CAHR Online Application

Clarkston Affordable Home Repair Program Application

This is an Equal Opportunity Program. Discrimination is prohibited.

L-C Valley Habitat for Humanity (LCV HFH) will contact you by phone as soon as your application is screened. To advance in the screening process you must complete all items and sign where required. If you would like to save your work, please email us for login information before you begin filling out this application.

APPLICANT INFORMATION

Applicant Name

First

Last

Applicant Mailing Address

Street Address / PO Box City State Postal / Zip Code

Applicant Phone

Applicant Date of Birth

Applicant Social Security Number

Applicant Email

Applicant Highest of Education Completed

CO-APPLICANT INFORMATION

Co-Applicant Name

First

Last

Co-Applicant Mailing Address

Street Address / PO Box City State Postal / Zip Code

Co-Applicant Phone

Co-Applicant Date of Birth

Co-Applicant Social Security Number

Co-Applicant Email

Co-Applicant Highest of Education Completed

Other Household Members

Name(1)

Age(1)

Date of Birth(1)

Social Security Number(1)

Name(2)

Age(2)

Date of Birth(2)

Social Security Number(2)

Name(3)

Age(3)

Date of Birth(3)

Social Security Number(3)

Name(4)

Age(4)

Date of Birth(4)

Social Security Number(4)

Name(5)

Age(5)

Date of Birth(5)

Social Security Number(5)

Name(6)

Age(6)

Date of Birth(6)

Social Security Number(6)

DEMOGRAPHIC INFORMATION

Total number of people in household

Female head of household?

Number in household who are:

White

Black

Hispanic

Native American

Male

Female

Non-binary/Other

Veteran

Two or More

Unknown

Disabled

Migrant/Farmworker

PROPERTY TO BE IMPROVED

Physical Address:

Street Address Street Address Line 2 City State Postal / Zip Code

Tax Assessed Value

Are you current on your property taxes?

Date Purchased

Purchase Price

Do you intend to reside in your home as your primary residence for no less than the next three years?

1st Mortgage Lender

1st Mortgage Lender Address

1st Mortgage Lender Phone

Amount Owed

Other Liens or Judgments on Property (Type and Amount)

Has code enforcement cited your property?(1)

If Yes, Why?

Home Insurance Company

Home Insurance Company Address

Home Insurance Company Phone

Do you have animals on the property?

Type and amount of each

Type of Heat

Foundation

Approx. Square Feet

Number of Bedrooms

Home Type

Do you own the property your home is on?

Year house was built

How did you hear about CAHR?

HOME REPAIRS NEEDED (Please describe in detail)

Foundation:

Siding:

Dry Rot:

Electrical:

Plumbing:

Roof/Gutters:

Septic/Sanitation:

Insulation:

Doors/Windows:

Special Needs:

Painting:

Flooring:

Heating:

Other:

DEBT

Creditors (include all credit or store cards)

Creditor Name (1)

Account Owner(1)

Original Amount(1)

Balance(1)

Monthly Payment(1)

Amount Past Due(1)

Creditor Name (2)

Account Owner(2)

Original Amount(2)

Balance(2)

Monthly Payment(2)

Amount Past Due(2)

Creditor Name (3)

Account Owner(3)

Original Amount(3)

Balance(3)

Monthly Payment(3)

Amount Past Due(3)

Creditor Name (4)

Account Owner(4)

Original Amount(4)

Balance(4)

Monthly Payment(4)

Amount Past Due(4)

Creditor Name (5)

Account Owner(5)

Original Amount(5)

Balance(5)

Monthly Payment(5)

Amount Past Due(5)

Creditor Name (6)

Account Owner(6)

Original Amount(6)

Balance(6)

Monthly Payment(6)

Amount Past Due(6)

Creditor Name (7)

Account Owner(7)

Original Amount(7)

Balance(7)

Monthly Payment(7)

Amount Past Due(7)

APPLICANT MONTHLY HOUSEHOLD INCOME

Applicant Wages

Applicant Social Security or SSI

Applicant Pension

Applicant Child Support/Alimony

Applicant Child Interest/Dividends

Applicant Other Income

Applicant Other Income(2)

Applicant Total Monthly Income

CO-APPLICANT MONTHLY HOUSEHOLD INCOME

Co-Applicant Wages

Co-Applicant Social Security or SSI

Co-Applicant Pension

Co-Applicant Child Support/Alimony

Co-Applicant Child Interest/Dividends

Co-Applicant Other Income

Co-Applicant Other Income(2)

Co-Applicant Total Monthly Income

Other Monthly Household Income (include 2nd jobs here as well)

Person Receiving Income(1)

Income Source(1)

Amount(1)

Person Receiving Income(2)

Income Source(2)

Amount(2)

Person Receiving Income(3)

Income Source(3)

Amount(3)

Person Receiving Income(4)

Income Source(4)

Amount(4)

Person Receiving Income(5)

Income Source(5)

Amount(5)

Total Other Income

ASSETS: Bank or Investment Accounts

Name of Bank(1)

Name/s on Account(1)

Type of Account(1)

Balance(1)

Name of Bank(2)

Name/s on Account(2)

Type of Account(2)

Balance(2)

Name of Bank(3)

Name/s on Account(3)

Type of Account(3)

Balance(3)

ASSETS: Automobiles

Automobile owned(1)

Value(1)

Automobile owned(2)

Value(2)

Automobile owned(3)

Value(3)

Automobile owned(4)

Value(4)

OTHER ASSETS (motor homes, boats, other property, etc.)Do not include household furnishings

Asset(1)

Value(1)

Asset(2)

Value(2)

Asset(3)

Value(3)

Asset(4)

Value(4)

Other (Type and Value)

The applicant/s certify that they:

1. Understand that submittal of an application is not a guarantee of funding and that income eligibility, the condition of the property, the work scope, program priorities and availability of funding will be all used to determine eligibility.

2. Any of the information contained in this application will be verified and may be obtained from any source named herein.

3. All information in this application, and all information furnished in support of this application is given for the purpose of obtaining an Affordable Home Repair Program grant, under a financial assistance program developed by the lender with CDBG funds provided under the Housing and Community Development Act of 1974, as amended, and is true and complete to the best of the applicants' knowledge and belief.

4. This is not an entitlement program and is subject to availability of funds, guidelines and eligibility requirements are subject to change.

5. Upon approval, homeowners will pay a $100 non-refundable deposit before repairs start as well as 10-15% of cost of materials. An affordable payment plan will be set up once actual amounts due are determined upon completion of the repair.

6. Owner of the property described in this application and that the LCV HFH Affordable Home Repair Program proceeds will be used only for work and materials allowable under and authorized by the home repair program for the property described in this application. If the approving officer determines that the rehabilitation grant proceeds will not or cannot be used for the purposes described herein, the applicant acknowledges that s/he shall have no further interest, right, or claim to the grant proceeds.

7. Furthermore, applicants attest that they cannot complete the home repair due to age, disability, or lack of income. Instead, homeowners will be willing to complete 24 hours of sweat equity, which will be designed around limitations.

8. Required supplemental documents to bring to a preliminary interview:

Most recent income tax return or a letter, signed by you, stating why they were not filed.
Most recent W-2
Last 2 pay stubs or other proof of income
Last 2 bank statements with all subaccounts. Must include names, banks address, and account numbers.
Proof of any other income, including but not limited to child support, alimony, public assistance, TANF, SSI, Workman’s Comp, or others.
Proof of homeownership: Deed of Trust or property tax receipt.

I declare that I have examined this request for grant assistance and, to the best of my knowledge and belief; the information contained in it is true, correct and complete.

Applicant Electronic Signature

Date

Co-Applicant Electronic Signature

Date