SENIOR HOME REPAIR GRANT (SHRG) Application Package 5555 Arlington Ave. Riverside, CA 92504 951-343-5469 Updated 10/22/12
Application Submission Checklist APPLICATION PACKAGE SUBMISSION CHECKLIST Participation in the (SHRG) requires proof that you meet the eligibility guidelines. Please submit the following documents with your application. All items are needed to determine if you qualify for assistance. Incomplete packages will not be considered. Please mark the appropriate boxes next to the items that are enclosed in your application package. APPLICATION PACKAGE Application- Complete, signed and dated (mail original with wet signatures to the EDA) Exhibit A- Complete, signed and dated (mail original with wet signatures to the EDA) Exhibit B- Only required for household members who did not file tax returns or claim no income PROOF OF INCOME & ASSETS Federal Tax Returns- copies of the last two year s Federal Tax Returns (all schedules) signed and dated. W2s and 1099- copies of the last two year s W2 and/or 1099 statements Employment Income- copies of the most recent month s pay check stub for all employed household members showing year-to-date income totals. Rental Income- copies of Rental Agreements and schedules identifying rental income. Social Security income- copy of the most recent year s award letters Retirement/Pension income- copy of award letters Alimony/Child Support- copy of Divorce Decree or Court Order Self-Employment Income- most recent year-to-date profit and loss statement and a balance sheet prepared and signed by an accountant. Bank Statements-copy of the most recent two months worth of bank statements for all asset accounts (checking, savings, stocks, bonds, retirement accounts, etc.)- all pages please PROOF OF OWNERSHIP Copy of the GRANT DEED for your property. Certified copy of Trust if property title is held in the form of a Trust Copy of the unexpired registration of title for a Mobile Home and State of California Department of Housing and Community Development (HCD) Decal number. (Registration must be current) ADDITIONAL DOCUMENTS Copy of your most recent property tax bill, documenting taxes are paid current Copy of your California Driver s License or Identification Card (must be current & valid) Copy of Power of Attorney, if applicable If your home is in a flood zone: copy of your flood insurance cover page showing your agent s name, address, phone number, property address and the amount of coverage for the current year. Copy of social security card for all household members Proof of citizenship for all household members (includes birth certificate, valid and unexpired passport, Permanent Resident Alien Card or Certificate of Naturalization) All sections of this application, including attachments and exhibits, must be complete and accurate to be considered for funding. Review your application and attachments/exhibits for completeness. MAIL COMPLETED APPLICATION PACKAGE TO: 5555 Arlington Ave. Riverside, CA 92504 Updated 10/22/12 Page 1 of 1
SECTION 1: PLEASE COMPLETE ALL SECTIONS AND PRINT CLEARLY Applicant: Date of Birth: Social Security #: Single Married Unmarried Widowed Are you the Owner-Occupant of the Property to be Repaired: Yes No Employer Name: Do you file a tax return: Yes No Application Co-Applicant: Date of Birth: Social Security #: Single Married Unmarried Widowed Are you the Owner-Occupant of the Property to be Repaired: Yes No Employer Name: Do you file a tax return: Yes No Co-Applicant s Relationship to Applicant is: Head of Household is Applicant Co-Applicant Head of Household Gender: Male Female Head of Household Age: 18-61 62 or older Language: English Spanish Other: SECTION 2: Applicant s Home Address: City: State: Zip Code: Home Phone: Cell Phone: Alternate Phone: Email : Mailing Address: City: State: Zip Code: Emergency Contact: Relationship: Phone: SECTION 3: Property to be Repaired is Your: Primary Residence Second Home Renter Occupied Do you have a Mortgage on the Home: Yes No If Yes- Are Payments Current: Yes No Do you have a Reverse Mortgage: Yes No Type of Residence: Stick Built House Mobile Home, Space/Unit Number If Mobile Home- Name of Mobile Home Park: Do You Pay Property Taxes: Yes No If Yes- Are Your Property Taxes Paid Current: Yes No (Property taxes must be current to be eligible for SHRG) SECTION 4: Property Characteristics: Year Built/Manufactured: (Properties built prior to 1978 are NOT eligible) Number of Bedrooms: Number of Bathrooms: Square Feet: Has Code Enforcement Cited Your Property: Yes No If Yes- Date of Citation: Items Cited: Please Select which Program-Eligible Repairs You are Requesting (check all that apply): SECTION 5: Head of Household Ethnicity (check one box): Hispanic Non-Hispanic Head of Household Race (check only one box): Asian Black White Native Hawaiian/Pac. Islander Asian & White Black. & White Other Multi-Racial Am. Indian or Alaskan Native (AIAN) AIAN & White AIAN & Black Are All Household Members Either a US Citizen or a Qualified Alien: Yes No (All household members must be either a US Citizen or a qualified alien as evidenced by valid documentation) Updated 10/22/12 Page 1 of 2
Application SECTION 6: Total Number of Persons Living in the Home: # of Adults 18 or older: #of Children: Does any Household Member Receive any of the Following Types of Income (check all that apply): Employment Income Social Security Pension/Annuity Child Support/Alimony TANF Disability Veteran Benefit Survivor Benefit Other Income: List information for ALL household members living in the home, including the head of household: Name Relationship To Head of Household HEAD Date of Birth Source of Income Gross Annual Income Participation in the (SHRG) is dependent upon meeting eligibility requirements. The amount of the grant will be dependent upon the work approved by the Economic Development Agency. All items requested on the Application Checklist must be submitted with your application- incomplete applications will not be processed. This information is required in addition to any information you may have already provided to the Office on Aging. A complete application will remain on file until eligibility is determined, but no more than one (1) year. This is not an entitlement program and is subject to availability of funds. Guidelines and eligibility requirements are subject to change at any time without notice. Penalty for false or fraudulent statement U.S.C. Title 28, Section 1001, provides: whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies... Or make any false, fictitious or fraudulent statement or entry, shall be fined up to $10,000, or imprisoned up to 5 years or both. I/we declare under penalty of perjury that the statements contained in this application are true and correct. I/we understand that if the if information herein is found to be inaccurate, my/our application may be denied. x x Applicant s Signature Date Co-Applicant s Signature Date Applicant s Printed Name Co-Applicant s Printed Name MAIL COMPLETED APPLICATION PACKAGE TO: 5555 Arlington Ave. Riverside, CA 92504 Updated 10/22/12 Page 2 of 2
Exhibit A EXHIBIT A AUTHORIZATION FOR RELEASE OF INFORMATION CONSENT The undersigned applicant(s) authorizes and directs any Federal, State or local agency, organization, business, or individual to release to the County of Riverside Economic Development Agency (EDA) any information or materials needed to complete and verify an application for participation and assistance. The undersigned applicant(s) understands and agrees that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) and California State Department of Housing and Community Development (HCD) in administering and enforcing program rules and policies. The undersigned applicant(s) also consents to allow EDA to conduct a credit inquiry and to release information from my/our file to HUD, HCD, credit bureaus, collection agencies, or future investors. This includes records on my/our payment history and violations of leases or agreements. COMPUTER MATCHING NOTICE AND CONSENT The undersigned applicant(s) understands and agrees that HUD or EDA may conduct computer-matching programs to verify the information supplied for my/our application. If a computer match is done, the undersigned applicant(s) understands that he/she/they has(have) the right to receive notification of adverse information found and a chance to disprove incorrect information. HUD or EDA may in the course of its duties exchange such automated information with other Federal, State, or local agencies. CONDITIONS The undersigned applicant(s) agrees that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file with EDA and will stay in effect for one year and one month from the date signed. The undersigned applicant(s) understands that he/she/they has(have) a right to review the file and correct any information that can be proven is incorrect. PERSONAL CREDIT INFORMATION Applicant s Name Applicant s Social Security Number Applicant s Date of Birth Co-Applicant s Name Co-Applicant s Social Security Number Co-Applicant s Date of Birth Street Address City State Zip Code BUSINESS CREDIT INFORMATION (for self-employed applicants only) Full Name of Business Name of Chief Executive Officer Business Street Address City State Zip Code I hereby authorize the release of any and all information required in the processing of my/our application. I further authorize EDA to release such information to any entity as required in the processing of my/our application. X X Applicant s Signature Date Co-Applicant s Signature Date Applicant s Printed Name Co-Applicant s Printed Name Updated 10/22/12 Page 1 of 1
Exhibit B Riverside County Economic Development Agency 5555 Arlington Ave. Riverside, CA 92504 951-343-5469 EXHIBIT B Income Tax Affidavit (You must also complete and sign the accompanying IRS Form 4506-T) This form and the IRS Form 4506-T must be completed & signed by any household members who: 1. Did not file income tax returns with the IRS for either of the most recent two years; and/or 2. Claim no income The information you provide may be verified with the IRS for accuracy. Check all that apply: 1. I hereby certify that I was Not Required By Law to File a Federal Income Tax Return for the following year(s) for the reason(s) stated below: No income was earned during that tax year Other: 2. I hereby certify that I Receive No Income (including unemployment income) effective the following date / / for the reason(s) stated:. I acknowledge and understand that this Affidavit will be relied upon for purposes of determining my eligibility for (SHRG) Assistance. I acknowledge that a material misstatement negligently made in any statement by me in connection with an application for SHRG assistance will constitute a federal violation punishable by a fine; and a material misstatement fraudulently made in any statement by me in connection with an application for SHRG Assistance will constitute a federal violation punishable by a fine and repayment of all Assistance received, which will be in addition to any criminal penalty imposed by law. In addition, I hereby acknowledge and understand that any false pretense, including false statement or representation, or the fraudulent use of any instrument, facility, article or other valuable thing or service pursuant to participation in any Riverside County program is punishable by imprisonment or by a fine. I declare under penalty of perjury that the statements above are true and correct. x Signature of Household Member Date Printed Name Updated 10/22/12 Page 1 of 3
Updated 10/22/12 Page 2 of 3 Exhibit B
Updated 10/22/12 Page 3 of 3 Exhibit B