LIVE NEWARK DEPARTMENT OF ECOMONIC AND HOUSING DEVELOPMENT DIVISION OF HOUSING AND REAL ESTATE HOME FACADE PROGRAM (HFP) APPLICATION Please PRINT and complete ALL pages of this application in its entirety and sign the last page. List the type of EXTERIOR Repairs you are experiencing on Section 6 of the application. Please note that assistance is based on priority of emergency at the discretion of the Program Coordinator. Your application may be placed on a waiting list in accordance to priority. SECTION 1-APPLICANT INFORMATION: (please print) Name: Social Security No. (Last 4 digits) Last First Middle Initial Co-Applicant: Social Security No. (Last 4 digits) Last First Middle Initial Property Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Email: Age: of Birth: Gender: Male Female Marital Status: Single Married Widowed Divorced (If Widowed please submit a copy of spouse Death Certificate) Are you Disabled? Yes No 1
COMPLETE FOR STATISTICAL USE ONLY Female head of Household Disabled Senior Citizen Marital Status: Married Single Divorced Widowed Race: White Black Hispanic Native Alaskan Asian/Pacific Other SECTION 2-HOUSEHOLD COMPOSITION: (please print) Complete the list of all persons (including children) living in the household, along with their corresponding current annual and or monthly gross. Household is a group of related or unrelated persons occupying the same house with at least one member being the head of household: Primary language spoken: Number of persons in the household: Number of persons Age 62 and older (excluding head of household): Number of disabled persons in the household (excluding head of household): Name Relationship of Birth 1. SELF 2. 3. 4. 5. 6. Age Monthly Income Annual Income SECTION 3-INCOME INFORMATION Our household income is received from: (check all that apply) Job income (Employment Verification form must be filled out) Social Security Pension Disability Alimony Child Support Workers Comp Unemployment Self-employed *Other *Please list other form of income: Attach a copy of the following when returning this completed application in order to qualify for services: Most recent two (2) months of pay statements for all persons who receive income in the household including: Pay stubs, Social Security, Disability, Pension, VA Benefits, Annuities, Alimony, Child Support, Workers Comp, Unemployment, Rental Income, Public Assistance, Self-Employment Business Ledgers for two (2) months. Valid copy of: NJ Driver s License, Passport, NJ State Identification, Military ID, for all persons over the age of 18. 2
SECTION 4-PROPERTY INFORMATION :(please print) Number of Units: One Two Three Four Year Built How long have you owned and lived in the home? Is this your primary residence? Is this home for sale? Yes No Are there any liens against this property? Yes No Do you operate a business out of your home? Yes No If Yes, please give name and nature of business: Have any of the current occupants been tested for lead and had an elevated blood level? Yes No Have you received a previous grant for this property from the City of Newark? Yes No If yes, date of grant: Has it been forgiven? If yes, date of discharged: Do you own any other real estate property? Yes No If Yes, please list address(s) 1. 2. Are you employed by or relative of any employee currently working for the City of Newark? Yes No If Yes, please list Names, Relationship, and Department: (please print) Names: Relationship: Department: 1. 2. 3
SECTION 5-HOMEOWNERSHIP AND MORTGAGE INFORMATION :(please print) Purchase Price: $ Year House was Purchased: Do you have a Mortgage on this property? Yes No Do you have property Ins. Yes No Mortgage Company Current Loan Balance $ Monthly Mortgage Payment $ Are taxes and insurance included in your monthly mortgage payment? Yes No Do you have a Second Mortgage on this property? Yes No Mortgage Company Current Second Mortgage Loan Balance $ Second Mortgage Payment $ SECTION 6-SERVICES REQUESTED: (please print clearly) Please print below and provide a description of your Exterior Repairs: 4
Financial Privacy Act Notice Applicant: Co-Applicant: Application #: : Notice This notice is provided to you pursuant to the requirements of the Right to Privacy Act of 1978 As a result of your request and/or receipt of financial assistance under the City of Newark Home Façade Program, the U.S. Department of Housing and Urban Development (HUD) will have access to financial records held by the City of Newark in connection with the consideration and/or administration of assistance to you. Pursuant to these rights of access, your financial records and information as contained therein will not be disclosed or released to any other person(s); government agency or department, without your prior written consent, except as may be permitted and or required by law. ACKNOWLEDGEMENT I have read the Right to Financial Privacy Act Notice presented above and by my signature below, acknowledge and accept the terms and conditions set forth therein. Applicant s Signature Co-Applicant s Signature 5
SECTION 7-APPLICANT SIGNATURE(S) AND CERTIFICATIONS: Please certify each of the following statements by initialing on the line to the statement. (If you cannot certify to each of the following you may not qualify for assistance) (initial) I certify that I own this property and it s my principal residence (initial) I understand the City of Newark may obtain a title and credit report to verify qualification (initial) I have received a copy of the Privacy Policy Disclosure (initial) I have received and read the Exterior Repair Program Outline The statements in this application are true, correct and complete, and represent a total disclosure of all my obligations and assets. I/We certify that the entire proceeds of this grant will be used exclusively for the purposes represented on this application. I/We understand that if I have knowingly omitted or falsified any of my financial information or other material information, that my application to the Home Facade Program (HRP) shall be permanently cancelled, or if the loan has been granted, it will require immediate repayment of any funds spent I certify that all the information I have given and will give in connection with this application, either in writing or orally is true and correct, I understand that false, fictitious or fraudulent statements, or representations to defraud the United States Government of Funds voids my application for assistance, and is punishable by fines not to exceed $10,000.00 or imprisonment for not more than five years, or both under U.S.C Title 18, Sec 1001. I understand that it is obligation of the City of Newark to prosecute violations. Signature of Applicant: Signature of Co-Applicant: FOR INTERNAL USE ONLY Application Received By: : Entered Into Database: File Created: ALL Documentation Received: Approved: Denied: Cancelled: Annual Income: $ AMI% Work Started: Work Completed: Contractor: Contractor: 6
LIVE NEWARK DEPARTMENT OF ECOMONIC AND HOUSING DEVELOPMENT DIVISION OF HOUSING AND REAL ESTATE EXTERIOR REPAIR PROGRAM (ERP) CHECKLIST Owner(s) Name(s): Property Address: Please check ( ) all that apply. Return this checklist with application, along with (COPIES) of the following Documentation (ORIGINALS WILL NOT BE RETURNED): Have you filled out and completed all of the questions on the application? Have you included your gross annual household income for all household members over the age of 18? Have you initialed and signed at all the appropriate spaces on the Certification Section (6) of the application? Have you included the following documentation for all occupants 18 and older? Recorded Deed (ALL PAGES) Copy of current water and pseg bill showing no past due balance Mortgage Statement for 3 months Most current statement of benefits (Social Security, Disability, Pension, Child Support, Alimony, Welfare or other public assistance, Unemployment/Workers Compensation) Pay Stubs for two (2) months Declaration page from your current Homeowner s Insurance Policy Copy of current property tax statement showing no past due balance Signed Federal and State Tax Returns for two years Waiver if no Tax Returns were filed Death Certificate Divorce Decree 7