city of fairborn 44 w. hebble avenue fairborn, oh … application - 2018-1.pdffactors are reviewed...

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


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


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


Fairborn, OH 45324p: 937.754.3060f: 937.754.3051

Community Development DepartmentMissy Frost

Community Development Coordinator


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


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.


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: