Owner Occupied Rehab Prgram This prgram utilizes grant funds frm the Indiana Husing and Cmmunity Develpment Authrity t assist the hmewner with repairs such as: rf, gutters, bathrm renvatins, flrs, drs, electrical and plumbing. Incme requirements must be met alng with: Prperty taxes currently paid t date Prf f hmewner's insurance Prf f wnership thrugh a title/deed Currently ccupying the residence Recrding a Restrictive Cvenant Lien Fr additinal infrmatin n this prgram please cntact Cathy Miller at 574-722-4451. Page 1 f 6
CITY OF LOGANSPORT HOMEOWNER APPLICATION Owner Occupied Rehabilitatin Please return cmpleted frm t Area Five Agency n Aging and Cmmunity Services, 1801 Smith Street, Lgansprt, IN 46947 POSTMARKED NO LATER THAN MONDAY, JUNE 30, 2014. Please cntact Cathy Miller f Area Five Agency with any questins at 574-737-2144. Please d nt fax r e-mail these frms they will nt be accepted. Citizenship Requirement: A Citizenship Declaratin Frm is required fr this prgram and is included with this applicatin. The hmewner (persn wh maintains wnership via deed/title) must meet citizenship requirement. Please fill in frm cmpletely and return alng with this applicatin. The Hmewner (nt husehld members) must als include a legible cpy f yur Scial Security card r Birth Certificate r ther valid dcument(s). Fr all blanks that d nt apply t yur husehld, please write N/A (nt applicable). Husing NOT eligible fr this prject: Creatin f secndary husing attached t a primary unit Prject-based tenant assistance Hmes within a 100- year fldplain Mbile hmes Rental husing Hmes that are nt ccupied by the wner Please nte: Manufactured Husing IS eligible if it meets the Indiana Husing and Cmmunity Develpment Authrity s Plicy (please ask fr mre clarificatin) 1. HOMEOWNER (circle ne): Yes r N 2. HOMEOWNER S NAME: (As it appears n Title/Deed) 3. ADDRESS: please list yur physical address and include a PO Bx if applicable. COUNTY: TOWNSHIP: 4. HOME PHONE #: CELL #: 5. LIST ALL PERSONS IN HOUSEHOLD AND AGES: 6. TOTAL NUMBER LIVING IN HOUSEHOLD: Page 2 f 6
7. LIST ALL EMPLOYERS AND GROSS WAGES (specify per week, mnth, r year) FOR ALL PERSONS AGE 18 AND OVER: 8. PLEASE LIST OTHER SOURCES OF INCOME AND GROSS AMOUNT (specify per week, mnth r year). Other surces include: Child Supprt, Scial Security, SSI, TANF Unemplyment, Self-emplyed, Any Other Regular Incme Received, etc.: 9. TOTAL GROSS HOUSEHOLD INCOME (add all members incme ver age f 18): Please circle ne: weekly / mnthly / yearly 10. IF A HOUSEHOLD MEMBER IS A STUDENT ATTENDING COLLEGE AND HE/SHE IS WORKING, PLEASE LIST HIS/HER NAME AND GROSS INCOME: 11. LIST ALL ASSETS AND VALUE (example: Checking Accunt, Savings Accunt, Certificate f Depsits, Pensin funds, Retirement accunt, Rental Prperty, Revcable trusts, Stcks, Bnds, IRA s, Life insurance: amunt available befre death, Persnal prperty held as an investment, Inheritance, Capital Gains, Mrtgages r Deeds f Trust, Land wned that is NOT primary residence, etc.): Attach additinal pages if needed. 12. IS THE HOMEOWNER OR A MEMBER OF THE HOUSEHOLD 62 YEARS OLD OR OLDER, HAVE A MENTAL OR PHYSICAL DISABILITY, OR IS A SINGLE PARENT (T qualify as a single parent, there must be a dependent child under the age f 18 living in the hme) YES NO 13. IF YOU MARKED YES TO QUESTION # 12 PLEASE CHECK THE CORRECT AREA(S) THAT DESCRIBES YOUR HOUSEHOLD: 62 OR OLDER DISABILITY SINGLE PARENT 14. PLEASE LIST THE BANK YOUR MORTGAGE IS WITH: Page 3 f 6
15. LIST ANY OTHER LIENS ON THE PROPERTY: 16. ARE YOUR PROPERTY TAXES PAID UP-TO-DATE? Y r N 17. DO YOU HAVE A CURRENT HOMEOWNERS INSURANCE POLICY? Y r N 18. IS YOUR HOME OWNED IN A FEE SIMPLE TITLE (Mrtgage), LAND CONTRACT, OR LIFE ESTATE? (circle ne r list ther : ) If yu select ther type f wnership, please clarify (living trust, cntract fr deed, etc.) 19. LIST REPAIRS NEEDED ON HOME IN ORDER OF NEED/PREFERENCE (must be structural, nt csmetic): **This infrmatin will need t be verified and will nly be used fr this funding prgram. I CERTIFY THAT THE DWELLING FOR WHICH I AM REQUESTING ASSISTANCE IS MY PRIMARY RESIDENCE. I GRANT AREA FIVE AGENCY PERMISSION TO USE THIS INFORMATION IN EXPLORING THE OWNER -OCCUPIED REHABILITATON GRANT PROGRAM THROUGH THE CITY OF LOGANSPORT. I AUTHORIZE AREA FIVE AGENCY TO PERFORM AN IN-DEPTH STUDY TO DETERMINE MY/OUR ACTUAL NEED. THIS INVESTIGATION MAY INCLUDE CONTACTING PAST AND PRESENT EMPLOYERS AND/OR A TITLE SEARCH. I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. FALSIFICATION OF DATA OR INCORRECT DATA MAY CONSTITUTE GROUNDS FOR DENIAL OF ASSISTANCE. _ SIGNATURE OF HOMEOWNER DATE WARNING: Title 18, Sectin 1001 f the US Cde states that a persn is guilty f a felny fr knwingly and willingly making false r fraudulent statements t any department f the United States Gvernment. Page 4 f 6
CITIZENSHIP DECLARATION FORM Only the hmewner (persn wh hlds deed/title t hme) is required t fill ut this frm. Last Name First Name Relatinship t Head f Husehld Sex Date f Birth Scial Security N. Alien Registratin N. Admissin Number (if applicable) (This is an 11-digit number fund n INS Frm I-94, Departure Recrd) Natinality (The freign natin r cuntry t which yu we legal allegiance. This is nrmally, but nt always the cuntry f birth). Save Verificatin N. (t be entered by wner if and when received) Cmplete the Declaratin belw by printing r typing the persn's first name, middle initial, and last name in the space prvided. Then review the blcks shwn belw and cmplete either blck number 1, 2, r 3. DECLARATION I,, hereby declare, under penalty f perjury that I am: 1. A citizen r natinal f the United States. If yu checked this blck, n further infrmatin is required. Sign and date belw and frward this frm t Area Five Agency, 1801 Smith Street, Lgansprt, IN 46947.If this blck is checked n behalf f a child, the adult wh will reside in the assisted unit and wh is respnsible fr the child shuld sign and date belw. Signature Date Check if adult signed fr a child: (Frm cntinues n reverse) Page 5 f 6
2. A nncitizen with eligible immigratin status in the categry checked belw: (i) A nncitizen lawfully admitted fr permanent residence, as defined by sectin 101 (a) (20) f the Immigratin and Natinality Act (INA), as an immigrant, as defined by sectin 101(a) (15) f the INA (8 U.S.C. 1001(a) (20) and 1101(a) (15), respectively) [immigrants]. (This categry includes a nncitizen admitted under sectin 210 r 210A f the INA (8 U.S.C. 1160 r 1161) [special agricultural wrker], wh has been granted lawful temprary resident status). (ii) A nncitizen wh entered the United States befre January 1, 1972, r such later date as enacted by law, and has cntinuusly maintained residence in the United States since then, and wh is nt eligible fr citizenship, but wh is deemed t be lawfully admitted fr permanent residence as a result f an exercise f discretin by the Attrney General under sectin 249 f the INA (8 U.S.C. 1259). (iii) A nncitizen wh is lawfully present in the United States pursuant t an admissin under sectin 207 f the INA (8 U.S.C. 1157) [refugee status]; pursuant t the granting f asylum (which has nt been terminated) under sectin 208 f the INA (8 U.S.C. 1158) [asylum status]; r as a result f being granted cnditinal entry under sectin 203(a) (7) f the INA (8 U.S.C. 1153(a) (7)). Signature Date Check if adult signed fr a child: REQUEST FOR EXTENSION (ptinal) I hereby certify that I am a nncitizen with eligible immigratin status, as nted abve, but the evidence needed t supprt my claim is temprarily unavailable. Therefre, I am requesting additinal time t btain the necessary evidence. I further certify that diligent and prmpt effrts will be under-taken t btain this evidence. Signature Date Check if adult signed fr a child: 3. Nt cntending eligible immigratin status and I understand that I am nt eligible fr financial assistance. If yu checked this blck, n further infrmatin is required and the persn named abve is nt eligible fr assistance. Sign and date belw and frward this frm t Area Five Agency, 1801 Smith Street, Lgansprt, IN 46947 If this blck is checked n behalf f a child, the adult wh is respnsible fr the child shuld sign and date belw. Signature Date Check if adult signed fr a child: Page 6 f 6