeowner's name and address. EMERGENCY/MINOR REPAIR Roof (speify) Eletrial (speify) Sewer (speify) Strutural (speify) Plumbing (speify) Handiap Modifiations (speify) Yes No Do you laim a disability for program eligibility purposes? Heat (speify) Code violation/enforement Other (speify) Other (speify) DESCRIPTION OF THE WORK TO BE DONE Building permits, whether required under Coeur d'alene City Code or by State Statute shall be the responsibility of the property owner. The owner may speify that their ontrator obtain and maintain all permits neessary for the projet work. DO NOT begin work, or inur any osts until Notie to Proeed is issued by Panhandle Area Counil. Any work done or osts for purhases made prior to the Notie to Proeed WILL NOT be eligible for payment under the loan program. For the purpose of partiipating in this program I (we) will allow the City of Coeur d'alene and their representatives to make any inspetion of my (our) house, inluding a photographi reord, as may be neessary for the administration, monitoring and ompletion of this projet under the City's Emergeny/Minor Repair program. I (we) ertify that I am the owner(s) of this property, that the statements ontained in this appliation are true, and ertify that the City of Coeur d'alene shall not be liable for damages that may arise out of, or in onnetion with, home repairs/modifiations done under this grant. I/WE ertify, under penalty of law, that the above information is full, true, and omplete to the best of my/our knowledge. I/We understand that any willful misstatement may be grounds for disqualifiation. In addition, any fraudulent, fititious or false statement on this appliation will require repayment of grant dollars reeived or other finanial help in full. My/Our signature(s) below onstitute my/our onsent to verifying information from any neessary soure. Appliant Signature Date Co-Appliant Signature Date Return ompleted appliation to: Panhandle Area Counil City of CDA Entitlement Program The City of Coeur d'alene does not disriminate on the basis of rae, sex, olor, age, national origin, religion or disability in its employment opportunities, programs, servies or ativities. Page 3

4 Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil Certifiation of Non-Inome Earning Assets I hereby ertify that my non-inome earning assets do not exeed 35,000. Soure Amount Total non-inome earning assets Non-inome earning assets may not exeed 35,000 in value exluding the value of their primary residene, qualified retirement savings, household furnishings, lothing, and vehiles used as primary mode of transporation. Appliants must ertify that the value of all of their "Non-inome earning assets" do not exeed 35,000. For illustration purposes only the following represents a few examples of asset types: NON-INCOME PRODUCING ASSETS Rereational Vehiles Summer House/Time Share Land Not Adjaent to Primary Residene Customized Cars/Motoryles INCOME EARNING ASSETS Rental Properties Inome from Qualified Retirement Plans Interest from Savings/Investments Farm Property/Equipment I/We ertify, under penalty of law, that the above information is full, true and omplete to the best of my/our knowledge. I/We understand that any willful misstatement may be grounds for disqualifiation. In addition, any fraudulent, fititious or false statement on this appliation will result in the alling in of any note, deferred grant or other finanial help in full. My/Our signature(s) below onstitute our onsent to verifying information from any neessary soure. Signature of Appliant Date Signed Signature of Co-Appliant Date Signed Page 4

5 Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil APPLICANT'S AUTHORIZATION I/We,, Appliant, and Co-Appliant, who reside at hereby authorize the release of all pertinent information to the City of Coeur d'alene and their representative, Panhandle Area Counil for use in determining my/our eligibility for an Emergeny/Minor Repair Program grant offered through the City of Coeur d'alene CDBG Entitlement Program. This authorization entitles: H H H All finanial institutions in whih I/we have/had business transations Plaes of employment Any other organization having aess to pertinent information to release said information to the City of Coeur d'alene or Panhandle Area Counil, when a written request is supplied along with a opy of this doument. Signature of Appliant Date Signed Signature of Co-Appliant Date Signed Page 5

6 Bid/Quote Proess Determine the sope of the projet; enter details on the Bid/Quote Worksheet. Outline the problem and the ativites neessary for orretion; please be speifi. This projet information should be used to obtain the bids/quotes and should ontain suffiient detail to allow bidders and/or suppliers to provide bids/quotes that are easily omparable. Contat the City of CDA Building Department regarding permit requirements. Building permits, whether required under Coeur d'alene City ode or by State Statute shall be the responsibility of the property owner. The owner may speify that their ontrator obtain and maintain all permits neessary fo the projet work. Obtain a minimum of three bids/quotes for the work/materials required for the projet. Bids/quotes must desribe omparable servies or materials. For example - a bid to repair a portion of a leaky roof annot be ompared to a bid to replae the roof. The lowest responsive bid/quote will be used. Enter information for eah bid/quote on Bid/Quote Worksheet. Projet Funding If projet osts are more than the maximum allowable grant amount, list other soures of funding to be used (savings, donation, ash gift, grant, loan, et.). Suffiient funding to omplete the projet must be identified prior to projet approval. Bids/Quotes Attah opies of bids and/or quotes to ompleted Bid/Quote Worksheet; submit to Panhandle Area Counil. DO NOT begin work, or inur any osts until Notie to Proeed is issued by Panhandle Area Counil. Any work done or osts for purhases made prior to the Notie to Proeed WILL NOT be eligible for payment under the grant program. Quotes for materials/applianes may be obtained by telephone or internet. Written doumentation of quotes must inlude: Speifiations of item to be purhased (i.e., for a furnae inlude the BTUs, effiieny rating, heating apaity, et.) Company name/ontat name Company address, telephone number or internet address Date and time of quote Timeline and delivery information Warranty (if appliable) Costs, inluding tax & shipping Any other pertinent information Page 6

7 Bid/Quote Worksheet Appliant Name Address Ativities to be ompleted: Bids/Quotes must desribe omparable servies or materials. For example - a bid to repair a portion of a leaky roof an not be ompared to a bid to replae the roof. In that instane the appliant ould submit more than 3 bids. (Three bids to repair the roof, and three bids to replae the roof, then hoose whih speifi projet to omplete.) Eah bid/quote should inlude priing information that allows the appliant to ompare osts aross bidders and ensure ost reasonableness. The lowest responsive and responsible bid/quote will be used. Budget Worksheet - Company Phone # Work Task Attah opies of Bids/Quotes Projet Estimate - 1 Projet Estimate 2 Projet Estimate - 3 Materials Materials Materials Labor Permits Other Other Other Tax Total Cost Low Bid/Quote Other funds or ontributions to omplete projet: Soure: Soure: Amount of Grant funds requested: Amount: Amount: Total Projet Cost: Estimated Start Date: Estimated Completion Date: Page 7

8 Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil Information for Monitoring Purposes - Optional Setion You are not required to answer the following questions, however, this information is being requested for reporting purposes. If you furnish the information, please provide both ethniity and rae. For rae, you may hek more than one designation. If you do not wish to furnish the information, please hek the box below. Appliant Co-Appliant Ethniity: Hispani or Latino Ethniity: Hispani or Latino Not Hispani or Latino Not Hispani or Latino Rae: White Rae: White Blak/Afrian Amerian Blak/Afrian Amerian Asian Asian Amerian Indian/Alaskan Native Amerian Indian/Alaskan Native Native Hawaiian/Other Paifi Islander Native Hawaiian/Other Paifi Islander Amerian Indian/Alaskan Native & White Amerian Indian/Alaskan Native & White Asian & White Asian & White Blak/Afrian Amerian & White Blak/Afrian Amerian & White Amerian Indian/Alaskan Native & Amerian Indian/Alaskan Native & Blak Afrian Amerian Blak Afrian Amerian Other Multi-Raial Other Multi-Raial Gender: Female Gender: Female Male Male Head of Household: Head of Household: Yes Yes No No I do not wish to furnish this information I do not wish to furnish this information Page 8

9 Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil Confirmation of Reeipt of Lead Pamphlet I have reeived a opy of the pamphlet, Protet Your Family From Lead in Your Home, informing me of the potential risk of the lead hazard exposure from renovation ativity to be performed in my dwelling unit. I reeived this pamphlet before the work began. Printed Name Address Signature Date Page 9

10 Appliation for Emergeny/Minor Home Repair Program Panhandle Area Counil Appliation Cheklist Appliation submittal must inlude the items listed below. Page 1 - Completed homeowner information. Page 2 - Completed worksheet listing all household inome, mortgage/tax, and age of home information. If any of the items do not apply to your individual situation, please write "NA" next to the item. Current year's Inome Tax Return with W-2s, and/or 1099s, for eah household member who filed a tax return. If appliant is self-employed, two year's tax returns and bank aount statements for proof of inome. Soial seurity number(s), with most urrent inome statements for household members who reeive soial seurity. Payhek stubs for the last two months for eah employed household member. All bank statements (heking, savings, et) for the last two months for eah employed household member. Copy of deed, ontrat of sale, and/or esrow agreement. Mortgage Balane Statement. Certifiate of urrent fire insurane overage. Divore deree, if you were awarded the property through a divore. Page 3 - Signed desription of problem and potential repair. Copy of written report of ity ode violation, if appliable. Page 4 - Signed Certifiation of Non-Inome Earning Assets. Page 5 - Signed Appliant Authorization. Page 7 - Completed Bid/Quote Worksheet. Inlude a MINIMUM of 3 quotes for eah ativity/materials/et. Page 8 - Completed Information for Monitoring Purposes. Page 9 - Signed Confirmation of Reeipt of Lead Pamphlet. Page 10 - Completed Appliation Cheklist (this page). Return ompleted appliation to: Panhandle Area Counil City of CDA Entitlement Program The City of Coeur d'alene does not disriminate on the basis of rae, sex, olor, age, national origin, religion or disability in its employment opportunities, programs, servies or ativities. Inomplete or unsigned appliations will not be proessed. Page 10