Residential Accessibility Program Application

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1 City of Topeka Neighborhood Relations 620 S.E. Madison ST, 1 st FL, Unit 8 Topeka, KS Phone: (785) FAX: (785) Residential Accessibility Program Application I. Address where modifications are to be made: II. Applicant's Information ( )( )( ) Name (Last, First, Middle Initial) Age DOB Soc. Sec. Number Current Address (Street, City, State, Zip) ( )( )( ) Spouse or Co-Applicant Name (Last, First, Middle Initial) Age DOB Soc. Sec. Number (Home) (Work) (Other) ( Address) Daytime Telephone Number(s) III. Please include a photo copy of a government issued identification with picture: List all other household members: Name (First and Last) SSN Age IV. Applicant's Residence Status (Please check appropriate box) Owns Home: [Owner s name if different than applicant: Relationship: Rents Home: [Owner s name or management name: Phone #: ]

2 V. Summary of Family Income Data (See Income Calculations pages ) ASSETS Family Member Asset Description Current Market Value Income from Assets 1. Total Net Family Assets Total Actual Asset Income If 1. is greater than $5,000, multiply line 1. by (passbook rate) and enter results here; otherwise leave blank. 3. ANTICIPATED ANNUAL INCOME Family Member a. Wages/ Salaries b. Benefits/ Pensions c. Public Assistance d. Other Income e. Asset Income 4. Totals a. b. c. d. e. 5. Enter total of items 4a.through 4e. This is the ANNUAL INCOME. 5. Please provide the verifications of your current gross income (Space available here to make income calculations):

3 VI Applicant Characteristics (Voluntary Information for Government Monitoring Purposes) Applicant: I do not wish to furnish this information (initial) (Because HUD requires this information, if not completed by the applicant, the agency taking the application shall complete it to the best of their ability.) Please check the appropriate category in each group listed below for the applicant listed in Section II. Ethnicity Race/National Origin (Head of Household) (Head of Household) AI American Indian/Alaska Native HS Hispanic/Latino AS Asian NHS Not Hispanic Black/African American HI Native Hawaiian/Other Pacific Islander Female-Headed Household WH White Yes IW American Indian/Alaska Native & White No AW Asian & White BW Black/African American & White Age IB American Indian/Alaska Native & Black/African American (Head of Household Over 62) OT Balance/Other Yes No VII. Description of Accessibility Modifications Requested by Applicant VIII. Right to Request Modifications of Program. The program applicant has a right to request modifications of program policies, procedures or practice to accommodate their individual disability. Requests for such modifications should be made on the line below. Request: IX. Applicant Acknowledgement and Agreement I/We acknowledge and attest that I/We have not previously received funding from this program, and all of the information provided in this application is true and correct to the best of my/our knowledge. It is my/our understanding that any intentional or negligent misrepresentation of the information may result in civil liability and/or criminal penalties. If any of the above information changes prior to the start of modifications, I/we will notify the City of Topeka, Neighborhood Relations (NR). I realize that the City may wish to use the work it has done to my house for proof of its work or advertising. By signing this application, I/we grant the City my/our consent to take photographs of my/our house and grounds before, as well as after construction and realize that the photographs may be displayed to the public in print as well as electronically for the City s benefit. Applicant Signature Date Spouse's Signature Date

4 Third Party, Medical or other Professional Verification Form Date: Applicant Name: The following modifications have been proposed for the above named applicant s residence: Important: Do not reveal the specific nature or severity of the individual s disability. APPLICANT: I hereby authorize the release of the information requested above. Applicant Signature Date BY SERVICE PROVIDER and/or QUALIFIED PROFESSIONAL: As a medical/social service professional with the knowledge necessary to make such a determination, I certify that this applicant is a person with a disability and that the accessibility modifications requested are consistent with his/her need, associated with his/her disability and that said modifications are necessary for increasing independent access to and from the home. (Signature): (Printed Name): Agency: BY PHYSICIAN: The proposed modification(s) are necessary and reasonable to increase the applicant s independent access to and from the home and is consistent with his/her need, associated with his/her disability. (Signature): (Printed Name):

5 Property Owner (rental) Consent Form Property Owner Address City State Zip Code Date: Apartment Address: Tenant Name: This document is to inform you that your tenant (name and address listed above) has requested accessibility modifications to be performed at said dwelling. The accessibility modification(s) requested are as follows: The modification(s) are being requested to make the dwelling more accessible to the occupant so full use of the home is enjoyed. Pursuant to federal and state Fair Housing Laws, a qualified individual with a disability has the right to request reasonable accommodations in order to have equal access into and through a dwelling. Reasonable accommodation/modification requests shall not create an undue financial burden on you as the property owner, and will not change or severely alter the basic structure of the dwelling. There is no cost to you as the property owner. The individual(s) named above is/are seeking financial assistance from NR through the Accessibility Improvement Program. Notification of the owner and a signature of acknowledgement and approval is required by the City, prior to any modifications being performed. Please sign in the space provided below, and return this letter to NR. A copy of this letter is attached for your files. I/We understand that should the tenant vacate the property during or after the modification is under construction or constructed, and the modification is not acceptable to a new occupant or me/us as owners, the City of Topeka will not be responsible for any repairs, or liable for any cost to restore the property to its condition or design prior to the modification. If you have any questions, you may contact Neighborhood Relations at phone number (785) Ask for the Project Manager for this job: I realize that the City may wish to use the work it has done to my house for proof of its work or advertising. By signing this application, I/we grant the City my/our consent to take photographs of my/our house and grounds before, as well as after construction and realize that the photographs may be displayed to the public in print as well as electronically for the City s benefit. I/We acknowledge and agree to the above-described modification(s) for the property address noted above. (Owner s Signature) (Owner s Signature)

6 Applicant Terms and Conditions The Applicant understands and agrees to the following: Understands funding is allocated on a first-come, first-serve basis and is determined by the time/date of the last piece of qualifying information received for the applicant. Understands no amount of money is guaranteed. Maximum assistance available for owner-occupied residences is $4, for the interior and $6, for the exterior.. Maximum assistance available for renter occupied homes is $4, for the exterior. Maximum assistance available for mobile homes is $1, for the exterior. Any expense that exceeds the maximum amount of funding allowed by the City of Topeka Accessibility Improvement Program will be the responsibility of the applicant. Have reviewed, understand and agree with the modifications being proposed to my home. Understands that the modifications work will be performed using the applicant s utilities, as needed. Competitive bids may be required by the City s NR. Accessibility modifications are the only modifications that will be approved. -General home repairs or home rehabilitation will not be approved. -Weatherization of homes will not be approved. -Must not ask the contractor to deviate from the approved bid specifications, unless authorized by the City of Topeka Neighborhood Relations Department The contractor must have access to the premises during normal working hours, in accordance with the terms of the notice-to-proceed, unless otherwise mutually agreed by the applicant and the contractor. Understands that the contractor will provide the supplies specified in the bid, and that the contractor will obtain those supplies from his/her selected supplier. The presence of lead-paint may require special activities and inconvenience, or in some situations, change or reduction in the amount of assistance available. Understands that the contractor has the right of salvage for items removed from the premises as part of the work unless mutually agreed otherwise. I further understand that after installation of a modification it is my responsibility or the property owner s for non-warranty maintenance and any removal / repair if required by the owner at the end of a tenancy. I, as an applicant for the City of Topeka Accessibility Improvement Program, have read and agree to the above stated terms and conditions. If any of the terms and conditions is not followed, funding can be withdrawn. (Applicant Signature)

7 Income Guidelines 2017 City of Topeka Residential Accessibility Program Income Limits Effective April 14, 2017 County/MSA % of Median 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person 8 Person Topeka MSA 80% $37,450 $42,800 $48,150 $53,500 $57,800 $62,100 $66,350 $70,650

CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM 445 E. FLORIDA AVE. HEMET, CA PHONE: (951) FAX: (951)

HEAD OF HOUSEHOLD CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM 445 E. FLORIDA AVE. HEMET, CA 92543 PHONE: (951) 765-2380 FAX: (951) 765-2359 Name Birthdate (Last) (First) (M.I.) Address Phone City SPOUSE