Building a Healthier Sulphur Springs 2015 Application Package

Building a Healthier Sulphur Springs 2015 Application Package Dear Applicant: Thank you for your interest in Rebuilding Together Tampa Bay s Building a Healthier Sulphur Springs Program. Rebuilding Together Tampa Bay (RTTB) is a local non-profit organization offering various home repair and rehabilitation services to low income Tampa Bay area homeowners, and in some cases tenants*. We have been providing these services since 2000 and our team of licensed skilled professionals proudly delivers top quality residential repairs throughout the Tampa Bay area. *The Building a Healthier Sulphur Springs program provides home improvements to tenant-occupied homes upon approval of the property owner and satisfaction of all program requirements. The purpose of our Building a Healthier Sulphur Springs Program, is to improve housing conditions for its residents by installing our Healthy Home Kit. This kit consists of products and materials that improve quality of life within the home, making it healthier, safer and more energy efficient. Please return this completed application package along with all documents on checklist to: Rebuilding Together Tampa Bay Attn: Intake & Assessment Division 911 E. 122nd Avenue, Tampa, FL 33612 Office: 813-878-9000 Fax: 813-513-3068 www.rttb.org Rebuilding Together Tampa Bay is an equal opportunity agency providing services to eligible persons without regard to race, national origin, sex, sexual orientation, age or handicap. Page 1 of 9

OUR PROGRAM: Building a Healthier Sulphur Springs This program is specific to residents of the Sulphur Springs neighborhood in the City of Tampa. The purpose of installing our Healthy Home Kit is to assist low-income residents to live in a healthier, safer and more energy efficient home by installing products that will improve overall living conditions. This program is offered free of charge to qualified owner-occupied AND tenant-occupied homes. Benefits to You: Over $2,000 in home improvements Potential reduction in your Homeowners Insurance with the installation of hardwired smoke alarms Savings in utility bills as the home is made more energy efficient. A valuable educational workshop entitled Living Healthier in My Home providing home maintenance knowledge to improve housing living conditions. You will have a healthier, safer and more energy efficient home. HOW THIS PROGRAM IS FUNDED: Each year RTTB raises funds from private and public agencies so we can provide our programs and services free of charge to Tampa Bay s neediest residents. Our programs and services are open until funding is exhausted and renewed when funding is once again secured. Note: The delivery and installation of the Healthy Home Kit is FREE and does NOT require a lien to be applied against the property. ELIGIBILITY: Our program serves low-income residents. To be eligible you must meet all of the following: For Owner-Occupied Homes: 1. Property must be an owner-occupied single-family house in the Sulphur Springs neighborhood. 2. Owner must be current with all property taxes and mortgage payments. 3. Applicant must not exceed the maximum household income limits set by HUD. For Tenant-Occupied Homes: 1. Property must be a tenant-occupied single-family home or duplex. 2. Property owner must be current with all property taxes and mortgage payments. 3. Tenant must be: a) Current with rent payments. b) Current with utility payments if applicable (electricity and water). c) Have lived in the dwelling for at least 6 months. d) Must not exceed the maximum household income limits set by HUD. Page 2 of 9

INCOME LIMITS: If the occupant s income exceeds these limits, they are not eligible for this program. The following income limits are based on 80% of Area Median Income (AMI) as determined by HUD. These limits are revised from time to time. The following limits are effective as of 03/16/2015. Maximum Income* Household Size 1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons $33,050 $37,800 $42,500 $47,200 $51,000 $54,800 $58,550 $62,350 *Maximum Income includes gross income from all sources of adult household members. If there are more than 8 persons in your household, please contact RTTB for maximum income limits APPLICATION PROCESS: Upon submittal of your complete application (including all required documentation), RTTB can begin to determine eligibility. Incomplete applications will not be considered. Your application will remain active in our database for a 12 month period, at which time it will expire and you will need to reapply for services. Selected Projects- Upon meeting all program guidelines, we will contact you to begin the project process. RTTB will set up a meeting to determine the needs of your home. Not all items in the Healthy Home Kit may be included as they are based on the need of the dwelling unit. Additionally, RTTB will monitor and supervise its work crews and volunteers throughout the project. NOTE: You are hereby informed that you have the right of appeal the decision made on this application, and you have the right to an expeditious review of your appeal. Should you want to appeal, please contact RTTB, who will furnish you with a copy of the Appeals Procedure established under the guidelines of Florida Statutes. RTTB will not discriminate against any applicant on the basis of race, color, religion, sex, national origin, handicap, age, familial status, or any other non-merit factor, as pursuant to the Fair Housing Act, Civil Rights Act and any other regulatory acts or executive orders. There is no application fee required to make application to receive assistance from RTTB. RTTB has not authorized any other person or entity to act as its agent for purposes of this application and any fees or costs associated with this application (paid by the applicant to any such persons or entity) are not fees or costs charged by RTTB. Page 3 of 9

REQUIRED DOCUMENTATION: In order for your application to be processed, you will need to submit copies of the following documents for the Applicant and any Co-Applicant. Applications submitted without these documents will not be considered. Do Not Send Originals RTTB will not be responsible for your originals. Your completed application can be faxed to 813-513-3068 or mailed to our office at 911 East 122 nd Avenue, Tampa, FL 33612. If you have any questions, please contact us at 813-878-9000, Ext 3. DOCUMENT CHECKLIST: For Owner-Occupied Homes: Copy of Mortgage Deed Deed must be in Applicant s name. Copy of most recent water and electric bill (needed to demonstrate the program s impact on energy savings) Tax receipt or mortgage escrow account statement as proof of paid property taxes Completed Application Form (attached) Signed Permission to Replace Mailbox if needed (attached) Signed Property Owner Acknowledgements and Agreement (attached) Signed Publicity Rights Consent and Release Agreement (attached) For Tenant-Occupied Homes - Property owner must provide: Copy of Mortgage Deed Deed must be in Applicant s name. Copy of most recent water and electric bill (needed to demonstrate the program s impact on energy savings) Tax receipt or mortgage escrow account statement as proof of paid property taxes Completed Application Form (attached) Signed Permission to Replace Mailbox if needed (attached) Signed Property Owner Acknowledgements and Agreement (attached) Signed Publicity Rights Consent and Release Agreement (attached) Page 4 of 9

APPLICATION FORM Please print clearly and complete this application, including all required signatures. ESPAÑOL: Si usted necesita ayuda para llenar esta forma, por favor póngase en contacto con nosotros al (813) 878-9000. Applicant Name: Co-Applicant Name: Address (No P.O. Box addresses) PROPERTY OWNER INFORMATION Applicant(s) must be the Property Owner(s) Last First Initial Last First Initial Street Address City State Zip Code County Phone #s Home Phone: ( ) Work Phone ( ) Cell Phone: ( ) Email: Have you ever applied to Rebuilding Together Tampa Bay? Yes No When: Has another agency made repairs or worked on your home? Yes No When: Name: PROJECT PROPERTY INFORMATION Tenant Information Property Address: Tampa, Florida 33604 Occupancy Owner Occupied: How long as current owner? years and months Tenant Occupied: How long with current tenant? years and months Tenant Phone #s If Tenant Occupied: Monthly Rent: $ Date of occupancy: Housing assistance if applicable. (Check all that apply) Section 8 Certificate Section 8 Voucher Other Assistance Home Phone: ( ) Work Phone ( ) Cell Phone: ( ) Email: Construction Year Built Date of Purchase: Type of Construction: Brick Wood Vinyl/Aluminum Siding Other # of Stories # of Bedrooms Taxes Other Property Are you current on your property taxes?: Yes No (Attach Tax Receipt or Mortgage escrow account statement showing taxes are paid) Do you own other residential property in Sulphur Springs?: Yes No Do you earn rental income from that property?: Yes No (If Yes to the questions above, please provide additional property information on the following page. Note: Additional rental homes in Sulphur Springs may qualify for the program as well). Page 5 of 9

Name: Property Address: Occupancy ADDITIONAL PROPERTY.INFORMATION Tenant, Tampa, Florida 33604 Owner Occupied: How long as current owner? years and months Tenant Occupied: How long with current tenant? years and months Tenant Phone #s If Tenant Occupied: Monthly Rent: $ Date of occupancy: Housing assistance if applicable. (Check all that apply) Section 8 Certificate Section 8 Voucher Other Assistance Home Phone: ( ) Work Phone ( ) Cell Phone: ( ) Email: Construction Year Built. Date of Purchase: Type of Construction: Brick Wood Vinyl/Aluminum Siding Other # Units in Building # of Stories # of Bedrooms Taxes Are you current on your property taxes?: Yes No (Attach Tax Receipt or Mortgage escrow account statement showing taxes are paid) Name: Property Address: Occupancy ADDITIONAL PROPERTY INFORMATION, Tampa, Florida 33604 Owner Occupied: How long as current owner? years and months Tenant Occupied: How long with current tenant? years and months Tenant Phone #s If Tenant Occupied: Monthly Rent: $ Date of occupancy: Housing assistance if applicable. (Check all that apply) Section 8 Certificate Section 8 Voucher Other Assistance Home Phone: ( ) Work Phone ( ) Cell Phone: ( ) Email: Construction Year Built. Date of Purchase: Type of Construction: Brick Wood Vinyl/Aluminum Siding Other # Units in Building # of Stories # of Bedrooms Taxes Are you current on your property taxes?: Yes No (Attach Tax Receipt or Mortgage escrow account statement showing taxes are paid) Page 6 of 9

OCCUPANT S INCOME Select the annual gross income (before taxes) Less than $10,000 per year $10,001 to $20,000 per year $20,001 to $30,000 per year $30,001 to $40,000 per year $40,001 to $50,000 per year $50,001 to $60,000 per year over $60,001 per year HOUSEHOLD SIZE Select the size of Occupant s household 1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons or more In order to determine my eligibility for the Building a Healthier Sulphur Springs Program, I certify that the income information I provided is true and correct to the best of my knowledge. PROPERTY OWNER(S): PERMISSION TO REPLACE MAILBOX I/We, hereby certify that I/we am/are the owner(s) of the property located at, Tampa, FL 33604, herein referred to as the Project Property. I/We hereby grant full permission to Rebuilding Together Tampa Bay, Inc. (RTTB) to replace the existing mailbox (if needed) located at the Project Property with a new mailbox to be clearly labeled with the street address number. This will improve the aesthetics of the neighborhood and providing clearly legible and visible address numbering on my property for emergency response purposes. I/We shall indemnify and save harmless Rebuilding Together Tampa Bay, Inc., its officers, agents, servants, employees and designees from all liability for death or injury to any person resulting from the installation of said mailbox on the Project Property. PROPERTY OWNER(S) Sample of Mailbox and Post Page 7 of 9

PROPERTY OWNER ACKNOWLEDGEMENTS AND AGREEMENT I/We understand and acknowledge that not all items in the Healthy Home Kit may be included as they are based on need of the dwelling unit. A representative of Rebuilding Together Tampa Bay, Inc. (RTTB herein) will conduct a site visit to determine needs. I/We hereby acknowledge and permit the use of information contained in this Application to be used to determine eligibility for participation in the RTTB s Building a Healthier Sulphur Springs Program. I/We hereby agree to provide any documentation needed to assist in determining eligibility. [Check One and Insert Names] Owner-Occupied Homes I/We, hereby certify that I/we are the owner(s) of the property described in this Application, and that said property is my/our principal place of residence. Tenant-Occupied Homes: I/We, hereby certify that I/we are the owner(s) of the property described in this Application, and that said property is currently leased to. Hold Harmless: I/We shall indemnify and save harmless Rebuilding Together Tampa Bay, Inc., its officers, agents, servants, employees and designees from all liability for death or injury to any person resulting from the improvements of my property. General Release: I/We hereby authorize RTTB or its designated agents to obtain and receive all records and information pertaining to eligibility for the Building a Healthier Sulphur Springs Program, including ownership information from all persons, companies, or firms holding or having access to such information. This authorization hereby gives RTTB the right to request all information that we can or could obtain from any persons, company or firms on any matter referred to above. I/we agree to have no claim for defamation, violation of privacy, or otherwise against any person or firm or corporation by reason of any statement or information released by them to the RTTB for the purposes of the program. I/We certify that all information in this Application and all information furnished in support of this Application are given for the purpose of obtaining services under RTTB s Building a Healthier Sulphur Springs Program and all information furnished is true, correct, complete, and nothing has been omitted, to be best of my/our knowledge and belief. PROPERTY OWNER(S): Witness: Witness: Page 8 of 9

RTTB may choose to install your Healthy Home Kit as part of a larger community event, which may result in your photograph (or video) being taken to promote this event. The following agreement allows us to use that image. Please read and sign. PUBLICITY RIGHTS CONSENT AND RELEASE AGREEMENT In consideration of the publicity I may enjoy, along with such other consideration the receipt and sufficiency of which is hereby acknowledged, I hereby grant to Rebuilding Together Tampa Bay, its affiliates, subsidiaries, agents, licensees, successors, assigns and any others acting with Rebuilding Together Tampa Bay s permission or under its authority (collectively RTTB) the right and license throughout the world to record, reproduce, display, perform, broadcast, transmit, edit, retouch and otherwise use my picture, likeness, name and/or other depiction of myself and my biographical information (the Publicity Rights ) for use in connection with its project. I understand and agree that I will not be monetarily compensated for consenting to this use of my Publicity Rights. I also understand and agree that RTTB has no duty to use the Publicity Rights granted. I agree that any picture, portrait, or other depiction of me is owned by RTTB and may be copyrighted in RTTB s name. If I should receive any print, negative or other copy thereof, I shall not use it or authorize its use by anyone else. I hereby waive any right to inspect or approve of any usage of the Publicity Rights described above. Further, I hereby release and discharge RTTB and its related companies from any and all claims arising out of or under this Consent and Release Agreement, including, but not limited to, any claims for blurring, distortion, optical illusion or alteration or any claims for failure of RTTB to use the Publicity Rights. I warrant and represent that (a) I have the full right and authority to enter into this Consent and Release Agreement; (b) I have not granted anyone else the exclusive right to use the Publicity Rights; and (c) RTTB s use of the Publicity Rights shall not infringe or violate the rights of any third party. I am twenty-one (21) years of age or older, and I understand and accept the terms of this Agreement: PROPERTY OWNER(S): Page 9 of 9