CITY OF CHICAGO Chicago Department of Public Health Lead Poisoning Prevention and Healthy Homes Program

Transcription

1 CITY OF CHICAGO Lead Poisoning Prevention and Healthy Homes Program Homeowner Application for Financial Assistance for the Lead-Based Paint Hazard Control Grant Program MAKING CHICAGO A LEAD SAFE CITY

2 CITY OF CHICAGO Lead Poisoning Prevention and Healthy Homes Program Homeowner Application for Financial Assistance for the Lead-Based Paint Hazard Control Grant Program Applicant s Name: Marital Status: Applicant s Home Address: Zip Code: Social Security #: Date of Birth: Telephone Number: Alternate Telephone Number: Monthly Pension: SSDI: SSI: Employer s Name: Address: Monthly Gross Pay: Monthly Income Source: Do you receive Medicaid: Yes No Monthly Rental Property Income: Other Income (describe source): Address(es) of other property owned: Co-Applicant s Name: Marital Status: Co-Applicant s Home Address: Zip Code: Telephone Number: Alternate Telephone Number: Monthly Pension: SSDI: SSI: Employer s Name: Address: Monthly Gross Pay: Monthly Income Source: Monthly Rental Property Income: Other Income (describe source): Address(es) of other property owned: In order to determine your eligibility, the (CDPH) will need information regarding applicant & co-applicant family size and income. List below the name, date of birth and monthly income by source of all adults (18+) residing in your household. Applicant s Household Information Number of household members: Name Date of Birth Monthly Income Income Source (Employment, Pension, AFDC, etc.) (Use a separate sheet of paper if additional family members reside in your household)

3 Co-Applicant s Household Information Number of household members: Name Date of Birth Monthly Income Income Source (Employment, Pension, AFDC, etc.) (Use a separate sheet of paper if additional family members reside in your household) PROPERTY INFORMATION Address of Property you are applying for: Type of Home: Single Family 2 Unit 3 Unit 4 Unit Title/Ownership of Property Name: How long have you owned the home/building? Please circle yes or no to the following questions: Are all units/apartments occupied? YES NO Are the Property Taxes Current? YES NO Do you have Homeowner s Insurance for this property? YES NO Are you in Foreclosure status on this property? YES NO Do you plan to sell the property? YES NO (If yes, When? ) Do you have a signed Lead Paint Hazard Mitigation Notice with the City of Chicago? YES NO

4 Property Household Information Please list below person s residing in rental unit: Name Apt/Unit # Date of Birth Age (Use a separate sheet of paper for additional persons) Applicant and Co-Applicant are required to submit the following documents with this application. 1. Copy of Photo Identification (State ID, Driver s License, or Passport) 2. Two (2) copies of Rental Unit Lease or Rent Receipts 3. Two (2) copies of most recent Pay Check Stubs 4. Most recent Social Security Award Letter or last year s IRS Most recent Pension Award Letter or last year s IRS Copy of Property Deed or Mortgage Statement (must be current) 7. Most recent copy of Homeowners Insurance Policy Declaration Page 8. Most recent Property Tax Bill Receipts (must be current) 9. Copy of Blood Lead Level Test results for every child 6 years of age or younger living in the home or visits 6 hours or more weekly 10. Copy of Medicaid Card (if applicable) APPLICANT S and CO-APPLICANTS CERTIFICATION: I/We certify that all information in this application and all other information furnished in support of this application are given for the purpose of obtaining a grant under the Chicago Department of Public Health (CDPH) Lead-Based Paint Hazard Control Grant Program, and are true and complete to the best of my/our knowledge. CDPH may obtain verification from any source named herein. I/We understand that CDPH may award a partial or a full grant depending on my/our income and the size of my/our building. I/We will be told what form of assistance is being provided before agreeing to have the work done. I/We will not sell the property for the next three (3) years, and if I/We do, I/We understand any amount granted may be subject to recapture by CDPH at the time of sale. I/We understand that it is my responsibility as the owner of the property to monitor all

5 mitigated areas and to make repairs in a proper manner if said repairs fail in accordance with Title 77, Chapter 1, Sub Chapter P of the Illinois Administrative Code. I/We understand and agree that CDPH personnel have the right for a period of one year to enter and inspect the areas of the abatement/mitigation for the purpose of determining the effectiveness and durability of the allowed alternative procedures. I/We agree to attend a homeowner lead workshop at CDPH and continue to maintain our property such that it remains free of lead hazards. If applying for a single family property, I/We further attest that there is a child six years of age or younger that either lives in the home or spends at least six hours per week in the home. If applying for rental property, I/We further agree that I/We will continue to rent to the current tenant(s) as long as they remain in good standing and priority will be given if a vacant units is available to families with children six years of age or younger. I/We will continue to offer more than half of the units at affordable rents for very low-income individuals and the remainder at affordable rents for low-income individuals as determined annually by the US Department of Housing and Urban Development for the next three years. I/We certify under penalty of law that the information contained in this declaration is true, accurate, and complete to the best of my knowledge. I/We understand that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations. Applicant Signature Date Co-Applicant Signature Date Return completed application with required documents to: Lead Poisoning Prevention and Healthy Homes Program Lead Based Paint Hazard Control Grant 2133 West Lexington Street Chicago, IL For questions or additional information, call Revised 05/09/2013

6 CITY OF CHICAGO Lead Poisoning Prevention and Healthy Homes Program Child Verification Form I, owner of the property located at,, Address City State swear the child(ren) listed below reside at this address Zip Code. The child(ren) are between the age of 6 months to 6 years of age. Child s Name DOB Age EBL Child s Name DOB Age EBL Child s Name DOB Age EBL Signature of Property Owner Date Subscribed and Sworn To Me This day of 20 Notary Public