city of fairborn 44 w. hebble avenue fairborn, oh … application - 2018-1.pdffactors are reviewed...
TRANSCRIPT
Fiscal Year 2018 CHIP and CDBG
Dear Applicant:
Some generally accepted types of rehabilitation/repairs include:
Roofs Electrical Water/Sewer line repair
Gutters Walk stairs Hot Water Tanks
Windows Plumbing Structural Deficiencies
Furnaces Doors Handicap Accessibility
Sincerely
Missy Frost
Development Services Assistant Director
Upon the submission of all required documents, your application will be reviewed for compliance. At that time,
the City's Rehabilitation Specialist will contact you to evaluate your home as part of the application process.
Once these items have been completed you will be notified of your eligibility in the program.
Only complete applications will be processed. Appointments are available with staff to review your application
and assist in ensuring all documentation is included by calling 937-754-3060.
Thank you for your interest in the City of Fairborn's Housing Rehabilitation Loan Program. Attached you will
find the materials necessary for your application.
The City provides financial assistance to low- and - moderate income homeowners to correct property
maintenance issues, lead based paint hazards as well as needed home repairs and improvements. Several
factors are reviewed prior to approval; those include the urgency of repair needed, overall condition of the
property, and the financial need of the applicant.
There are two forms of assistance avaiable, depending on the condition of the home. 1). If the home needs
complete rehabilitation, assistance will be in the form of a 5 year zero (0%) interest deferred/forgivable loan
reducing 15% each year with 25% remaining due upon transfer of the property. This will be secured by a
mortgage and promissory note with a declining repayment agreement. 2). In the event the home needs
minor repairs, assistance will be in the form of a 2 year zero (0%) interest deferred/forgivable loan which
reduces 50% each year but due and payable upon transfer of the property during those two years (same as
above). This will be secured by a mortgage and promissory note.
City of Fairborn44 W. Hebble Avenue
Fairborn, OH 45324p: 937.754.3060f: 937.754.3051
Development Services DepartmentMissy Frost
Development Services Assistatnt Director
1 q Photo identification of all loan applicants (driver's license or State ID)
2 Written verifications of all household income listed that applies (all persons over the age of 18)
q Last 2 months pay stubs
q Verification form signed by employer(s)
q Recent Bank statements (at least 6 months)
q Verification form signed by bank(s)
q Recent statements from savings accounts, investments, or other assets (at least 6 months)
q Social Security Award letter(s), if applicable
q Proof of Child Support or Alimony, if applicable
q Proof of Retirement income (VA, OPERS, IRA, Annuities, Civil Service), if applicable
q Last 3 year's tax returns (1040 form with W-2's, if self-employed)
q IRS Form 4506 (if self-employed)
3 q Proof of Ownership; Property Deed
4 q Homeowner's Insurance Declaration Page from Insurance Policy
5 q Proof Property Taxes are current
6 q Proof City Income Taxes are current
7 q Mortgage Statement (payment information)
8 q Home Equity Statement (payment information), if applicable
9 q Current monthly utility obligations
q Water q Gas q Electric
10 q Owner Occupancy Statement
11 q Receipt for Lead Based Paint Booklet and Fair Housing Information
12 q Walk Away Provision Statement
13 q Not employed, please provide signed statement regarding same
14 q The application has been signed by all property owners listed on the deed
Docmentation Required for a Housing Rehabilitation Loan
All items must be included to ensure a complete application is submitted.
Please contact us to schedule an appointment to review the completed application.
Name SSN#
Birthdate Gender: Male Female
Marital Status: Married Separated
Unmarried (includes single, divorced, widowed)
2. Co-Applicant (Spouse or Co-Owner)
Name SSN#
Birthdate Gender: Male Female
Marital Status: Married Separated
Unmarried (includes single, divorced, widowed)
3. Address
Address No. and Street
City Zip
Years at residence:
Number of Bedrooms
4. Contact Information
Home # Email
Cell # Co-Applicant Cell #
Work # Co-Applicant Work #
1. Applicant (Head of Household)
Housing Rehabilitation Loan ApplicationIn order for this application to be complete, all items listed on the "Documents Required" checklist must
be included.
Number of Baths
Year Built
5. Household Members
DOB Age
1
2
3
4
5
6
Are any of these members handicapped or disabled?
Yes No Age
Please indicate what type of special housing accommodations are needed, if applicable.
Are any of these members an Armed Forces Veteran?
Yes No
Are any of these members experiencing Elevated Blood Levels from Lead Based Paint?
Yes No Age
6. Race and Ethnicity
Please check which one applies to you.
I do not wish to furnish this information
White (Caucasian)
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiin/Other Pacific Islander
American Indian/Alaskan Native & White
Asian & White
Black/African American & White
American Indian/AlaskanNative & Black/African American
Asian & Pacific Islander
Hispanic
Not Hispanic
Full Name Relationship
7. Employment (List all income for household members over the age of 18)
Applicant's Employer
Address
Phone No.
Position
Date Employed
Applicant's 2nd Employer
Address
Phone No.
Position
Date Employed
Co-Applicant's Employer
Address
Phone No.
Position
Date Employed
Co-Applicant's 2nd Employer
Address
Phone No.
Position
Date Employed
7. Employment (List all income for household members over the age of 18)
Other Member's Employer
Address
Phone No.
Position
Date Employed
Other Member's 2nd Employer
Address
Phone No.
Position
Date Employed
8. Gross Monthly Income of all household members over the age of 18
Base Pay
Hourly rate
Overtime Pay
Social Security
Rental Income
Disability
Pension/Retirement
Alimony/Child Sup
Unemployment
Other/Royalties
Military Pay
Workers Comp
Self-Employment
Investments
Total Monthly Income
Description of Other Income:
9. Assets
Applicant Co-Applicant Other Member
Real Estate Owned (other than primary residence):
Address
Mortgage Balance Value
Gross Monthly Rent Return
10. Expenses
1st Mortgage
2nd Mortgage
Taxes
Mortgage Insurance
Past Due Taxes
Water
Gas
Electric
Homeowner's Insurance Provider
Name
Address
Phone Number
Policy Number
11. Credit History
Applicant
Check if Yes
Co-Applicant
Check if Yes
Do you have any outstanding judgements?
Have you declared bankruptcy in last 7 years?
Have you had a property foreclosed upon?
Are you a co-maker, co-signer or endorser of a note?
Are you obligated to pay alimony, child support or maintenance?
Are you party to a lawsuit?
BalancesMonthly Payments
Both the Applicant and Co-Applicant must answer all that apply.
12. Home Improvements Needed
Please list the items at your residence that you feel are in need of rehabiliation. Give a brief
description/explanation as to why these items are needed. Keep in mind that some of the generally
accepted types of rehabilitation include: Roofs, gutters, windows, doors, furnaces, electrical
upgrades, walk stairs, plumbing, water/sewer line repairs, hot water tanks, structural
deficiencies.
13, Certifications by Applicant
(Initials)
(Initials)
(Initials)
(Initials)
(Initials)
(Initials)
Signature of Applicant Date Signature of Co-Applicant Date
I (we) understand that the personal financial information contained in this application is necessary for evaluation of my application
for rehab assistance. This information, however, will remain confidential and will not be disclosed to the news, media or other
third parties. I further understand that my name, address and total amount of rehabilitation assistance will be subject to public
disclosure since public funds are being utilized to rehabilitation my property.
WARNING: Whoever knowing makes any false statement, including over-valuation of any asset or omission of any liability on this
or any other document in connection with any transaction with this lender, will be subject to fine and/or imprisonment under
provisions of the US Criminal Code.
The undersigned hereby submit this application for a Housing Rehabilitation Loan from the City of
Fairborn. Furthermore, I/We swear that the information provided in this application is true, correct and
complete.
All applicants must read and initial the following statements. If you do not understand any part of it or
have any questions about what you are asked to sign, please ask someone at the City of Fairborn to help
you.
I (we) hereby certify that all the information in this application is true and complete to the best of my (our)
knowledge, and hereby give the City of Fairborn, Department of Community Development (or any lender acting on
the City's behalf) to conduct further credit and financial investigations, as deemed necessary to determine eligibility.
Furthermore, I (we) agree to abide by the eligibility and program requirements set forth in connection with any
opportunities that may be offered to me (us) by the City of Fairborn pursuant to this application. I (we) understand
that false, inaccurate, or incomplete information in the foregoing application shall be considered cause for me to be
disqualified from participation in the City of Fairborn's Housing Rehabilitation Program, and I (we) must immediately
notify the City of any change in my (our) income or household size prior to closing for re-verification. I also
understand that if there are delays beyond six (6) months, then updated income information will be required.
I (we) understand that we are applying for a loan which may be secured by a mortgage or deed of trust on the property described
herein and represent that the property will not be used for any illegal or restricted purposes.
I (we) hereby consent to and authorize the City of Fairborn, HUD, ODSA, and/or the designated lender, after the giving of
reasonable notice, to enter the improved property for the sole purpose of determining that the improvements specified in this
application have been completed and Minimum Property Standards have been met.
I (we) understand that the construction contract will be between me (us) and the contractor/dealer. I (we) will be responsible
for the selection of the contractor, acceptance of the materials used, and the work performed. Neither the City of Fairborn,
HUD, ODSA guarantees the materials or workmanship.
Permission to order a lien search and/or verify other information relevant to this application.
Municipal Income Tax Alimony/Separation Payments Income from Business
Municipal Water Assets (all sources) Pension/Annuities
County Property Tax Bank Accounts Social Security Benefits
Municipal Services Child Support Payments Tax Returns (all)
High Grass and Weed Invoice Employment Unemployment Benefits
Property Liens Income (all sources VA Benefits
Printed Name of Applicant Date Printed Name of Co-Applicant Date
Signature of Applicant Date Signature of Co-Applicant Date
Printed Name of Adult family member Date Printed Name of Adult family member Date
Signature of Adult family member Date Signature of Adult family member Date
I authorize and release the City of Fairborn and/or HUD to obtain information, about me and my household,
that is pertinent to my eligibility for participation in the City of Fairborn Housing Rehabilitation Program,
and to verify the information I provided.
AUTHORIZATION AND RELEASE OF CONFIDENTIAL INFORMATION
I/We give permission to the City of Fairborn, its agents and/or employees to obtain and access information relevant to
the loan application and evaluation process. I/We understand that this information is used to determine if I/We qualify
for assistance through the City of Fairborn Housing Rehabilitation Program.
This release and authorization specifically includes, but not limited to a title lien search, municipal income tax
information, municipal water bill records, other city obligations, items listed below and the ability to repay an
obligations arising out of the loan or other financial assistance for which I am applying.
Privacy Act Notice Statement: The U.S. Department of Housing and Urban Development (HUD) is requiring the collection of the information derived
from this application to determine an applicants eligibility to participate in the CDBG and HOME-funded City of Fairborn Housing Rehabilitation
Program. This information will be used to establish the level of benefit from the CDBG and/or HOME program; to protect the Government's financial
interest; and to verify the accuracy of the information furnished. It may be released to appropriate Federal, State, and Local agencies when relevant,
to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in a delay or rejection of your
eligibility approval. The Department is authorized to ask for this information by the National Affordable Housing Act of 1990.
I/We further understand that I must be current with the City of Fairborn at the time of application and must remain
current throughout the process. Failure to come current and remain current shall result in this application being void.
TO:
RE:
Position Held:
Dates of Employment: From To
Base Pay Rate:
$ /Hour or $ /Week or $ /Month
Average hours worked per week:
Overtime Pay Rate:
$ /Hour or $ /Week or $ /Month
Average hours worked per week:
Expected average number of hours overtime worked per week during the next 12 months:
Any other compensation not included above (specify for commissions, bonuses, tips, etc.)
For : $ Per
Signature of Employer:
Title: Date:
Phone Number:
Signature of Applicant:
Date:
This employee is applying to the City of Fairborn for a home rehabilitation program that is funded via
federal grants. We ask your cooperation in supplying this information as it will be used only to
determine the eligibility status and level of benefit to the household.
Comments:
Request for Verification of Employment
City of Fairborn44 W. Hebble Avenue
Fairborn, OH 45324p: 937.754.3060f: 937.754.3051
Community Development DepartmentMissy Frost
Community Development Coordinator
TO:
RE:
Checking Acct. No.
6 Month Avg. Balance
Savings Acct. No.
6 Month Avg. Balance
Certificate of Deposit
Balance
Withdrawal Penalty
Account No.
Amount
Withdrawal Penalty
Signature of Representative
Title Date
Signature of Applicant
Date
IRA, Keogh, Retirement, Money Market Accounts
Interest Rate
Signatures
Request of Verification of Assets
This client is applying to the City of Fairborn for a home rehabilitation program that is funded via
federal grants. We ask your cooperation in supplying this information as it will be used only to
determine eligibility status and level of benefit to the household.
Interest Rate
Interest Rate
Interest Rate
Checking and Savings
City of Fairborn44 W. Hebble Avenue
Fairborn, OH 45324p: 937.754.3060f: 937.754.3051
Community Development DepartmentMissy Frost
Community Development Coordinator
Signature of Applicant Date Signature of Co-Applicant Date
OWNER OCCUPANCY STATEMENT
I/We hereby certify that I/We are the owner(s) of ________________________________ (property
address) and utilize it as my/our primary residence.
I/We further state that I/We will continue to reside at ____________________________(property
address) throughout the time period of financial assistance/loan repayment.
I/We understand the failure to do so shall result in the loan acceleration with remaining loan balance
becoming immediately due and payable.
Protect your Family From Lead in your Home, published by the US EPA
Fair Housing - Summary of Fair Housing Laws, published by the City of Fairborn
Signature of Applicant Date Signature of Co-Applicant Date
Property Address
RECEIPT OF LEAD BASED PAINT &
FAIR HOUSING INFORMATION
By signing, I/We acknowledge receipt of the following documents about protecting our family from
lead based paint and ensuring our rights accessing housing are not discriminatory in nature.
Please check that you received:
Structurally unsound dwellings that are, or should be condemned for human habitation.
Evidence of substantial, persistent infestation of rodents, insects and other vermin.
Excessive odors, clutter, garbage or other unsanitary conditions in any area of the unit.
Negligent housekeeping practices that limit access /create a cumbersome working environment.
Presence of/and or use of any controlled substance before or during rehab.
Suspected manufacturing of a controlled substance before or during rehab.
Threat of violence.
Occupants allowing only limited access to the dwelling.
Environmental hazards such as serious moisture problems, friable asbestos or other hazardous
materials, which cannot be resolved before rehab work is to start.
Staff Cost Estimate exceeds maximum amount of per unit limits
The presence of animal feces in any are of the dwelling unit.
Signature of Applicant Date Signature of Co-Applicant Date
WALK AWAY PROVISION
The City reserves the right to "Walk Away" from a housing unit that poses undue threat to health or safety
of the inspector or contract at any time. Housing units that violate the following will not be assisted: