Do you or any member of your household own any other real estate? Do you qualify for Medicaid? May we contact other agencies on your behalf?
|
|
- Eileen Walton
- 6 years ago
- Views:
Transcription
1 Agency (if applicable): Contact Name: Phone Number: Last Name: First Name: M.I: Physical Address: City: Zip: Mailing Address: City: Zip: County: Phone: Social Security #: Gender: Race: Marital Status: Birth date: / / Do you own the home in need of repair? Do you live in the home? # of years in residence: Home Type: (Circle one) MOBILE CONDO DUPLEX SINGLE-FAMILY # people in household: Alternate contact (in case we are unable to reach you) Name: Phone: Do you or any member of your household own any other real estate? Do you qualify for Medicaid? May we contact other agencies on your behalf? Have you previously applied for assistance from WARM? Do you own any pets? Is anyone residing in the home a Military Veteran or the spouse of a Military Veteran? In order to process your application, we need a copy of the following documents; please do not mail originals to us. Proof of Ownership: Information proving you own the home in need of repairs, you live on heirs property, or you have lifetime rights. For example: a copy of your deed, a will, or a county tax statement. In the case of a mobile home, please submit a copy of the title from the North Carolina Department of Motor Vehicles. In the case of lifetime rights, please submit a notarized document signed by all homeowners granting you right to live on the property as long as you live. Proof of Income: Information about your income and for all those living in the household. For example: your last four pay stubs from your employer, your MOST RECENT Social Security, SSI, or Disability statement. These documents should match the list of sources you complete in the Household Information section. Rev 08/2015 WARM Application for Assistance Page 1 of 5
2 Please complete the following information for EACH household member, including yourself. Name Employment Relation to you Birth date Social Sec. # M/F of Household Member Status Self Please complete the following income information for all household members. Please include all salaries, Social Security, SSI, Disability, veteran benefits, pensions, child support, alimony, unemployment, etc. Name of Household Member Source of Income (Salary, Social Security, SSI, Disability, etc.) Monthly Earnings Total monthly income for all household members: FOR OFFICE USE ONLY Review Date: Reviewed by: Homeowner Verification: Deed Tax statement Other: (describe) Background Check: Denied Approved Date: Total household monthly income x 12 equals (annual). Number of persons residing in the household is. Median income for a household of person(s) according to income limits dated is (Median Income) for County. (Annual Income) / (Median income x 2) = The income of the above household as a percentage of the median is %. Please reference HUD 20 Income Requirements for (Circle One) B NH P County Rev 08/2015 WARM Application for Assistance Page 2 of 5
3 I hereby authorize Wilmington Area Rebuilding Ministry, Inc. (WARM, Inc.) to release and/or receive to/from any agency or person ANY information that is relevant to the purpose of providing assistance for my needs and/or the needs of my household. I further authorize WARM, Inc. to complete a criminal background screening on each member of my household, listed on this application, for the purpose of application approval. I understand that the release of this information does not guarantee that assistance will be provided but that without the information, my case cannot be processed for consideration of WARM, Inc. services. I understand confidential information may be collected from relatives, friends, acquaintances, coworkers, employers, other assistance agencies, and businesses with whom I have interacted. WARM, Inc. may release or receive information regarding my social and family history, my employment status, my finances, or any other information they deem necessary to review my application. If my project is selected for WARM services, I agree to allow photographs and videos of my home and any household members present during rebuilding activities. I further agree to allow these to be used for recordkeeping, reporting, marketing, and media publication without using my full name or my address. Homeowner (Print Name) Homeowner (Print Name) Homeowner Signature Date Homeowner Signature Date Address, City, State, Zip The execution of this Consent does not guarantee that the assistance you require or desire will be provided. This information will be given only to one or more social agencies (or to persons requested by a social agency to be provided with this information) which may request it. WARM cannot, and does not, decide whether, or how, any other agency may provide assistance to you. Rev 08/2015 WARM Application for Assistance Page 3 of 5
4 In what year was the house built? How many stories? How many bedrooms? How many bathrooms? Does the home contain asbestos materials? Yes No Is mold present in the home? Yes No Is anyone in the home a smoker? Yes No Water source: (Circle one) PUBLIC WELL Type of sewer system: Power company: Power company account number: Are all utility bills paid up-to-date? Yes No If no, which are behind? Is your mortgage paid up-to-date? Yes No Are your property taxes paid? Yes No If you own a mobile home on a rented lot, is the lot rental payment paid up-to date? Yes No Lot owner name: Phone number: Please list any resources you have for these repairs, such as building materials, funds, or family and friends willing to help perform or pay for the work. This information is for planning purposes only. These resources are NOT required to apply, nor will they be used to determine your eligibility. Please check the repairs needed to make your home safe and secure. Appliance Heating/Air Conditioning Sewage/Septic Repairs Door Repair/Replacement Interior Wall Repair Stairs & Landing Electrical Plumbing Water Supply Repairs Exterior Wall Repair Ramp Construction Window Repair Floor Repair Roof Repairs Other (Please Specify) What is the monthly cost of healthcare, including medical visits and prescriptions? How many colds or infections did residents have during the past year? Describe any contagious diseases or conditions in the household. Describe any respiratory illnesses or other types of chronic or terminal illnesses in the household. Describe any falls, burns, or other accidents in the home. Rev 08/2015 WARM Application for Assistance Page 4 of 5
5 Must be completed. Use back of this sheet if necessary. 1. Please tell us more about your situation so we can understand what you are going through. 2. How is the condition of your home affecting you and any other residents? 3. How do you hope WARM s services will improve your situation? I hereby certify that I own and occupy the home in need of repairs, the information on this profile is correct, all income from each person living in my household has been reported, and I am not preparing my home for sale. I understand that failure to report all income, or deception on this application in any way, may result in WARM, Inc. denying me services, or halting services without notice. I understand this information may be used for statistical reporting, and may be furnished to other agencies which may provide assistance. I understand that submittal of this application does not guarantee that assistance will be provided. I agree to promptly provide WARM any additional information needed to process my application. If I am approved, I understand that WARM reserves the right to halt the project at any time, for any reason. Homeowner Signature Date Homeowner Signature Date Rev 08/2015 WARM Application for Assistance Page 5 of 5
DISASTER RECOVERY APPLICATION FOR HOME REPAIR OR NEW HOME CONSTRUCTION. Name: Date:
Appalachia Service Project Headquarters: 4523 Bristol Highway, Johnson City, TN 37601 Ph: (423) 854-8800 / Fx: (423) 854-9771 To locate a field office, call the number above or visit: ASPhome.org! DISASTER
More informationRural Housing, Inc. 1
Rural Housing, Inc. 1 Application for Assistance: Property Taxes General Guidelines: Must be under 50% County Median Income by family size, call for specific $ limit Housing costs must be affordable, less
More informationRural Housing, Inc. 1
Rural Housing, Inc. 1 Application for Assistance: Security Deposit General Guidelines: Must be under 50% County Median Income by family size, call for specific $ limit Housing costs must be affordable,
More informationA Brush with Kindness
A Brush with Kindness The Ramps & Rails Programs provides home repairs for low-income seniors, people with disabilities, and veterans living in Tillamook County who need assistance. Please contact us at
More informationNeighborhood Revitalization Home Repair Program Eligibility Guidelines
Neighborhood Revitalization Home Repair Program Eligibility Guidelines Habitat s Neighborhood Revitalization Home Repair program offers limited home repairs and improvements in order to maintain safe,
More informationEMERGENCY REPAIR OF PRIVATELY OWNED HOMES PROGRAM
MUSCOGEE (CREEK) NATION DEPARTMENT OF HOUSING P. O. BOX 297 / Okmulgee, OK 74447 / 918 549-2500 /1-800-482-1979 APPLICATION FOR THE EMERGENCY REPAIR OF PRIVATELY OWNED HOMES PROGRAM For Office Use Only
More informationCITY OF MOBILE COMMUNITY PLANNING & DEVELOPMENT DEPARTMENT
CITY OF MOBILE COMMUNITY PLANNING & DEVELOPMENT DEPARTMENT HOMEOWNER REHAB LOAN PROGRAM FOR ELIGIBLE RESIDENTS CITY WIDE Are You Having Problems with Your Plumbing? Do You Need a New Roof? Are Your Windows
More informationAbout the Home Preservation Program
About the Home Preservation Program Habitat s vision: A world where everyone has a decent place to live. Habitat Capital Region s Home Preservation Program provides affordable critical exterior home repairs
More informationAge-Friendly Home Investment Program 2018
Age-Friendly Home Investment Program The Cleveland Department of Aging has a program to help seniors age 60 years and older and adults with a disability address one home maintenance or home repair need.
More informationHAMMERS OF HOPE APPLICATION HOME REPAIR PROGRAM
Hammers of Hope is a program of: HAMMERS OF HOPE APPLICATION HOME REPAIR PROGRAM Mission Hammers of Hope is intended to be a safety net that provides home repairs, focused on safety, increased independence,
More informationYakama Nation Housing Authority Elder Minor Home Repair Program
Applicant Name: ******OFFICE USE ONLY****** DO NOT WRITE IN THIS SPACE Date Submitted: Time Submitted: Received by: Yakama Nation Housing Authority Elder Minor Home Repair Program Please make sure your
More informationCity of Modesto Homeowner Rehabilitation Program
City of Modesto Homeowner Rehabilitation Program Overview: Grants and Loans available for low income homeowners to complete: Health and Safety Repairs o Plumbing, roof, electrical, HVAC Accessibility Repairs
More informationPlease complete and return to: Monroe County Habitat for Humanity 354 Memorial Blvd Tobyhanna,PA Phone: (570)
Monroe County Habitat J I I for Humanity Please complete and return to: Monroe County Habitat for Humanity 354 Memorial Blvd Tobyhanna,PA 18466 Phone: (570) 216-4390 Dear Applicant, Thank you for your
More informationCAPE FEAR HABITAT FOR HUMANITY
Disaster REBUILD Program Application Cape Fear Habitat for Humanity s Disaster REBUILD Program (DRP) provides up to $35,000 per home rebuilding assistance to lowto moderate income homeowners in New Hanover,
More informationFINANCIAL ASSISTANCE APPLICATION: COVER LETTER
FINANCIAL ASSISTANCE APPLICATION: COVER LETTER Thank you for choosing Children s of Alabama to provide for the healthcare needs of your child. Please find attached the forms you must complete in order
More informationOwner Occupied Housing Rehab Loan Program
City of Davenport Community Planning and Economic Development Owner Occupied Housing Rehab Loan Program This application is for use in determining eligibility for the City of Davenport s Owner Occupied
More informationCITY OF ANTIGO OWNER OCCUPIED REHABILITATION PROGRAM
CITY OF ANTIGO OWNER OCCUPIED REHABILITATION PROGRAM Please complete the entire application and return it to our office along with all applicable. How did you hear about the program? (circle all that apply)
More informationPlease contact this office at the numbers listed above should you have any questions about the program, its requirements, or procedures.
DISABILITY OPTIONS NETWORK/USDA HOUSING PRESERVATION PROGRAM APPLICATION 831 HARRISON STREET, NEW CASTLE, PA 16101 Tel. (724)652-5144 Fax (724) 856-8973 TTY/VP (7 24) 652-5152 Dear Homeowner: Attached
More informationCritical Home Repair Program Application
Critical Home Repair Program Application Habitat MontDelco s Critical Home Repair Program provides low-cost home repairs to residents of Montgomery and Delaware Counties. Repairs must address critical
More informationExterior Accessibility Grant Program
City of Davenport Community Planning and Economic Development Exterior Accessibility Grant Program This application is for use in determining eligibility for the City of Davenport s Exterior Accessibility
More informationHOMEOWNER APPLICATION
About Us: is an all-volunteer registered non-profit organization that provides entirely free home repair services for low-income homeowners and non-profit facilities. We are part of the Rebuilding Together
More informationHousing Rehabilitation Assistance Program 0% Interest Home Improvement Loans for Prince George s County Homeowners
Housing Rehabilitation Assistance Program 0% Interest Home Improvement Loans for Prince George s County Homeowners The Prince George s County Department of Housing and Community Development has partnered
More informationA United Way Member Agency. 7 Hopkins Street, St. Augustine, FL (904) Fax (904)
A United Way Member Agency 7 Hopkins Street, St. Augustine, FL 32084 (904)826-3252 Fax (904)819-1780 www.habitatstjohns.org A United Way Member Agency 7 Hopkins Street, St. Augustine, FL 32084 (904)826-3252
More informationYOU MUST MEET THE FOLLOWING BASIC REQUIREMENTS TO BE CONSIDERED FOR SELECTION:
YOU MUST MEET THE FOLLOWING BASIC REQUIREMENTS TO BE CONSIDERED FOR SELECTION: You must have attended a Homeowner Information Meeting within the past 6 months. You must have lived or worked in Lee or Hendry
More informationNebraska Ryan White Program
For office use only: Date Received: MR#: Nebraska Ryan White Program Application Information Date: Check all the programs applying for: Part B Part C Part D ADAP ADAP co-payment assistance Wait list If
More informationCity of Modesto Homeowner Rehabilitation Program
City of Modesto Homeowner Rehabilitation Program Overview The City of Modesto s (City) Homeowner Rehabilitation Program is designed to repair or eliminate health and safety hazards in residential properties,
More informationRESIDENTIAL APPLICATION- HUD Properties
Please complete this application and return to: 188 Warburton c/o The Community Builders, Inc. 43 Ashburton Ave. Management Yonkers NY 10701 Application No. Interviewer Applicant s Last Name Date Received
More informationhome repair program application overview a world where everyone has a decent place to live
get started Maumee Valley Habitat for Humanity welcomes Lucas County homeowners to apply to our home repair program for assistance with their home. Please take time to read through this applicant overview
More informationHomeowner Lead Hazard Control Program Application Check List: The following documents will need to be submitted with your application:
CITY OF DUBUQUE HOUSING & COMM. DEVELOPMENT Lead Hazard Control Department 350 W. 6 th Street, Suite 312, Dubuque, IA 52001 563-589-1724 This is an equal opportunity program. Discrimination is prohibited
More informationWhat is Rebuilding Together?
What is Rebuilding Together? Rebuilding Together Montgomery County (RTMC) is a non-profit organization that works in partnership with community volunteers to provide free home repairs and accessibility
More informationRESIDENTIAL APPLICATION- LIHTC Properties
Please complete this application and fax or email to: The Lofts At NoDa Mills (857) 241-2332 nodamills@tcbinc.org Application No. Interviewer Applicant s Last Name Date Received Time Received RESIDENTIAL
More informationHousing Rehab Matching Rebate Program. Program Information & Application Instructions
The City of Rocky Mount is offering a 50/50 matching rebate for up to $12,500 for homeowners to have eligible repairs to their homes that are at least fifty (50) years old. Those applicants who submit
More informationHomeownership Program Application
Homeownership Program Application Coordinated by: The Homeowner Selection Committee Due before October 15, 2017 Via mail or dropped off at Habitats Headquarters Mailing Address: Habitat for Humanity Attn:
More informationRental Application for New Horizons 20 Benson Avenue Worcester, MA (508) / TTY (978)
For Internal Use Only Rental Application for New Horizons 20 Benson Avenue Worcester, MA 01605 (508) 852-2711 / TTY (978) 630-6754 Date Received Time Received If you have a disability and as a result of
More informationHOUSING APPLICATION COVER S HEET
HOUSING APPLICATION COVER S HEET WHAT IS HABITAT? Habitat for Humanity of South Hampton Roads is a nonprofit organization that builds homes for deserving moderate income families. An affiliate of Habitat
More informationRebuilding Together - Fredericksburg P. O. Box Fredericksburg, Virginia 22404
Rebuilding Together - Fredericksburg P. O. Box 41280 Fredericksburg, Virginia 22404 Received: Rebuilding Together Fredericksburg PO Box 41280 Fredericksburg, VA 22404 www.rebuildingtogetherfbg.org 540-373-9807
More informationApplications will only be accepted from
May 2018 Dear Applicant, Thank you for your interest in applying to Pikes Peak Habitat for Humanity! Enclosed you will find the Habitat for Humanity application. Before completing the application, please
More informationTIDELANDS HEALTH FINANCIAL ASSISTANCE APPLICATION
TIDELANDS HEALTH FINANCIAL ASSISTANCE APPLICATION Please read the application in its entirety and attach ALL required information that applies to your situation on page two. Incomplete applications will
More informationEmergency Home Repair (EHR) Information & Application
Emergency Home Repair (EHR) Information & Application Objective: Clearfield City has established the Emergency Home Repair (EHR) Program to provide lower income homeowners up to $3,000 in grant money to
More informationNYS Affordable Housing Corporation (AHC) Madison County Facade Rehabilitation
NYS Affordable Housing Corporation (AHC) Madison County Facade Rehabilitation Thank you for inquiring about the facade rehabilitation program through Partnership for Community Development (PCD) and the
More informationGENERAL INTAKE AND APPLICATION FORM FOR HOME REPAIR
Rebuilding Together Bismarck/Mandan PO Box 874, Mandan, ND 58554 Email: rebuildbisman@hotmail.com Ph: (701) 221-3232 Website: http://www.rebuildingtogetherbisman.com Received Database Case# GENERAL INTAKE
More informationFAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) FAIM New Participant Application Form AGENCY USE ONLY : Agency Name:
FAMILY ASSETS FOR INDEPENDENCE IN MINNESOTA (FAIM) AGENCY USE ONLY : FAIM New Participant Application Form Revised 05/23/14 Agency Name: Bank Account Number of 1 st Deposit Asset Grant First Name MI Last
More informationClient Intake Form. Food Pantry USDA Commodities Weatherization Utility Assistance Migrant Services Date: Head of Household Last First
Client Intake Form Food Pantry USDA Commodities Weatherization Utility Assistance Migrant Services Date: Head of Household Last First Street Address City Zip Code Township Telephone # Date of Birth Gender
More informationCDBG HOME OWNER REPAIR PROGRAM APPLICATION CHECKLIST
CDBG HOME OWNER REPAIR PROGRAM APPLICATION CHECKLIST City of LaPorte Office of Community Development & Planning 801 Michigan Ave., LaPorte, IN 46350 Phone: (219) 362-8260 FAX: (219) 325-0656 CDBG Home
More informationCortland Housing Assistance Council, Inc. Housing Application
Cortland Housing Assistance Council, Inc. 36 Taylor Street Cortland, NY 13045 607-753-8271 Phone 607-756-6267 Fax Housing Application 1 to 3 Bedroom Units * Rent ranges $450 - $600 * Includes Heat & Hot
More informationHubbard County HRA Down Payment Assistance Application
MEMO TO: FROM: SUBJECT: Interested Applicant Levi Haar, Lending and Accounting Specialist Hubbard County HRA Down Payment Assistance Application Thank you for your interest in the Hubbard County HRA Down
More informationThe Fuller Center of NW Portage County
The Fuller Center of NW Portage County Information Packet and Application Online at http://fullercenter.org/northwest-portage-ohio/ About Us The Fuller Center for Housing of NW Portage County is a Christian
More informationTHE FUCCI COMPANY 6 Regency Manor, Suite 1, Rutland, VT Tel Fax
THE FUCCI COMPANY 6 Regency Manor, Suite 1, Rutland, VT 05701 Tel. 802-773-9107 Fax 802-773-0518 PLEASE PRINT ALL INFORMATION CLEARLY : PROJECT APPLYING FOR: BEDROOM SIZE: ANY SPECIAL ACCOMODATIONS NEEDED?:
More information2018 Program Year Mobile Home Renovation Loan Program Application
2018 Program Year Mobile Home Renovation Loan Program Application Thank you for your interest in the Town of Hamburg s Mobile Home Renovation Loan Program. I am pleased to include the attached program
More informationCold Springs Crossing
Cold Springs Crossing 127 Hospital Drive Blaine County, Idaho 83340 Application and Tenant Selection Information Completed applications for the Cold Springs Crossing Apartments should be returned to the
More informationHOME OWNER REHABILITATION DEFERRED LOAN PROGRAM
HOME OWNER REHABILITATION Dear Homeowner: Thank you for your interest in our rehabilitation loan program. Enclosed are the following: The APPLICATION for the loan program, including a checklist of items
More informationPatient Financial Assistance Policy. The following criteria will be used to determine eligibility.
! Patient Financial Assistance Policy POLICY: St. Luke Community Healthcare, a not for profit hospital and affiliated medical clinics offering a broad range of medical care, and is committed to providing
More informationHabitat for Humanity of Hardee County, Inc (HFH) a Registered affiliate with. Neighborhood Revitalization Initiative ~ A Brush With Kindness Program
Habitat for Humanity of Hardee County, Inc 502 East Main Street Bowling Green, FL 33834 863-375-2160 hardeehabitat@hotmail.com Habitat for Humanity of Hardee County, Inc (HFH) a Registered affiliate with
More informationHOMEOWNERSHIP APPLICATION (Rev. 3/16/17) = Submit a copy of each requested item to the application
PART 1: Applicant(s) Information HOMEOWNERSHIP APPLICATION (Rev. 3/16/17) = Submit a copy of each requested item to the application Application deadline: no exceptions APPLICANT (Head of Household owner
More informationTHDA REBUILD AND RECOVER DISASTER PROGRAM HOMEOWNER APPLICATION
THDA REBUILD AND RECOVER DISASTER PROGRAM HOMEOWNER APPLICATION Date: Name of Interviewer: Please submit the following with this application: 1. Proof of ownership in the form of a warranty deed, a 99-year
More informationAffordable Homeownership Program Application: Instructions
Affordable Homeownership Program Application: Instructions Habitat reviews applications on a first come, first served basis. Please expect the entire application process to take between 1 3 months. Instructions
More informationThank you for your interest in the White Earth Reservation Housing Authority Home Owner Rehabilitation Programs.
WHITE EARTH RESERVATION HOUSING AUTHORITY 3303 US Hwy 59 S Waubun, MN 56589 Tel: 218-473-4663 Toll Free: 800-726-4016 Fax: 218-473-2910 APPLICANT: Thank you for your interest in the White Earth Reservation
More informationBURLEIGH COUNTY GENERAL ASSISTANCE APPLICATION. You may return your completed, signed application by:
BURLEIGH COUNTY GENERAL ASSISTANCE APPLICATION A signed application for General Assistance must be completed and returned to Burleigh County. The application should be completed by a household member who
More informationChildren s National Financial Assistance Application
Children s National Financial Assistance Application Children s National will offer financial assistance to patients who are unable to pay their hospital and/or clinic bills due to difficult financial
More informationAPPLICATION FOR FAIR & AFFORDABLE HOMEOWNERSHIP PRINT HOUSE LOFTS 75 MAIN ST., VILLAGE OF DOBBS FERRY, NEW YORK DEADLINE NOVEMBER 1
APPLICATION FOR FAIR & AFFORDABLE HOMEOWNERSHIP PRINT HOUSE LOFTS 75 MAIN ST., VILLAGE OF DOBBS FERRY, NEW YORK DEADLINE NOVEMBER 1 Mail or Hand Deliver Completed Application to: at 55 South Broadway,
More information2. Sign and date the Authorization and Release forms (section 12 on the application). If there are coapplicants,
P. O. Box 445 Troy, MO 63379 636 528 4112 www.habitatlincolnco.org Dear Applicant: Thank you for your interest in Lincoln County MO Habitat for Humanity. Please return the enclosed application form and
More informationCOMPANY NAME: WinnResidential Phone: (202) Third Street SE, Suite 200 Fax: (202) Washington, DC 20032
Elementary, Middle or High School College, University, or Trade School COMPANY NAME: WinnResidential Phone: (202) 561-8600 4319 Third Street SE, Suite 200 Fax: (202) 516-8054 Washington, DC 20032 Email:
More informationAPPLICATION FOR FAIR & AFFORDABLE HOMEOWNERSHIP GATEWAY PEEKSKILL CONDOMINIUM 704 & 716 MAIN ST., CITY OF PEEKSKILL, NEW YORK
APPLICATION FOR FAIR & AFFORDABLE HOMEOWNERSHIP GATEWAY PEEKSKILL CONDOMINIUM 704 & 716 MAIN ST., CITY OF PEEKSKILL, NEW YORK DEADLINE FEBRUARY 19, 2019 Mail or Hand Deliver Completed Application to: at
More informationAPPLICATION FOR RESIDENCY
Please note: Each adult 18 years of age and older needs to complete a separate application unless a married couple. APPLICANT INFORMATION Name: Spouse: Current Address: Telephone: Email: Bedroom Size Requested:
More informationRx for Oklahoma P.O. Box 603 Jay, OK Phone: ext 34 or 29 Fax:
Rx for Oklahoma P.O. Box 603 Jay, OK 74346 Phone: 918-253-4683 ext 34 or 29 Fax: 918-253-6059 Email: lindaely@neocaa.org Email: lrutherford@neocaa.org Serving Craig, Delaware and Ottawa Counties Thank
More informationTOWN OF BEDFORD, NH WELFARE DEPARTMENT APPLICATION FOR ASSISTANCE
TOWN OF BEDFORD, NH WELFARE DEPARTMENT DATE: APPLICATION FOR ASSISTANCE (COMPLETE THIS APPLICATION IN ITS ENTIRETY BEFORE RETURNING TO THE WELFARE OFFICE) Have you ever applied for Bedford Town Welfare
More informationApply for Home Preservation!
! Thank you for your interest in Habitat for Humanity of Wake County s Home Preservation program. Through Home Preservation, we seek to serve homeowners who are either unable to afford, or unable to complete
More informationGUADALUPE APARTMENTS APPLICATION FOR
APPLICATION FOR GUADALUPE APARTMENTS Kind of Housing LIHTC Studio, 1, and 2 bedroom apartments for people at or below 30% of area median income Section 8 vouchers for each unit provides rent to based on
More informationNAHASDA EMERGENCY ASSSISTANCE APPLICATION ELIGIBILITY and CHECKLIST FORM
Page 1 of 6 Shawnee Tribe Housing Department P.O Box 189 Miami, OK 74355 Phone: 918-542-2441 Fax: 918-542-2922 ELIGIBILITY and CHECKLIST FORM THE FOLLOWING INFORMATION IS REQUIRED IN ORDER TO DETERMINE
More informationApplication and Tenant Selection Information
1277 Shoreline Lane Boise, Idaho 83702 (208) 336-4610 Phone ~ (208) 345-8990 Fax, TDD #1-800-545-1833 Ext. 298 Application and Tenant Selection Information Completed applications for the should be returned
More informationHodges Development Corporation Hodges Properties, Inc Hodges-Portsmouth, LLC Hodges-Pembroke, LLC Instructions: Please follow carefully - Incomplete applications will be returned 1. Complete all areas.
More informationAPPLICATION FOR RENTAL REHAB./LANDLORD LOAN PROGRAM
APPLICATION FOR RENTAL REHAB./LANDLORD LOAN PROGRAM A. PROPERTY OWNER Date: Name Address Telephone Date of Birth Social Security Number Type of Rental Agreement: month-to-month lease lease to buy Are any
More informationCHRIC Owner-Occupied Housing Rehab Program CHRIC offers financial assistance to help low-income homeowners make necessary home repairs.
CHRIC Owner-Occupied Housing Rehab Program CHRIC offers financial assistance to help low-income homeowners make necessary home repairs. Visit our website at: www.chric.org Below is an overview of the program.
More informationHOME SWEET HOME COMMUNITY REDEVELOPMENT CORPORATION
Customer Intake Form CUSTOMER 1 P age HOME SWEET HOME COMMUNITY REDEVELOPMENT CORPORATION Please print Name: Address: City: State: Zip Code: Date of Birth: / / Social Security: - - Gender: Male Female
More informationRENTAL APPLICATION. Total number of occupants to live in apartment: Adults Children Do you have a pet? Yes No If yes, describe:
RENTAL APPLICATION : Time: Desired: Full Name of Applicant Social Security Number Male Female of Birth Full Name of Co-Applicant Social Security Number Male Female of Birth Children s Names Male Female
More informationIf you answered 'no' to any questions above, STOP, as you will NOT CURRENTLY QUALIFY for this program
Code Enforcement Rehabilitation Program Application This program is to remove potentially dangerous health and/or safety hazards from homes owned by very low income persons as their primary residence.
More informationApplication for Legal Assistance
Application for Legal Assistance Apply in person at Government Plaza, 205 Government St., Room 427 Check VLP voicemail or website to get current days & times to apply in person To return completed application:
More informationMassachusetts Department of Transitional Assistance
DTA - DPC P.O. Box 4406 Taunton, MA 02780-0420 Massachusetts Department of Transitional Assistance Name: Address: City/Town: Your Monthly Report From To Name If your name, address or telephone is DIFFERENT,
More information# of people who will be living in unit: Application Denied
Rental Application Information on this application will be used to determine your eligibility to be a Project NOW housing resident. Fill out all sections completely. This application will not be processed
More informationTENANT APPLICATION EMERALD HILLS ESTATES ALLEGANY, NEW YORK
EQUAL HOUSING OPPORTUNITY TENANT APPLICATION EMERALD HILLS ESTATES ALLEGANY, NEW YORK MAIL ONLY ONE (1) APPLICATION PER FAMILY TO: EMERALD HILLS ESTATES PO Box 235 Allegany, NY 14706 716-373-2202 TDD Number:
More informationUNC Pharmacy Assistance Program (PAP)
(PAP) INSTRUCTIONS Requirements and Documents for Application If you have questions about the PAP application or the 14 day Temporary PAP Benefit, please call (919) 966-7690, option 1. A counselor is available
More information1. APPLICANT INFORMATION. Co-Applicant (spouse must be Co-Applicant) Name Male Female Name Male Female
Return by on to: Habitat for Humanity of Greater Plainfield & Middlesex County 2 Randolph Road Plainfield, NJ 07060 Include 25 processing fee in check or money order only. Questions? Call Plainfield Habitat
More informationDuke Energy Refrigerator Replacement Program Application and Instructions
Duke Energy Refrigerator Replacement Program Application and Instructions To determine your eligibility, please review the guidelines below and use it as a checklist to determine which of the attachments
More informationRURAL SELF-HELP HOUSING PROGRAM Pre-Application
RURAL SELF-HELP HOUSING PROGRAM Pre-Application Self-Help Housing is a group method of home construction available to limitedincome households. Eligible households qualify for low-interest loans and work
More informationPLEASE READ EVERYTHING COMPLETELY BEFORE FILLING OUT THE ELIGIBILITY QUESTIONNAIRE
Homebuyer Eligibility Questionnaire Packet The Habitat for Humanity program is one in which you purchase a Habitat house or rehab that you also help build! The qualifications are that you have a need for
More informationApplicant s Name (print legibly): KIHA Use Only: Date & time signed application received by KIHA: Date: Time: By:
Applicant s Name (print legibly): KIHA Use Only: Date & time signed application received by KIHA: Date: Time: By: WEATHERIZATION/RENOVATION PROGRAM APPLICATION PACKET INSTRUCTIONS: COMPLETE & RETURN THIS
More information- Please return this packet with the needed information found on the second page. - DON T forget anything or it will delay the application!
IU Health La Porte Community Health Center IU Health La Porte Dental Center 400 Teegarden Street, Suite B 400 Teegarden Street, Suite A La Porte, Indiana 46350 La Porte, Indiana 46350 Phone (219) 326-0043
More informationAddress. PLEASE PRINT. PLEASE ANSWER ALL QUESTIONS! Do not leave any space or blanks, write NO or N/A where appropriate.
APPLICATION for LOW INCOME HOUSING TAX CREDIT (LIHTC) PROPERTY Project Name Unit # No. of Bedrooms Phone (home) (Cell) (work) Current Address: Email Address PLEASE PRINT. PLEASE ANSWER ALL QUESTIONS! Do
More informationPREAPPLICATION NOTE: NO PETS ALLOWED WITHOUT MANAGEMENT APPROVAL. Applicant Name First Middle Last State ID # State
PREAPPLICATION NOTE: NO PETS ALLOWED WITHOUT MANAGEMENT APPROVAL Contact Information: Applicant Name First Middle Last State ID # State Co- Applicant Name First Middle Last State ID # State Email Phone
More informationAgent for Abenaki Springs Phase I LP 17 Avery Lane, Walpole, NH Phone: (603) Fax: (603)
Dear Housing Applicant: Agent for Abenaki Springs Phase I LP 17 Avery Lane, Walpole, NH 03608 Phone: (603) 904-4169 Fax: (603) 588-6133 www.alliancenh.com Thank you for your interest in Alliance Asset
More informationDear Prospective Homeowner,
Dear Prospective Homeowner, Thank you for expressing an interest in partnering with Habitat for Humanity to help build and occupy a new home. The application process of our homeownership program is detailed
More informationLast Name First Name Middle. Address Number & Street City State Zip Code. Date of Birth Applicant Co-applicant / / / / Month Day Year Month Day Year
PARKVIEW APARTMENTS HOUSING APPLICATION Mr. Ms. Miss Date: Mrs. Mr. & Mrs. Last Name First Name Middle Address Number & Street City State Zip Code ( ) ( ) Home Phone Number Alternate Contact Number How
More informationHOUSING APPLICATION FOR THE MARVIN APPLICATION MUST BE COMPLETE. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED
HOUSING APPLICATION FOR THE MARVIN APPLICATION MUST BE COMPLETE. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED 1. APPLICANT NAME (Legal Name and Maiden Name if Applicable): Street City State Zip Telephone
More informationPlease review below charts, check boxes & sign below to return with application. Required Income Qualifications
Please review below charts, check boxes & sign below to return with application. Required Income Qualifications Annual income Monthly income Qualifying area $22,800 $1,900 Blanchard/OKC infill lots $25,200
More informationCITY OF FRASER BOARD OF REVIEW 2018 POVERTY EXEMPTION POLICY & GUIDELINES
CITY OF FRASER BOARD OF REVIEW 2018 POVERTY EXEMPTION POLICY & GUIDELINES The attached guidelines and application are to be used for 2018 only Section 211.7u(1) of the Michigan General Property Tax Act
More informationI am interested in living in the following bedroom size (please circle all that apply):
Please fill out and submit to: Housing Visions Consultants, Inc. 1201 East Fayette Street Syracuse, NY 13210 315-472-3820 Phone 315-422-4317 Fax 711 TDD For management office use: Candlewood Court I&II
More informationIn order to process this application we require:
Keck Medical Center of USC (KMC), which includes Keck Hospital of USC, USC Norris Cancer Hospital, and Verdugo Hills Hospital (VHH), is dedicated to providing quality health care to our patients. We realize
More informationRENTAL APPLICATION CHECKLIST
RENTAL APPLICATION CHECKLIST Please note: The application will not be accepted with incomplete information and missing documentation. All documents requested must be provided. Name: Date & Time: Applicant(s)
More informationFamily Size Gross Yearly Income 1 $16,700 2 $19,050 3 $21,450 4 $23, $25,750 6 $27,650. Subject to Change
C i t y o f C l e v e l a n d B e d B u g A s s i s t a n c e P r o g r a m Family Size 2016 2017 Gross Yearly Income 1 $16,700 2 $19,050 3 $21,450 4 $23, 800 5 $25,750 6 $27,650 Subject to Change Bed
More informationCity of Tacoma Single Family Homeowner Occupied Rehabilitation Loan Program Services
PROGRAM GUIDELINES AND STANDARD OPERATING PROCEDURES City of Tacoma Single Family Homeowner Occupied Rehabilitation Loan Program Services Under the Single Family Homeowner Occupied Rehabilitation Services
More information