Habitat Nassau Application for Super-storm Sandy Home Repairs PLEASE READ CAREFULLY BEFORE COMPLETING THE APPLICATION Habitat for Humanity of Nassau County, NY Inc will help low to moderate income homeowners recover from Super-storm Sandy Habitat Nassau offers home repairs necessary for restoring and maintaining safe and sound living conditions Volunteer teams along with subcontractors working under the direction of Habitat staff to do the necessary repairs Eligible work includes all areas of construction inside and out and is performed at cost for homeowners who would be unable to complete and fund such home repairs on their own Homeowners may contribute to the project by working on the house alongside volunteers or by performing other volunteer activities (sweat equity) This program was created to help families whose homes were affected by the October 2012 Superstorm: Sandy Who Can Qualify: Any existing homeowner meeting the criteria shown below and having Median Household Income less than 80% of the Area Median Income ( AMI ) (currently about $86,000 for a family of 4) Applicants must certify that they own and reside in their own, single family home, have no present intention to move or offer the home for sale at the present time, and that they have homeowners insurance Project Size: Project size will be dependent on need and available funds Initial Project Location: Homes must be in Nassau County, NY To submit an application, please do the following: 1 Collect all of the documents on this checklist if it applies to you (Items listed in italics are forms provided by Habitat) 2 Please submit only COPIES of your DOCUMENTS No Originals 3 Return the application and supporting documents to HFHNC at the address above Application completely filled out and signed by all applicants State Issued Photo Identification for all applicants and adult household members (age 18 or older) Social Security Cards for all applicants and household members Deed, Warranty Deed or Deed of Trust, whichever applies Proof of Homeowner's Insurance (declaration page) Privacy Statement - signed Benefit letters or statements for SS, SSI, Disability or other non-taxable income Employment verification for income from employment Copies of tax returns for two most recent years If you did not file taxes in these years, you must get a Statement of Non-Filing from the IRS Copy of all FEMA letters
Section A Household Information: PLEASE PRINT CLEARLY DO NOT USE PENCIL Instructions: Applicant and Co-Applicant Information A co-applicant is someone who shares ownership of the home, responsibility for the mortgage, and who will also live in the home Not everyone has a co-applicant Please print clearly and fill out ALL information If something does not apply to your situation, please mark through it so that we know that you have considered the question and it does not apply Applicant Information Name: First Middle Last Preferred Name: Date of Birth: Social Security # - - Marital Status: married unmarried (incl single, divorced, widowed) separated Applicant Contact Information Co-Applicant Information Name: First Middle Last Preferred Name: Date of Birth: Social Security # - - Marital Status: married unmarried (incl single, divorced, widowed) separated Co-Applicant Contact Information Home Address: Street address Apartment # Home Address: Same as applicant: (skip address section) Street address Apartment # City Zip Code Mailing Address, if different: Phone numbers: Please check your preferred number home: ( ) work: ( ) cell: ( ) Best time of day to call: If it is okay to call you at work, check here: e-mail address: Note: HFHNC will not share your e-mail with anyone else Are there any special instructions about contacting you? If so please describe:, City Zip Code Mailing Address, if different: Phone numbers: Please check your preferred number home: ( ) work: ( ) cell: ( ) Best time of day to call: If it is okay to call you at work, check here: e-mail address: Note: HFHNC will not share your e-mail with anyone else Are there any special instructions about contacting you? If so please describe:,
Instructions: Other Household Members Please list everyone who lives in your home (other than the applicant and co-applicant) Income limits are based on family size Name Gender Date of Birth Age Relationship to Applicant If you need more room, please add an additional page Section B Household Income: Instructions: Income from Employment Current Employment: Please use the employment verification form included in your application packet to provide information on all current employment Employment verification forms must be completed and included with your application Applicant Information Co-Applicant Information Current Employer(s): Completed verification form is attached: yes no Completed verification form is attached: yes no Completed verification form is attached: yes no * add an additional page, if necessary Current Employer(s): Completed verification form is attached: yes no Completed verification form is attached: yes no Completed verification form is attached: yes no * add an additional page, if necessary
Instructions: Other Household Income If the applicant and/or co-applicant has income other than from employment; if another household member has income and/or if you receive income on behalf of another household member, please list the source of that income and provide documentation with your application Types of income include employment (all household members regardless of age), SSI, SSDI, pension, Social Security, AFDC, child support, child only grant, trust funds, etc Note: Child support must be included in this section as ordered (even if it is not paid) Child support should also be documented in two ways: as ordered and as paid Please use a separate line for each type of income It is extremely important to document all household income Under certain circumstances, we may not have to count all sources of income but we need to be aware of it Because our income limits are strict, if undeclared income is discovered, the application will be declined Name of Household Member Type of Income Monthly Amount If disability, child support, grants, etc, what is the ESTIMATED END DATE for this income? Documentation of this income is provided yes yes yes no no no If necessary, add an additional page Please provide the above information on all additional household income Section C Home Ownership: Applicants must own their home on which repair is being requested Please enclose with this application a copy of the deed on your home or other proof of homeownership, along with proof of current homeowner s insurance Type of Debt Home Mortgage Name of Lender and Account Number Current Balance $ estimated payoff date: month / year Payment Amount $ monthly bi-weekly other (specify) This account is current If necessary, add an additional page Please provide the above information on all additional household debts Documentati on of this account is provided yes no yes no
Section D Financial Information: Accounts and Other Things that Are Worth Money (Assets) Instructions: Liquid Assets (Money Accounts) Please list all of the accounts containing money that the applicant and co-applicant have This includes all bank accounts (checking and savings), Certificates of Deposit, retirement savings, escrow or Individual Development Account (IDA), and any other accounts worth money that you may have Note: An escrow or IDA account is a special matched savings account set up through certain programs to provide assistance with education, business start-up, or homeownership Not everyone has one of these accounts Type of Account (for example: checking, savings, CD, retirement, escrow/ida, etc) Name of Financial Institution Account Number Current Balance Documentation of this account is provided yes no yes yes yes yes no no no no If necessary, add an additional page Please provide the above information on all additional household accounts Do you own land or property other than your current home? yes no If yes, please provide the location of the property Location: Instructions: List of Any Other Assets Please list any of the following things, if you have them: cars, motorcycles, recreational vehicles, inheritance, timeshares, boats, and anything else worth more than $500 For vehicles, include the model and year Add an additional page, if necessary 1 Home Value: 3 2 4 Have you filed bankruptcy in the last 7 years? Chapter 7 Chapter 13 yes no yes no Have you ever been, or are you now, involved in a lawsuit? If yes, indicate: Involved now Not involved now, but was before yes no yes no Have you had property repossessed (car, furniture, etc)? yes no yes no If so, indicate month and year: Have you ever been convicted of a crime? yes no yes no If you answered yes to any of these questions except the first one, please include an explanation with your application packet
SECTION E Declarations: Are you a US citizen or permanent resident? yes no yes no Is your home in foreclosure or at immediate risk of foreclosure? yes no n/a yes no n/a Do you have any court-ordered debt payments or judgments against you? yes no yes no SECTION F Requested Repairs: Briefly describe the type of work you would like done on your home Attach a separate piece of paper if there is not enough space to list all repairs Remember that the items listed below will be considered for repair, but the final decision on what work can be done with our time and financial resources will be made at the discretion of Habitat of Nassau County, NY, Inc The work done by HFHNC will focus on repairs, improvements, safety and independence A written estimate of the project costs will be prepared by the HFHNC staff prior to finalizing the application Area 1: Describe the Area of Repair and Help Needed from Habitat (PLEASE PRINT AND BE SPECIFIC) Area 2: Were you impacted by the October 2012 storm? Did you receive FEMA funds? Do you have FEMA money remaining to commit to this project?
Special Needs: Do you have any special needs that need to be considered in the home repairs and renovations? Section G Media and Publicity: Where did you learn about Habitat Nassau Repairs? TV Radio Newspaper Flyer Friend Neighbor Neighborhood Organization OTHER: please describe If HFHNC selects your house to be repaired, pictures of you and your home may be taken YES My home and my story can be used in HFHNC media promotions Section H Personal Statement: Please write a brief explanation of why you feel you should be selected for Habitat Nassau repairs and how it will help you
Section I Ability and Willingness to Partner with Habitat for Humanity: Instructions: Ability and Willingness to Partner The following needs a response from both the applicant and co-applicant If you have questions about the sweat equity requirements, please contact the Habitat office Applicant Co-Applicant 1 Are you willing to partner with HFHNC according to the sweat equity requirements? yes no yes no Under The Federal Equal Credit Opportunity Act, Fair Housing Law and Consumer Credit Protection Act: We do not discriminate on the basis of race, sex, color, age, disability, religion, national origin, family status or marital status, or because all or part of income is derived from any public assistance program
AGREEMENT AND AUTHORIZATION Please read carefully Both applicant and co-applicant are required to sign in order for the application to be considered I certify that the information on this application is accurate and that I own and use as my primary residence the property at the address given on this application and that I have current homeowner s insurance on that property I have no present intention to move or offer my home for sale at the present time I confirm that any physically able persons residing in my home or visiting for the project day(s) will contribute to the project by working alongside Habitat of Nassau County, NY, Inc (HFHNC) volunteers I confirm that, except for the conditions listed above, my home is a safe place for volunteers To the extent permitted by law and without affecting the coverage provided by the required homeowners insurance, I agree to sign the release and waiver of liability I understand that in signing this application, I am authorizing Habitat for Humanity of Nassau County, NY, Inc (HFHNC) to evaluate my actual need for the Habitat Nassau Repairs program repairs and renovations and my willingness to partner with HFHNC according to its partnership requirements which includes my ability to repay the no-interest loan I understand that the evaluation will include a personal visit to my home; verification of household income, employment, and residence; verification that I own my home and of its value; and requests for other pertinent information about me including but not limited to credit worthiness I will notify HFHNC of any changes in employment, income and/or debt that occur during the selection process I have disclosed all of the assets owned by the applicant and co-applicant (as defined in the application instructions) I have answered all the questions on this application truthfully I understand that if I have not answered the questions truthfully, my application may be declined, and, even if I have already been approved for the HFHNC Habitat Nassau Repairs program, I may be disqualified from that program I understand that Habitat for Humanity of Nassau County, NY screens all applicant families on the sex offender registry By completing this application, I am submitting to such inquiry I understand that HFHNC reserves the right to refuse to partner with any individual, as recommended by the HFHNC s Board of Directors I understand that this application and all supporting documents will become the property of HFHNC and will not be returned to me, and that HFHNC will keep the original application on file, whether or not it is approved All supporting documentation must be attached Applicant Signature Date Co-applicant Signature Date