homeowner reimbursement program application -...

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Homeowner Reimbursement Program Application

APPLICATION INSTRUCTIONS 1. Applicant Information: In this section you must complete all fields. If something in not applicable, indicate with

N/A.2. Co-owner Information: Only use this section if there is a co-owner that also occupies the damaged home. If yes,

complete all fields or indicate with N/A. If there is a co-owner, but they do not live in the home, do not completethis section.

3. Eligibility Information: You must answer all the questions in this section. To be eligible for the HomeownerReimbursement Program you must have spent your own money on repairs directly related to damages fromHurricane Harvey. You must also be in good standing on your property taxes or be on a current payment plan. Ifyou are required to pay child support, you must also be current or on a payment plan. All repair for which you arerequesting reimbursement for must be completed at the time of the application.

4. Household Composition and Characteristics: Here you are required to provide information for all members ofyour household. All members: to include everyone living in the home related or not. You will start with yourself asHead of Household.

a. Member Name: Here you will provide the household members first and last name.b. Marital Status: Provide the marital status of each household member.c. Relationship to Head of Household: Describe that household member’s relationship to you.d. Date of Birth: Here you will provide the date of birth for each household member.e. Dependent: Here you will indicate with Y(yes) or N(no) for each household member, if he or she is your

dependent. f. Annual Income: For each household member you will be required to report his or her annual income. If

the household member does not have an income indicate with N/A. You will be required to provide themost current tax transcript from each household member.

5. Household Demographic Information: Provide the following details for all household members listed in section 4using the same order as above.

a. Ethnicity: Provide the ethnicity of each household member as one of the following: Hispanic/Latino, NotHispanic/Latino, or Other.

b. Race: Provide the race of each household member.c. Sex: Provide the sex of each household member as either M or F.d. Single (unmarried) Head of Household with Children: This field only applies if you are a single unmarried

female Head of Household with children. e. Full-time Student: Indicate with Y(yes) if a household member is a full-time student or N(no) if not.f. Veteran: For each household member answer either Y(yes) or N(no) to indicate if he or she is a veteran of

the U.S. Armed Forces.6. Damaged Property Information: In this section you will be asked questions related to the damaged home. You

must answer all questions in this section. Below you will find descriptions to help with questions listed on theapplication.

a. A separate dwelling unit is something like a garage apartment or separate building located on yourproperty that is occupied by a renter.

b. Your primary residence is your main home where you lived most of the time in 2017c. Commercial or storefront activities do not include running a home office or storing items for your

business at your home.A home is built completely over water if it is on piers and the house is surrounded on all 4 sides by water at high tide.

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7. Housing Assistance and Insurance Information: In this section you will be asked to provide details about storm-related assistance or insurance payouts you received. You must complete this section in its entirety.

a. Storm-related assistance: The first three question will ask about FEMA, SBA, and construction relatedassistance. Provide if applicable your FEMA Individual Assistance IA Registration number, and SBAApplication and Loan Number. If you received construction assistance from DAHLR, PREPS, HAP, and/orOther check the respective boxes in this section.

b. Insurance Related questions: You need to indicate if you had any of the following insurance policies atthe time of the storm: Flood Insurance, Windstorm Insurance, and/or Homeowner’s insurance. For eachpolicy you will need to provide the following information and provide documents:

i. Carrier’s nameii. Policy number

iii. Agent’s nameiv. Phone numberv. Amounts paid out for structural, contents, ALE, and other.

8. Housing Assistance and Insurance Details: In this section provide amounts received from each source. If noamount was received indicate with N/A

9. Disaster-Related Expenses: Reimbursement Program Declaration of Harvey Expenses form must be completedbefore submitting your application. The form provides a detailed explanation on how to fill it out.

For the remaining sections, please read each disclosure and provide all requested information. All sections of this application must be filled out to be considered.

All Fields Must be Completed or Indicated with “N/A” 1. APPLICANT INFORMATION:Applicant Name: Street Address: City/State/Zip: County: Primary Email: Home Phone: Secondary Email: Cell Phone: Preferred Method of Contact: Preferred Language: 2. CO-OWNER INFORMATION: (If applicable)Applicant Name: Street Address: City/State/Zip: County: Primary Email: Home Phone: Secondary Email: Cell Phone: Preferred Method of Contact: Preferred Language: 3. ELIGIBITY INFORMATION: Please answer all the following questions:Did you spend your own money for disaster related expenses beyond what you received from other sources (FEMA, SBA, Insurance, or Non-Profit)?

☐ Yes☐ No

Are you currently in good standing on your property taxes or in good standing with a payment plan?

☐ Yes☐ No

If you are required to pay child support, are you current on your payments or in good standing with a payment plan?

☐ Yes☐ No☐ N/A

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Have you completed all of the repairs for which you are claiming reimbursement in this application?

☐ Yes☐ No

4. HOUSEHOLD COMPOSITION AND CHARACTERISTICS: List all current members of the householdMember Name Marital Status Relationship to Head

of Household Date of Birth Dependent Annual Income

1. Head of Household 2. 3. 4. 5. 6. 7. 8.

Total Number of Household Members:

5. HOUSEHOLD DEMOGRAPHIC INFORMATION:Ethnicity Race Gender Single (Unmarried) Head of

Household with Children? Full-time Student?

Veteran?

1 (Head) 2 3 4 5 6 7 8

6. DAMAGED PROPERTY INFORMATION:What type of structure is the property?

☐ Single FamilyHome

☐ Multi-FamilyHome

☐ ManufacturedHousing Unit(MHU)

☐ Condominiumor Cooperative

☐ OtherDescribe:

Damaged Property Street Address: Year Built: City/State/Zip: County: Please answer all the following questions: Do you currently own a property that was damaged by Hurricane Harvey?

☐ Yes☐ No

Did you own the damaged property at the time of the disaster? ☐ Yes☐ No

Is the home occupied by tenants/renters, or is it owner-occupied? ☐ Owner-Occupied Only☐ Renter-Occupied Only☐ Occupied by Owner and Renter

How many dwelling units are in the structure? ☐ One☐ More than one

Was the home your primary residence at the time of the storm? ☐ Yes☐ No

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Is the home currently your primary residence? ☐ Yes☐ No

Is any portion of the property a separate unit that is exclusively for commercial/storefront activities?

☐ Yes☐ No

Is the structure built completely over water? ☐ Yes☐ No

Is the structure a manufactured home or travel trailer? ☐ Yes☐ No

If a manufactured home or travel trailer, is it built on a permanent frame, has had all wheels removed, and is attached to a permanent foundation?

☐ Yes☐ No

Is your property currently eligible to carry flood insurance going forward?

☐ Yes☐ No

If your home repairs included the elevation of the structure, do you have an elevation certificate demonstrating that the home was elevated to at least two (2) feet above base flood elevation?

☐ Yes☐ No☐ N/A (repairs did not include elevation)

7. HOUSING ASSISTANCE AND INSURANCE INFORMATION:Have you applied for and storm-related assistance for damage to your home from any source (local, state, federal, or private) or filed an insurance claim for storm-related damage? If yes, proceed with this section. Do you have a FEMA IA Registration # for Hurricane Harvey? ☐ Yes

If yes, enter your FEMA Registration number:

☐ NoHave you received any disaster-related assistance from SBA (e.g. an SBA loan) for structural damage to the home?

☐ YesIf yes, enter your SBA Application Number:

and your SBA Loan Number:

☐ NoDid you receive any additional source of assistance for the repair of your home?

☐ DALHR☐ PREPS☐ HAP☐ OtherIf Other, describe:☐ N/A

Please answer all the following flood insurance related questions: Were you required to carry flood insurance on the structure as a condition of receiving assistance from a previous disaster?

☐ Yes☐ No

Was there a flood insurance policy in effect for the property at the time of the storm?

☐ YesIf yes, enter your flood insurance policy number:

☐ No

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If applicable, what type of flood insurance coverage did you have?

☐ Structural coverage☐ Contents coverage☐ Both Structural and Contents coverage☐ N/A

If applicable, what is the name of your flood insurance carrier and your policy number?

Carrier’s Name: Policy Number:

If applicable, provide your flood insurance agent’s name and phone number.

Agent’s Name: Phone number:

If applicable, please enter the flood insurance claim amounts your received: (attach documentation)

Structural: $__________ Contents: $__________ ALE: $__________ Other: $__________

Please answer all the following homeowner/hazard insurance questions: Was there a homeowners/hazard insurance policy in effect for the property at the time of the storm?

☐ Yes☐ No

If applicable, what is the name of your homeowners/hazard insurance carrier and your policy number?


If applicable, provide your homeowners/hazard insurance agent’s name and phone number.


If applicable, did you file a claim with your homeowners/hazard insurance carrier?

☐ Yes☐ No☐ N/A

If applicable, what is the claim number for your homeowners/hazard insurance claim?

Claim Number:

If applicable, please enter the homeowner/hazard insurance claim amounts your received: (attach documentation)


Please answer all the following windstorm insurance questions: Were you carrying windstorm insurance on the property at the time of the storm?

☐ Yes☐ No

If applicable, what is the name of your windstorm insurance carrier and your policy number?


If applicable, provide your windstorm insurance agent’s name and phone number.


If applicable, please enter the windstorm insurance claim amounts your received: (attach documentation)


8. HOUSING ASSISTANCE AND INSURANCE DETAILS:Please enter amounts received for each listed below. If you didn’t any benefits, type N/A.

Source Amount Received FEMA temporary housing benefits $ FEMA Additional Living Expense (ALE) benefits $ FEMA structural repair benefits $ FEMA home replacement benefits $ FEMA permanent housing construction benefits $

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SBA Personal Loan - Real Estate Property Damage $ SBA Personal Loan – Mitigation $ SBA Business Loan – Real Estate Property Damage $ SBA Business Loan – Mitigation $ Flood insurance (NFIP) building loss benefits $ Flood insurance (non-NFIP) building loss benefits $ NFIP Increased Cost of Compliance (ICC) benefits $ Homeowners/Hazard insurance structural loss $ Homeowners/Hazard insurance Additional Living Expense (ALE) benefits $ Texas Windstorm Insurance structural loss $ Texas Windstorm Insurance Additional Living Expense (ALE) benefits $ Legal settlement from insurance arising from disaster losses $ Other philanthropic cash assistance benefits for structural repair $ Other philanthropic cash assistance benefits for temporary housing $

9. SBA RELEASE:

The U.S. Small Business Administration has my permission, as required by the Privacy Act, to release information to the Texas General Land Office (GLO), and its assigns, employees, agents, and contractors, in connection with this application for a grant, loan or other benefit related to disaster recovery.

☐ I Agree☐ I Decline

Signature of Applicant: Date:

Signature of Co-Applicant: Date:

10. RIGHT OF ENTRY:I, hereby, provide and authorize the Texas General Land Office (GLO) and each of their respective employees, vendors, and contractors, the "Right-of-Entry" in and onto the property describe above for the purpose of performing all necessary activities to carry out the CDBG-DR Program. I will confirm that the officer, official, or employee will present credentials including photo identification, and state the reason for the site visit in order to request entry. Under penalties of perjury, I/we certify that the information presented in this Affidavit is true and accurate to the best of my knowledge and belief. I/we further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in my ineligibility to participate in this program or any other programs that will accept this Affidavit. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a FELONY if he/she knowingly and willfully makes a false statement to any department of the United States Government.

☐ I Agree☐ I Decline



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11. CHILD SUPPORT CERTIFICATION:Applicant certifies that he/she is not more than 30 days delinquent in the payment of child support under a valid court order and, therefore, is not barred from receiving the benefits of this grant under Section 231.006(a)(2) of the Texas Family Code. Applicant acknowledges that eligibility for the assistance may be violated if this certification is false, or if delinquency is determined during the period in which assistance is being provided. I, the below-listed Applicant, certify the following:

1) I am NOT more than 30 days delinquent in the payment of a child support obligation and am eligible to receive the benefitsof this program in accordance with Section 231.006(a)(2) of the Texas Family Code).2) I acknowledge and understand that providing false representations herein constitutes an act of fraud and is punishableunder 18 U.S.C. Section 1001.Signature of Applicant: Date:


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12. CERTIFICATION OF TAX RETURN:Your most recent IRS tax return is required to determine eligibility. If you do not have your tax return, please follow this link to begin the process of requesting a copy of your tax return from the IRS:

https://www.irs.gov/individuals/get-transcript

The IRS states it takes approximately 5 days to process a request. Once have obtained a copy of your most recent tax return, upload the document here. If you had made the request of the IRS and 5 days have already passed without a response from the IRS, you may check the box below to proceed with processing the remainder of your application. Subsequently, a partner of the GLO will ask you for a copy during their review. You will need a copy of your tax return to process your application. If you have a copy of your tax return, please proceed to the next step.

1. I certify under penalty of perjury that I requested a copy of my tax return from the IRS, however, 5 days have passedwithout a response from the IRS. Please proceed with processing my application and I will provide my tax return uponrequest at a later date.

☐ Yes☐ No

If you are not required to file a tax return, please certify which of the reasons below pertains to your household. If these conditions apply to you, you will need to complete and upload the AGI Worksheet form that will be required to process your application. It can be found at the following link.

http://recovery.texas.gov/files/resources/housing/s4-adjustedgrossincomeworksheet.xls

If you need assistance completing this form, please email [email protected] or call 1-844-893-8937 or 512-475-5000.

2. I certify under penalty of perjury that my income was equal to or less than the standard deduction.

☐ Yes☐ No

3. I certify under penalty of perjury that I am at least 65 years old, receive Social Security income during the year, and ambelow the income threshold set by the IRS that exempts me from filing a tax return.

☐ Yes☐ No

4. I certify under penalty of perjury that I am a dependent claimed on someone’s tax return and do not earn more thanthe income threshold set by the IRS that exempts me from filing a tax return.

☐ Yes☐ No



https://www.irs.gov/individuals/get-transcript

http://recovery.texas.gov/files/resources/housing/s4-adjustedgrossincomeworksheet.xls

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13. ELIGIBILITY RELEASE:

Name:

Address:

Instructions to Applicant: Your signature on this Eligibility Release, and the signatures of each member of your household who is 18 years of age or older, authorizes the Texas General Land Office (GLO) and its contractors and agents to obtain information from a third -party regarding your eligibility and continued participation in the:

Community Development Block Grant Disaster Recovery (CDBG-DR) Homeowner Reimbursement Program (HRP)

Privacy Act Notice Statement: The Texas General Land Office (GLO) requires the collection of the information listed in this form to determine an applicant’s eligibility for the CDBG-DR Program. This information will be used to establish the level of benefits for which the applicant is eligible to receive and to verify the accuracy of the information furnished. Information received from an applicant as a result of verifying an applicant’s eligibility may be released to the appropriate federal, state, and local agencies or, when relevant, to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in delay or rejection of your eligibility approval.

Each adult member of the household must sign this Eligibility Release prior to the receipt of benefits to establish continued eligibility.

Note: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. If a copy of a tax return is needed, IRS Form 4506, “Request for a Copy of Tax Form” must be prepared and signed separately.

Information Covered: Inquiries may be made about items initialed below by the applicant.

Description Verification Required Initials of Applicants

Disaster Assistance (FEMA, SBA, Insurance, etc.) X Income (all sources) X

Occupancy Preference (Special Needs) (if applicable) X Child Support Verification X Other (list): Dependent Information: X WARNING:

By signing this application, the applicant(s) authorizes the state or any of its duly authorized representatives to verify the information contained herein, including this section. Any person who knowingly makes a false claim or statement to Housing and Urban Development (HUD) may be subject to civil or criminal penalties under 18 U.S.C. 287, 1001 and 31 U.S.C. 3729. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willfully makes false or fraudulent statements to any department of the United States Government.



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14. APPLICATION CERTIFICATION:Under penalties of perjury, I/we certify that the information presented in this application is true and accurate to the best of my knowledge and belief. I/we further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in my ineligibility to participate in this program or any other programs that will accept this Affidavit. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a FELONY if he/she knowingly and willfully makes a false statement to any department of the United States Government. Signature of Applicant: Date:


15. DISASTER-RELATED EXPENSES:Attachment A (Reimbursement Program Declaration of Harvey Expenses) at the end of this application, must be filled out and submitted with this application and all other required documents.

Texas General Land Office Community Development and Revitalization

Homeowner Reimbursement Program Declaration of Harvey Expenses

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APPLICANT INFORMATION

FIRST NAME LAST NAME APPLICATION NUMBER

STREET CITY, STATE ZIP This form allows you to report the expenses that you incurred related to Hurricane Harvey so that the Texas General Land Office can calculate if you are eligible to receive reimbursement for eligible Hurricane Harvey construction related expenses. It is extremely important that you follow the instructions below. Failure to provide receipts in the format listed below may result in the Program rejecting your application.

FORM INSTRUCTIONS

You must complete each section of this form and you must attach all required documentation to this form in order for your application to be processed. You must also sign this form. You may submit this form and all supporting documentation using the following methods:

1. You may scan this form and all supporting documentation at the time that you complete your Homeowner Reimbursement Programapplication.

2. You may scan this form and all supporting documentation and email an electronic copy to [email protected]. You may mail a copy of this form and all supporting documentation to a regional intake office near you:

Rockport Office: 2317 Rath Street, Rockport, TX 78382

Fort Bend Office: 1 Sugar Creek Center Blvd, Suite 200, Sugar Land, TX 77478

Galveston Office: 600 Gulf Freeway, Texas City, TX 77591

South East Texas Office: 505 Orleans St., Suite 100, Beaumont, TX 77701

Conroe Office: 200 River Pointe Dr., Conroe, TX 77304

If you choose to mail a copy of your documentation or if you choose to submit your documentation at an HRP service center, keep a full copy of this form and all of the documentation you submit. Do not mail any original documents.

SUPPORTING DOCUMENTATION INSTRUCTIONS

You must provide documentation such as receipts, invoices, contracts, bank statements, credit card statements. Each section of this form will explain what types of information you need to attach for the types of expenses you are claiming.

IMPORTANT: DO NOT ATTACH ORIGINAL DOCUMENTATION TO THIS FORM. IF YOUR RECEIPT IS SMALLER THAN A STANDARD SHEET OF PAPER, COPY THE RECEIPT ONTO A STANDARD SIZED SHEET OF PAPER. PLEASE MAKE SURE



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THAT ALL RECEIPTS ARE READABLE AND THAT THEY CONTAIN A DATE, THE NAME OF THE VENDOR AND THE AMOUNT PAID. ALL RECEIPTS MUST BE NUMBERED AND THE NUMBER ON THE RECEIPT MUST CORRESPOND TO THE NUMBER LISTED IN EACH SECTION OF THIS DECLARATION.

Step 1 - CONTRACTORS, VENDORS, INSPECTORS AND PERMIT FEES: In this section, you may list expenses you incurred to hire a construction contractor or other vendor that performed work related to your home. This would include construction contractors, electrician, plumber, roofer, demolition companies, debris removal companies, flood cleanup companies, architects, designers, surveyors, engineers, pest control companies, tree removal services, stump grinders and abatement companies. Please also list any permit fees, inspection fees or other fees associated with construction related to Hurricane Harvey.

You must provide a clear description of the work that was completed and where the work was completed (work is completed inside the footprint if the work was done inside the home or to the exterior or roof of the home, work is completed outside of the footprint when work is done in your yard or on other structures such as a detached garage). You must also attach receipts to prove the expense AND a bank statement or credit card statement that shows that you incurred the expense you are claiming. If you made multiple payments to the same contractor, list each payment separately. Receipts must be dated between August 25, 2017, and February 28, 2019.

Name of Contractor or Vendor Description of Work Completed or Type of Expense

Payment Amount

(From Bank or Credit

Card Statement)

Work Inside or Outside

of the Footprint of the Home?

Date of Payment

Receipt Number

Receipt Attached?

Bank or Credit Card

Statement Attached?

Example: ABC Construction Contractors

Demolition of flood damaged interior, floor replacement, rewiring house, drywall replacement, repair of kitchen and bathroom fixtures

$15,000.00 ☑ Inside

☐ Outside1/9/2018 1 ☑ Yes ☑ Yes

$ ☐ Inside

☐ Outside☐ Yes ☐ Yes

$ ☐ Inside ☐ Yes ☐ Yes



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☐ Outside

Name of Contractor or Vendor Description of Work Completed or Type of Expense

Payment Amount

(From Bank or Credit Card Statement)

Work Inside or Outside of the Footprint of the Home?

Date of Payment

Receipt Number

Receipt Attached?

Bank or Credit Card

Statement Attached?

$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside




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$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside




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Step 2 – MATERIALS SUPPLIERS: In this section, you may list expenses that you incurred when you purchased items from a materials supplier such as Lowes, Home Depot, hardware stores or lumber yards. If there are multiple expenses on a single receipt, they must be reported separately. If you have multiple expenses on the same receipt, do not include sales tax.

You must provide a clear description of the work that was completed and where the work was completed (work is completed inside the footprint if the work was done inside the home or to the exterior or roof of the home, work is completed outside of the footprint when work is done in your yard or on other structures such as a detached garage). You must also attach receipts to prove the expense AND a bank statement or credit card statement that shows that you incurred the expense you are claiming. Receipts must be dated between August 25, 2017, and August 29, 2018.

Name of Material Supplier Description of Work Completed or Type of Expense

Individual Item Cost

(From Receipt)

Work Inside or Outside

of the Footprint of the Home?

Date of Payment

Receipt Number

Receipt Attached?

Bank or Credit Card

Statement Attached?

Example: Aransas Hardware 10 Sheets of Drywall for Living Room Repairs $15.00

☑ Inside

☐ Outside2/10/2018 22 ☑ Yes ☑ Yes

Example: Aransas Hardware

1 5 Gallon Bucket of Drywall Joint Compound for Living Room Repairs $7.00

☑ Inside

☐ Outside2/10/2018 22 ☑ Yes ☑ Yes

$ ☐ Inside


$ ☐ Inside


$ ☐ Inside




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Individual Item Cost (From Receipt)


Date of Payment

Receipt Number

Receipt Attached?

Bank or Credit Card

Statement Attached?

$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside




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Individual Item Cost (From Receipt)


Date of Payment

Receipt Number

Receipt Attached?

Bank or Credit Card

Statement Attached?

$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside


$ ☐ Inside




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Step 3 – TEMPORARY REPAIRS: In this section, you may list all expenses that you incurred when you purchased items for the purposes of temporary repairs. Temporary repairs include items such as tarps to put on a damaged roof or plywood to cover damaged windows. If there are multiple expenses on a single receipt, they must be reported separately. If you have multiple expenses on the same receipt, do not include sales tax.

You must provide a clear description of the work that was completed and where the work was completed. You must also attach receipts to prove you incurred the expense. You do not need to attach a bank statement or credit card statement for these types of expenses. Receipts must be dated between August 25, 2017, and February 28, 2019.



(From Receipt)

Date of Payment

Receipt Number

Receipt Attached?

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes



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Step 3 Continued – TEMPORARY REPAIRS (ATTACH ADDITIONAL SHEETS AS NEEDED)



(From Receipt)

Date of Payment

Receipt Number

Receipt Attached?

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes

$ ☐ Yes



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Step 4 – TEMPORARY HOUSING OR STORAGE FEES: In this section, you may list all expenses that you incurred for temporary housing after Hurricane Harvey and all expenses you incurred to rent storage space if stored furniture and household goods while your home was undergoing construction.

If you are claiming an expense for a hotel room, you must include your paid hotel bill. You will only receive credit for the amount paid for each night’s stay. You will not receive credit for additional expenses such as room service or movie rentals and room and sales taxes will be removed if such expenses appear on the receipt. If you are claiming an expense for a short-term rental or storage expenses, you must provide a lease showing that the rental started after the date of Hurricane Harvey. You must also list each month’s payment separately and you must provide proof of the payment such as a receipt from your landlord or the storage company. You will only receive credit for the monthly rental cost. You will not receive credit for utilities or other charges associated with the rental. Receipts must be dated between August 25, 2017, and February 28, 2019.

Name of Hotel, Storage Company or

Landlord Description of Expense Payment

Amount Date of

Payment Receipt Number

Receipt Attached?

Lease Attached?

Example: Extended Stay Motel, Waco Texas

Temporary housing for my family from August 30, 2017, through September 5, 2017 $450.00 9/5/2017 56 ☑ Yes

☐ Yes

☑ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A



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Step 4 Continued – TEMPORARY HOUSING OR STORAGE FEES (ATTACH ADDITIONAL SHEETS AS NEEDED)

Name of Hotel, Storage Company or

Landlord Description of Expense Payment

Amount Date of

Payment Receipt Number

Receipt Attached?

Lease Attached?

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A

$ ☐ Yes☐ Yes

☐ N/A



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Step 5 – OTHER EXPENSES: In this section, you may list other types of eligible expense types that may have been incurred by you after Hurricane Harvey. Each type of expense has different documentation requirements, so please carefully read the requirements and submit the required documentation if you wish to receive credit. All documentation must be dated between August 25, 2017, and February 28, 2019.

Expense Type Documentation Instructions Expense Amount

Date of Payment

Receipt Number

Required Documents Attached?

Forced Mortgage Payoff

You may only claim credit for a forced mortgage payoff if your mortgage company involuntarily retained all or part of the insurance proceeds that you received from Hurricane Harvey. In order to claim this type of expense, you must provide a signed and dated letter from your mortgage company that states that: 1. You did not have access to the insurance proceeds in question; and2. That the mortgage payoff was involuntary.If the documentation does not contain this information, it will be rejected.

$ ☐ Yes

Independent Adjustor or Damage Assessor Fees

If you hired an independent adjustor or damage assessor after Hurricane Harvey to increase your insurance settlement amount, you may receive credit for that expense. You must provide a paid invoice from the company that you hired that clearly states that you received these services.

$ ☐ Yes

Attorney’s Fees Related to Insurance Litigation

If you hired a lawyer after Hurricane Harvey to increase your insurance settlement amount, you may receive credit for that expense even if it was paid out of the settlement. You must provide a letter from your attorney that clearly states (1) the amount of the settlement and (2) the amount of expenses and attorney’s fees that were paid to the lawyer out of the settlement.

$ ☐ Yes

Contractor Fraud

If you hired a contractor and the contractor failed to perform ANY work on your home, you may receive credit for that expense. You must provide the following information to claim contractor fraud as an expense: 1. The original receipt or paid invoice showing that you paid the contractor to perform work on

your home.2. A police report dated within six (6) months of the invoice that clearly states that the

contractor failed to perform any work on the home.You will not receive credit for contractor fraud if the contractor performed work on your home and the work was substandard or if the contractor performed part of the work on your home.

$ ☐ Yes



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APPLICANT INFORMATION

FIRST NAME LAST NAME APPLICATION NUMBER

STREET CITY, STATE ZIP

Certification

Under penalties of perjury, I/we certify that the expense(s) claimed on this form are true and correct and the expense(s), was (were) incurred by the undersigned as a result of Hurricane Harvey and that the information presented in this form is true and accurate to the best of my/our knowledge and belief. I/we further certify that the expense(s) identified on this form include ALL of the expenses that were incurred for the property listed on the application relating to Hurricane Harvey and that all of the expenses listed herein were incurred between August 25, 2017, and February 28, 2019. I/we understand that we will not be allowed to supplement this form with claims of additional expenses after submission. I/we further understand that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information may result in my ineligibility to participate in this program or any other programs that will accept this Affidavit. Title 18, Section 1001 of the U.S. Code states that a person is guilty of a FELONY if he/she knowingly and willfully makes a false statement to any department of the United States Government.

________________________________________ Applicant (Print Name)

________________________________________ Signature

_____________________ Date

________________________________________ Co-Applicant (Print Name)

________________________________________ Signature

_____________________ Date