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

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1 HEAD OF HOUSEHOLD CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM 445 E. FLORIDA AVE. HEMET, CA PHONE: (951) FAX: (951) Name Birthdate (Last) (First) (M.I.) Address Phone City SPOUSE Zip Social Security # Name Birthdate (Last) (First) (M.I.) Social Security # OTHER HOUSEHOLD MEMBERS: Name Age Name Age Name Age INCOME (Per month) SOURCE OF INCOME Head of Household: $ Spouse: $ Other Household Member $ Other Household Member $ TOTAL MONTHLY INCOME $ I hereby certify that all the above statements are true and complete. Head of Household Signature Co-Homeowner Signature Date Date

2 Project/Activity Title: CITY OF HEMET Beneficiary Qualification BENEFICIARY QUALIFICATIONS STATEMENT This statement must be completed and signed by each person or head of household (legal guardian) receiving benefits from the described project/activity. Please answer each of the following questions. 1. How many persons are in your household? For this question, a household is a group of related or unrelated persons occupying the same house with at least one member being the head of the household. Renters, roomers, or borders cannot be included as household members. Note that a list of the 2006 VERY LOW income category is presented below. Please calculate the combined gross annual of all persons in your household from all sources of income. 2. Circle your combined gross annual income. CIRCLE THE NUMBER OF PERSONS AND YOUR COMBINED ANNUAL INCOME Number of Persons in Your Household VERY LOW INCOME 50% and Below (NOT TO EXCEED) $20,700 $23,700 $26,650 $29,600 $31,950 $34,350 $36,700 $39, (Per HUD regulations effective FY 2006) Do you identify yourself as: You may identify both a Race and a Hispanic Ethnicity. This information is confidential and is only used for government reporting purposes to monitor compliance with equal opportunity laws. Please note that self-identification of race/ethnicity is voluntary. RACE: White Hispanic/Black/African American Black/African American Hispanic/Asian Asian Hispanic/American Indian/Alaskan Native American Indian/Alaskan Native Hispanic/Native Hawaiian/Other Pacific Islander Native Hawaiian/Other Pacific Islander Hispanic/American Indian/Alaskan Native & White American Indian/Alaskan Native & White Hispanic/Asian & White Asian & White Hispanic/Black/African American & White Black/African American & White Hispanic/American Indian/Alaskan Native & Black/ Am. Indian/Alaskan Native & Black/African Am African American Asian/Pacific Islander Other Multi-Racial Hispanic/White HISPANIC/LATINO ETHNICITY? Yes No Yes, Mexican/Chicano Yes, Cuban Yes, Puerto Rican Yes, Other Hispanic/Latino: 4. AGE: 55 to to to 79 Over Is FEMALE THE HEAD OF HOUSEHOLD: Yes No 6. Are you DISABLED? Yes No ACKNOWLEDGMENT AND DISCLAIMER I CERTIFY UNDER PENALTY OF PERJURY THAT INCOME AND HOUSEHOLD STATEMENT MADE ON THIS FORM ARE TRUE. NAME: DATE: ADDRESS: PHONE#: SIGNATURE: This information you provide on this form is for the Community Development Block Grant(CDBG)Program purposes only and will be kept confidential.

3 CITY OF HEMET Senior and/or Disabled RAMP PROGRAM (951) APPLICATION INFORMATION In order to allow the City of Hemet staff to review and process your application the following information is required. Please return COPIES (we will not be responsible for the originals) of the following items: Please mark the boxes of the items that you are enclosing: Proof of Ownership: Copy of Grant Deed and/or Quit Claim Deed Copy of current Certificate of Title and Registration (for mobile homes) Copies of six (6) most recent Bank Statements, all of the pages Copy of Federal Income Tax Returns for year 2005 Copies of six (6) months current Paycheck Stubs; and/or Proof of Income One copy of each: Social Security Award Letter Social Security Benefits Statement Pensions IRA Income CD/Mutual Funds Other Copy of Driver s License or State Identification Card on all person living in the home over the age of 18 years Copy of Death Certificate spouse (if their name is still on deed or title) A letter from your doctor verifying the need for a ramp *Please note all applications are processed based on date application is received and funding availability*

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5 CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM (951) CONSENT TO GATHER INFORMATION I understand that additional information may be needed for my application. I hereby give my permission to contact the Employment Development Department, Physician, Social Security Administration, Financial Institutions and the Internal Revenue Service to obtain only the needed information for completion of my application. It is further understood that the information is confidential and will only be used for completion of my application for the Senior and/or Disabled Ramp Program. Dated: Property Owner: Mailing Address: Site Address: Telephone Number: ( ) Signature: Signature: Signature:

6 CITY OF HEMET SENIOR &/or DISABLED RAMP PROGRAM (951) WAIVER FOR OWNER - OCCUPIED PROPERTY As a participant in the Disabled Ramp Program, I understand that the City of Hemet will choose a contractor who has a current City of Hemet business license to build a ramp authorized under the program and is on the current approved list of contractors. I also understand that there are certain risks to persons and property inherent in building a ramp. I further understand that the contractor selected to built the ramp at my home is not in any way affiliated with the City of Hemet and that any personal injury or damages caused by the contractor to my personal or real property, are the sole responsibility of the contractor. Given my understanding of the above, I agree not to file any claim, demand or lawsuit against the City of Hemet, it s elected or appointed officials, employees or agents arising from or related in any way whatsoever to the actions of any repair person performing work on my home in connection with the program. Dated: Property Owner: Mailing Address: Site Address: Telephone Number: ( ) Signature: Signature: