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Snow Belt Housing Company, Inc. Cheryl L. Shenkle-O’Neill, Executive Director
7500 South State Street * Lowville, NY 13367
(315) 376-2639 * (315) 376-2518 fax
NYS Relay Service No. – TTD 1-800-662-1220
E-mail:
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REHABILITATION/HOME IMPROVEMENT PROGRAMS
APPLICATION
Applicant’s Name Social Security Number Date of birth
Co-Applicant’s Name Social Security Number Date of birth
Dependents (Name, Age, Relationship)
Other Adult Members of Household (Non-Dependent) (Name, Age, and Relationship)
911 Address: (Street, Township, City, and Zip Code) Home Telephone Number
Mailing Address (if different than above) Cell Number
How long at the above address?
Earned Income (Include employment and self-employment income for all household members for the last tax year):
Name Employer Annual Gross Wges Date
2011 Income - List all income (year-to-date earnings) for 2011:
Other Income Sources (Veterans, SSI, Pension, Rental Income, Interest, Child Support, Alimony, etc.):
$ Per
$ Per
Bank Accounts: Name/Address of Bank(s)
____Yes ____No Checking $___________ ____________________________________
____Yes ____No Savings $___________ ____________________________________
Other Assets - Please list your assets and estimate the value of: home, car(s), other real property, mutual funds, stocks, bonds, etc.
$ $
$ $
Debts - Please list your debts and the amounts: mortgage installment accounts, auto and other loans.
Debtor Purpose Pmt Amt Balance Date Incurred
____________
____________
____________
Home Improvement – Have you owned and occupied your residence for one year or longer?
Yes_____ or No_____
Number of Rooms Number of Bedrooms Number of Baths
____________
*Directions to the Home*:
Name of Title/Deed Holder(s):
What is your current property tax assessment?
Type of Home (i.e. single, multi-family, mobile, farm, etc.):
Year Built (approximate): Date of Mortgage (approximate):
CONFLICT OF INTEREST – Are you related to:
Any Board Member of Snow Belt Housing Company, Inc.? Yes_____ No_____
Any employee of Snow Belt Housing Company, Inc.? Yes_____ No_____
Any Public Official of the Municipality in which you live? Yes_____ No_____
If YES, to what agency? ________________________________________________________________
If applied to another agency and not approved, why was it denied? _____ _________________________
____________________________________________________________________________________
____________________________________________________________________________________
HOUSE ASSESSMENT
Foundation: GOOD FAIR POOR
What type of foundation does your house have? _____ ____ ______
_________________________ Condition?
Roof:
What type of roof (asphalt, shingle, metal roll)? _____ _____ ______
Condition?
Exterior:
What type of siding? _____ _____ _____
Condition?
Doors and Windows: _____ _____ _____
How many doors? Condition?
Windows? Condition?
Plumbing: _____ _____ _____
Type of plumbing? Condition?
Electrical: _____ _____ _____
What size electrical entrance? Amps
_____Fuse Type? _____Breakers? Do you use many extension cords?
Heating System: _____ _____ _____
What type of heating system?
How old is the heating system? Years
What specific home improvements do YOU feel are most necessary?
___________________
___________________________________________________________________
The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname.
1. Check applicable box:
___ White ___ Black/African American ____ Asian ____ Asian & White ____ American Indian/Alaskan Native
____ Native Hawaiian/Other Pacific Islander ____ American Indian/Alaskan Native & White ____ Asian/Pacific Islander
____ Black/African American & White ___ American Indian/Alaskan Native & Black/African American
____ Other Multi-Racial
2. Check applicable box:
______ Hispanic or Latino _____ Not Hispanic or Latino
Federal and State Law prohibit discrimination on the basis of age, sex, race, national or ethnic origin, handicap or familial status. Snow Belt Housing Company, Inc. is committed to serving its community without discrimination, and will comply with all rules and regulations regarding Fair Housing, Equal Opportunity, and Minority and Small Business Participation. The following data is for statistical purposes only and will not be used by any local, state or federal agency in making decisions regarding assistance.
Sex of Head of Household: ________ Male ________ Female
Age of Head of Household: ________years of age
Is any member of household handicapped? _________ Yes _________ No
Is any member of household disabled? __________ Yes ___________ No
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.
THEN SIGN AT THE BOTTOM.
ALL ADULT HOUSEHOLD MEMBERS MUST SIGN.
i. I (we) hereby apply for Rehabilitation/Home Improvement financial assistance from Snow Belt Housing Company, Inc. for funds toward the cost of improvements to our existing owner-occupied home, which I (we) certify is my (our) legal, full-time, primary residence.
ii. I (we) have read the accompanying Handbook and agree to sign a “5-year affordability/residency requirement agreement” for the amount of the cost of the rehabilitation work done to my (our) home.
iii. I (we) hereby certify that the above statements are true, accurate, and complete to the best of my (our) knowledge and belief. False statements made knowingly by applicant will disqualify the applicant from participation in the program and may be subject to prosecution.
iv. I (we) hereby consent and authorize Snow Belt Housing Company, Inc. to:
(a) obtain verification of information required for compliance within the regulations of this program, including expenses, employment, property appraisal, contractor estimates, and credit report;
(b) upon giving reasonable notice, to enter the applicant’s property for the purpose of determining what improvements are needed and to inspect completed work.
v. I (we) hereby give Snow Belt Housing Company, Inc. permission to discuss this application and/or project with the following people (family members, partners, case workers, etc.) [check one box and fill in a, b, or c as necessary]:
As listed below or With no one
a)
Name & Telephone number Relationship
b)
Name & Telephone number Relationship
c)
Name & Telephone number Relationship
Applicant’s Signature Date Co-Applicant’s Signature Date
Household Member Signature #3 (adult) Date Print Name of Household Member #3 Date
Household Member Signature #4 (adult) Date Print Name of Household Member #4 Date
*What is the best way to reach you during business hours (Monday – Friday 9:00 am – 4:00 pm)
(please provide-contact information)
____________________________________________________________________________________
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