HOME REPAIR APPLICATION PACKET 2017-2018 THE CITY OF PLANTATION The Grass is always Greener The primary purpose of the City home repair programs are: I. To abate any health and safety problems in your home 2. To stop weather penetration to make your home more energy efficient 3. To provide safe electrical and mechanical systems 4. To improve the general condition of your home more energy efficient 5. To correct Municipal Code Violations Please contact MBC to make an Appointment to bring in your application for review. Applications cannot be mailed or dropped off. You must return application in person by appointment to MBC. PLEASE COMPLETE & RETURN ORIGINAL APPLICATION PACKET TO: Broward County Minority Builders Coalition (MBC) Attention: Janice Hayes 665 SW 27 th Avenue, Suite # 12, Fort Lauderdale, FL 33312 Phone (954) 792-1121 EXT 25 *Email: janice.hayes@minoritybuilders.org ------------------------------------------------------------------------- Please Complete All Sections of Application or Write in Not Applicable (N/A) Applicant s Name: Co-Applicant s Name: Address: Unit # City: _ State: Zip Cell Phone: Home Phone: Alt. Phone: Email Address: Page 1 of 18 Applicant s Initials: CO-Applicant s Initials:
GENERAL APPLICATION INFORMATION Applicant s Information Full Name Last First Middle Date of Birth Social Security # Age: Marital Status (Circle One): Married Single Divorced Separated Home Address Apartment/Unit # City, ST, Zip Mailing Address (If different from above) Phone Home: Cell: Other: EMAIL: Are you a USA Citizen: (Select One) YES NO Legal Permanent Resident Other If you answered yes, to Legal Permanent Resident, a copy of the Resident/Green Card must be provided CO-APPLICANT Full Name Last First Middle Date of Birth Social Security # Age: Marital Status (Circle One): Married Single Divorced Separated Home Address Apartment/Unit # City, ST, Zip Mailing Address (If different from above) Phone Home: Cell: Other: EMAIL: Are you a USA Citizen: (Select One) YES NO Legal Permanent Resident Other If you answered yes, to Legal Permanent Resident, a copy of the Resident/Green Card must be provided (1) OTHER MEMBERS RESIDING IN THE HOUSEHOLD Name Date of Birth Age Relationship to Applicant Document Used For Verification (2) (3) (4) (5) Page 2 of 18 Applicant s Initials: CO-Applicant s Initials:
Is Applicant, Co-Applicant, or other household member, age 18 or older, a full-time Student? (Circle one) YES NO If YES, please list name(s) of Full-time Student: Applicant s Name: Employer/Name of Company (Current or Last): Employer Address: City, State, Zip: Supervisor s Name: Employer Phone #: Employer Fax #: Employer Email: Co-Applicant s Name: APPLICANT EMPLOYMENT INFORMATION Position/Title: Pay Rate: Pay Frequency: Annual Gross Salary: Annual Overtime, Tips, Bonus: Length of time Employed: CO-APPLICANT EMPLOYMENT INFORMATION Employer/Name of Company (Current or Last): Employer Address: City, State, Zip: Supervisor s Name: Employer Phone #: Employer Fax #: Employer Email: Position/Title: Pay Rate: Pay Frequency: Annual Gross Salary: Annual Overtime, Tips, Bonus: Length of time Employed: OTHER HOUSEHOLD MEMBERS EMPLOYMENT INFORAMATION Household Member s Name: Employer/Name of Company (Current or Last): Employer Address: City, State, Zip: Supervisor s Name: Employer Phone #: Employer Fax #: Employer Email: Position/Title: Pay Rate: Pay Frequency: Annual Gross Salary: Annual Overtime, Tips, Bonus: Length of time Employed: OTHER HOUSEHOLD MEMBERS EMPLOYMENT INFORAMATION Household Member s Name: Employer/Name of Company (Current or Last): Employer Address: City, State, Zip: Supervisor s Name: Employer Phone #: Employer Fax #: Employer Email: Position/Title: Pay Rate: Pay Frequency: Annual Gross Salary: Annual Overtime, Tips, Bonus: Length of time Employed: Page 3 of 18 Applicant s Initials: CO-Applicant s Initials:
SOURCE OF INCOME (Please list Annual Income Amounts) ANNUAL GROSS INCOME INFORMATION APPLICANT CO- APPLICANT OTHER MEMBER 18 OR OLDER OTHR MEMBER 18 OR OLDER Employment $ Self-Employment/Business Net Income $ Unemployment Benefits $ Social Security Benefits $ Supplemental SS Benefits $ Social Security Disability $ VA or Military Benefits $ Short/Long Term Disability $ Workman Comp Benefits $ Pensions, IRA, 401K Benefits $ Welfare Payments $ AFCD/TAN/ESS Payments $ Rental Property Net Income $ Other (List): $ TOTAL HOUSEHOLD ANNUAL INCOME (Add all Columns above to determine Annual Household Income for All) TOTAL ASSETS AND ASSET INCOME (For All Household Members, List All Bank Accounts-Checking & Savings, IRA s, Pension Plans, Life Insurance, etc.) Name of Bank / Financial Institution Name of Bank / Financial Institution (Bank, Pension Plan, etc.) APPLICANT S ASSET INFORMATION Type of Asset (Checking, Savings, 401K, etc.) Asset Value Balance Amt. CO-APPLICANT S ASSET INFORMATION Type of Asset (Checking, Savings, 401K, etc.) $ Interest Rate % TOTAL: $ Asset Value Balance Amt. Interest Rate % Amt. Income earned from Asset Amt. Income earned from Asset If necessary, Please make Additional Copies of this Page Page 4 of 18 Applicant s Initials: CO-Applicant s Initials:
OTHER HOUSEHOLD MEMBERS 18 YEARS AND OLDER ASSET INFORMATION Type of Asset Asset Value Interest (Checking, Savings, 401K, etc.) Balance Amt. Rate % Name of Bank / Financial Institution TOTAL: $ OTHER HOUSEHOLD MEMBER 18 YEARS and OLDER ASSET INFORMATION Type of Asset Asset Value Interest (Checking, Savings, 401K, etc.) Balance Amt. Rate % Name of Bank / Financial Institution TOTAL: $ Amt. Income earned from Asset Amt. Income earned from Asset Does the Applicant, CO-Applicant or any other Household Member, Age 18 or Older, Own any other Property, Real Estate or Land? (Circle One): YES NO If Yes, please list: Do you have any outstanding unpaid Collections, Liens or Judgments (Circle One): YES NO If Yes, What at the Amounts? (1) $ (2) $ (3) $ LIABILITIES / DEBTS (Annual Expenses) Creditor s Name/Type Applicant CO-Applicant Other Member 18 or Older Mortgage/Rent: Car Payment Car Insurance Credit Cards Medical Other Loans Other (List): TOTAL HOUSEHOLD ANNUAL LIABILITIES (Add all Columns above to determine Annual Household Liabilities for All) $ Other Member 18 or Older Page 5 of 18 Applicant s Initials: CO-Applicant s Initials:
ASSET ADDENDUM TO APPLICATION (Must be completed for all persons, including minors, who will occupy assisted housing) In order to properly qualify an applicant for program assistance, the following asset information for all persons, including minors, who will occupy the assisted housing, must be obtained. This information will be used for qualification purposes only. Assets include, but are not limited to: Cash held in savings and/or checking accounts, safe deposit boxes, homes, etc.; trust funds (revocable trusts); equity in real estate and other capital investments; stocks, bonds, Treasury Bills, certificates of deposit, money market and other investment accounts; IRA, Keogh and similar accounts; retirement and pension funds; cash value of life insurance policies available to the individual before death; mortgage or deed of trust; lump sum receipts (i.e. lottery winnings, inheritances, victim's restitution, insurance claims, or settlements, etc.) and, personal property held as an investment (i.e. gem or coin collections, paintings, antique cars, etc.) NOTE: Do not include property such as clothing, furniture, cars, wedding bands, etc. CERTIFICATION: I/WE hereby state that the combined value of my/our assets Please check one: Assets Does NOT exceed $5,000 Yes, Assets exceed $5,000 Please write in the Total value of your assets: $ Total value of assets (Do Not include your Primary Residence, Furniture, or Clothing. Etc) $ Total Annual income expected to be derived from assets Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 6 of 18 Applicant s Initials: CO-Applicant s Initials:
CHILD SUPPORT AFFIDAVIT Child support payments that are received shall be included as income whether or not there is yet a court awarding payment Child support Amounts awarded by the courts, but not received can be executed only when the Applicant certifies that payments are not being made and further documents to show proof that all reasonable legal actions to collect amounts due, including filing with appropriate courts or agencies responsible for enforcing payment, have been taken. Please Check only One box below: Not Applicable (Child support is not applicable to our household) Yes, we have an order for Child support or we plan to file for child support. If Yes, Please complete the following: A. Do you received child support (Circle one): Yes No Payment Amount: $ Frequency: Name of Source (Person paying Child Support): Name of Custodian (Person receiving Child Support payments): (1) Name of Child: (2) Name of Child: (3) Name of Child: (4) Name of Child: B. Have you been awarded child support by court order (Circle one): Yes No a. Provide a copy of the entire documents b. Enter Child support Award Amount: $ and Frequency: c. Is payment being received as awarded: (Circle one): Yes No d. Indicate the manner by which payment is received (Check below): Enforcement Agency: Name of Agency: Court of Law: Court Name: Direct from responsible party: Provide Notarized Letter from Payee Other: Explain: e. If payment is not being received of if amount received is less than the amount awarded provide details and documentation of collection efforts. Under penalty of perjury, I certify that the information presented in this affidavit is true and accurate to the best of my knowledge. The undersigned further understands that providing false representation herein constitutes an act of fraud. False, misleading or incomplete information will result in the denial of your application for assistance. Applicant's Signature Print Name Date Custodial Parent s Signature Print Name Date Page 7 of 18 Applicant s Initials: CO-Applicant s Initials:
Citizenship Declaration PLEASE CHECK ONLY ONE BOX BELOW (Either Box 1, or Box 2 or Box 3) 1. A citizen or national of the United States. 2. A noncitizen with eligible immigration status as evidenced by one of the documents (Alien Registration, Arrival-Departure Record, Form I-94, Temporary Residency Card, Employment Authorization Card, DHS Replacement Document, Form I-151 AR Receipt Card) 3. I am not contending eligible immigration status and I understand that I am not eligible for financial assistance. I, hereby declare, under penalty of perjury, that I am (Signature) Check here if adult signed for a child (Signature of adult signing for child) (Print name of adult signing for child) LAST NAME: FIRST NAME: RELATIONSHIP TO HEAD OF HOUSEHOLD: DATE OF BIRTH: SEX: SOCIAL SECURITY #: - - REGISTRATION NO.: ADMISSION NUMBER: if applicable (this is an 11-digit number found on DHS Form I-94, Departure Record) NATIONALITY: (Enter the foreign nation or country to which you owe legal allegiance. This is normally but not always the country of birth. SAVE VERIFICATION NO: (to be entered by owner if and when received) If necessary, Please make Additional Copies of this Page This form must be completed for every household member, including minors. Page 8 of 18 Applicant s Initials: CO-Applicant s Initials:
APPLICATION ACKNOWLEDGMENT IMPORTANT-READ BEFORE SIGNING The information provided is true and complete to the best of my/our knowledge and belief. I/WE consent to the disclosure of such information of purposes of income verification related to my/our application for financial assistance. I/We understand that any willful misstatement of material fact will be grounds for disqualification. Applicant(s) understand(s) that the information provided is needed to determine assistance eligibility and in no way assures qualification for assistance. The applicant(s) also agrees to provide any other documentation needed to verify eligibility. WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S775.082 o 775.83 Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 9 of 18 Applicant s Initials: CO-Applicant s Initials:
AUTHORIZATION FOR THE RELEASE OF INFORMATION Please do not use white out and do not scratch out I/We the undersigned, hereby authorize the release without liability, information regarding my/our employment income, and/or assets to: The Broward County Minority Builders Coalition, Inc. (MBC) and the City of Plantation for the purposes of verifying information provided, as part of determining eligibility for assistance under the Home Repair program. I/We understand that only information necessary for determining eligibility can be requested. Types of information to be verified: I/We understand that previous or current information regarding me/us may be required. Verifications that may be requested are, but not limited to: personal identification; employment history, hours worked, salary and payment frequency, commissions, raises, bonuses, and tips; cash held in checking/savings accounts, stocks, bonds, certificate of deposits (CD), Individual Retirement Accounts (IRA), interest, dividends, etc.; payments from Social Security, annuities, insurance policies, retirement funds, pensions disability or death benefits; unemployment, disability and/or worker's compensation; welfare assistance; net income from the operation of a business; and, alimony or child support payments, etc. Organizations/Individuals that may be asked to provide written/oral verification are, but not limited to: Past/Present Employers Banks, Financial or Retirement Institutions State Unemployment Agency, Social Security Administration, VA Welfare Agency Alimony/Child/Other Support Providers and Other entities related to assets and income Agreement to Conditions: I/We agree that a photocopy of this authorization may be used for the purposes stated above. I/We understand that 1/We have the right to review this file and correct any information found to be incorrect. Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 10 of 18 Applicant s Initials: CO-Applicant s Initials:
CONFLICT OF INTEREST DISCLOSURE In accordance with 24 CFR 570.611, applicants can be denied participation in the City's Home Repair Program if a conflict of interest exists. A conflict of interest exists if an applicant is an employee, agent, consultant, officer, elected official or appointed official of the recipient or sub recipients and the applicant currently or within the past 12 months: 1) Exercises or has exercised any functions or responsibilities with respect to funds for this program. 2) Participates or has participated in the decision making process related to funds for this program. 3) Is or was in a position to gain inside information with regard to program activities. A conflict of interest may also arise if an applicant for assistance is related by family or has business ties to any employee, officer, elected or appointed official or agent of a unit of local government who exercises any functions or responsibilities with respect to the City's program. When a conflict of interest or perceived conflict of interest exists, the applicant must acknowledge and disclose that conflict. Please read statement #1 and #2 and check the statement that applies to you. I/We DO NOT have a conflict of interest as it relates to applying for assistance from the City. (Initials) Yes, I/We have a conflict of interest as it relates to applying for assistance from the City. (Initials) If you placed a checkmark by statement #2, please explain the Conflict of Interest: Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 11 of 18 Applicant s Initials: CO-Applicant s Initials:
FALSE STATEMENTS DISCLOSURE AND ACKNOWLEDGMENT By signing this disclosure and completing this application, you attest to the fact that you own and occupy the property you are applying for as your primary residence and the property will remain as your primary residence as stipulated in the terms of your agreement with the City. You will be required to maintain a homestead exemption status and maintain flood and hazard/homeowners insurance for the duration of the term stipulated in your agreement with the City. FEDERAL WARNING: Title 18, Section 1001 of the U.S. Code makes it a criminal offense to knowingly and willingly make fraudulent statements or misrepresentations of any material fact in the use of or obtaining the use of federal funds. There are fines and imprisonment for anyone who makes false, fictitious, or fraudulent statements or entries in any matter within the jurisdiction of the Federal Government (18 U.S.C 1001). STATE WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S775.082 o 775.83. LOCAL WARNING: The local government overseeing the administration of this program may also impose fines and/or imprisonment,for anyone who makes false, fictitious or fraudulent statements regarding, income assets, liabilities, household size, occupancy and any other information necessary to determine eligibility for this program. I/WE have read, understand and acknowledge the above disclosure to be true and accurate. (Initials) (Initials) Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 12 of 18 Applicant s Initials: CO-Applicant s Initials:
HOMEOWNER S ACKNOWLEDGEMENT CONCERNING RESPONSIBILITIES I understand that participation in the Plantation Community Development Block Grant Minor Home Repair Program (the Program) is voluntary. I understand that the primary purpose of the Program is to provide financial assistance to my household for certain qualified home improvement projects that I undertake, and have the responsibility to complete. Only qualified types of minor home repair will be eligible for financial assistance through the use of the Program s Funds. If I am determined to be qualified to participate in the Program, I will be engaging a contractor to do the home improvements. I can select a contractor from a list of contractors provided by the Consultant, Minority Builders Coalition, Inc. (MBC), which have been reviewed by the City of Plantation as being familiar with the requirements and procedures for the Program. In the event I wish MBC to evaluate competitive proposals from a contractor that is not one of contractors that have been pre-qualified by the City for the Program (in this paragraph, Contractor ), I will inform MBC of the name of the Contractor I wish to be considered. If I do this, I understand and agree that I would already be satisfied with the Contractor s ability, reputation, and experience. MBC shall notify the City, and the City shall review the Contractor s qualifications to determine that the Contractor is licensed, the Contractor is familiar with the Program s requirements, and that the Contractor has not been subjected to disciplinary proceedings within the last five (5) years. The City shall advise MBC whether the Contractor meets these general qualifications, and if so, MBC shall allow the Contractor to submit competitive proposals for the repair of my home. MBC shall determine the most responsible, responsive, lowest bidder according to the Program s guidelines. However, at any time before I sign a contract with a contractor, I understand, and agree that I can decide not to participate in this voluntary Program. I further understand, and agree, that if I have any complaints, concerns, or disputes with a Contractor prior to completion of the project, neither the City of Plantation, nor MBC, has any authority or obligation to facilitate resolution of the complaint, concern, or dispute. While MBC will attend a meeting of the parties if so requested, MBC is not responsible for arbitrating, mitigating, or mediating any such complaints, concerns, or disputes. I understand, and agree, that neither the Program, nor the City in conducting plan review, permitting, or inspection governmental functions, will result in the City assuming a general or special duty of care to me or to any person who has a legal or beneficial interest in my home. I further understand, and agree, that the City may observe conditions with respect to my home in conducting governmental (building) inspections, and may require such conditions to be rectified at my expense, to comply with the Florida Building Code before the City issues a Certificate of Occupancy or Page 13 of 18 Applicant s Initials: CO-Applicant s Initials:
its equivalent, even if the condition is not part of the scope of work initially defined for the purpose of the Program s financial assistance. I understand that the documents presented as part of the Program and the documents I may be requested to sign, create legal obligations. I have had ample opportunity to consult with a lawyer of my choice to seek legal advice concerning the documents, and I have had ample opportunity to ask questions or obtain information about the Program from a lawyer of my choosing. I understand, and agree, that no discussions, promises, representations, agreements, or understandings about the Program can be effective unless they are contained in the Program s authorized written Materials. I also understand, and agree, that neither the City, nor Consultant, is assuming any obligation to protect my interests. In seeking financial assistance through the Program, I understand, and agree, that it is my responsibility to comply with all the requirements of the Program. Homeowner (Signature and Date) Homeowner (Printed or Typed) Co-owner (Signature and Date) Co-owner (Printed or Typed) Witness (Signature and Date) Witness (Printed or Typed) Witness (Signature and Date) Witness (Printed or Typed) Page 14 of 18 Applicant s Initials: CO-Applicant s Initials:
HOME REPAIR PROGRAM TERMS AND CONDITIONS I/We the undersigned agree and accept the terms and conditions of the Residential Rehabilitation Program as a condition of our/my receiving grant assistance under the program should I/We become income eligible for assistance. Maximum Amount of Assistance: $50,000 Interest Rate: 0% Second Mortgage/Affordability Period: 15 year, 0% interest, deferred payment loan, secured by a mortgage and promissory note. The loan is forgivable in its entirety at the end of 15 years from the date of execution of said mortgage and note, provided that title remains under the ownership of the individuals signing said mortgage and not and said property remains their primary residence. The mortgage shall be due if the home is sold, title is transferred or conveyed, or the home ceases to be the primary resident of the owner during the affordability period. Applicants receiving assistance will be allowed to refinance for the purpose of obtaining a better interest rate at any point during the recapture period. Applicants are not allowed to take cash-out when refinancing. Income Eligibility: 120%-SHIP Funding, 80% -CDBG Funding of the area median income (AMI) adjusted for household size. Income limits are determined by the Department of Housing and Urban Development. Property Eligibility: Single Family detached, condominium and townhouse units, including units in Plan Unit Developments, located in the City of Plantation. If funded through HOME, the estimated value of the property, after rehabilitation, cannot exceed 95 percent of the median purchase price for the area. Scope of Work and Project Completion: The project completion date for work to be completed, as described in the Budget Breakdown of work to be completed is 120 days after the issuance of the Notice to Proceed (NTP). Contractors have 30 days to secure permits and 90 day to complete the project after permits are approved. Property Standards: All properties are subject to the city s home repair standards and the Residential Rehabilitation Home Inspection Occupancy Standards Checklist. Federal and State statutes, regulations and programs governing this application are subject to change at any time. I/We understand and agree to the terms and conditions outlined above. Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date _ City of Plantation (Representative s Signature/Title) Print Name Date Page 15 of 18 Applicant s Initials: CO-Applicant s Initials:
NOTICE OF COLLECTING SOCIAL SECURITY NUMBER FOR GOVERNMENT PURPOSES The City collects your social security number for a number of different purposes. The Florida Public Records Law (specifically, section 119.071(5), Florida Statutes (2007), requires the City to give you this written statement explaining the purpose and authority for collecting your social security number. Your social security number is being collected for the purposes of income certifying you for the City's housing assistance program, which requires third-party verification of assets, employment and income. In addition, this information may be collected to verify unemployment benefits, social security/disability benefits and other related information necessary to determine income and assets and your eligibility for the program that is funded by local, Federal and/or State program dollars. Authorization to Collect Social Security Number 24 CFR 5.609, referred to as "Part 5 Annual Income" - Code of Federal Regulations. The City s Home Repair Program Implementation Procedures. Your social security number will not be used for any other purpose other than verifying your eligibility for the City's program. I/WE have read, understand and acknowledge the above disclosure. (Initials) (Initials) Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 16 of 18 Applicant s Initials: CO-Applicant s Initials:
PUBLIC RECORDS DISCLOSURE AND ACKNOWLEDGMENT Information provided by the applicant may be subject to Chapter 119, Florida Statutes regarding Open Records. Information provided by you that is not protected by Florida Statutes can be requested by any individual for their review and/or use. This is without regard as to whether or not you qualify for funding under the program(s) for which you are applying. Having been advised of this fact prior to making application for assistance or supplying any information, I/We agree to hold harmless and indemnify Broward County Minority Builders Coalition, Inc. and the City of Plantation, any governmental agency, its officers, employees, stockholders, agents, successors and assigns from any and all liability and costs that may arise due to compliance with the provisions of Chapter 119, Florida Statues. I/We agree that neither Broward County Minority Builders Coalition, Inc. or the City of Plantation have any duty or obligation to assert any defense, exception, or exemption to prevent any or all information given to Broward County Minority Builders Coalition, Inc. or the City of Plantation in connection with this application, or obtained by them in connection with this application, from being disclosed pursuant to a public records law request. Furthermore, by signing below, 1/We agree that neither Broward County Minority Builders Coalition, Inc. nor the City of Plantation have any obligation or duty to provide me/us with notice that a public records law request has been made. I/We agree to hold harmless Broward County Minority Builders Coalition, Inc. and the City of Plantation or any governmental agency, its officers, employees, stock holders, agents, successors and assigns from any and all liability that may arise due to my/our applying for any grant or mortgage or my/our purchase of any real estate, or any matter arising out of any housing rehabilitation project funded by the City of Plantation. I/WE have read, understand and acknowledge the above disclosure. (Initials) (Initials) Applicant s Signature Print Name Date Co-Applicant s Signature Print Name Date Page 17 of 18 Applicant s Initials: CO-Applicant s Initials:
HEAD OF HOUSEHOLD (ONLY) DATA Note: Information in this Section is being gathered for statistical use only. No resident is required to give such information unless they desire to do so. Refusal to provide information in this Section will not affect any right household has as residents. There is no penalty for households that do not complete the form. Total Number Of Person(s) Residing in Household: Household elects to participate in this Data Collection Survey: (Circle One): YES NO If yes, please complete this form. Signature of Household Head: _ HEAD OF HOUSEHOLD (Full Name ): If No, Circle No and Sign. Phone (Home): Phone (Cell): Address: City ST Zip Head of Household Marital Status (Circle One): Head of Household Relationship to Applicant (Circle One): Divorced Married Single Self Spouse Child Parent Other: HEAD OF HOUSEHOLD BY RACE (Circle One): American Indian Asian Black Mixed White Other: HEAD OF HOUSEHOLD BY ETHNICITY (Circle One) : Hispanic Non-Hispanic BY AGE (Circle One) 0-25 26-40 41-61 62+ EMPLOYMENT STATUS (Circle One): Full-Time Part-time Retired Unemployed Business Owner Independent/Contract Worker SCHOOL STATUS (Circle One): Full-time Student Part-Time Student N/A ALL OTHER HOUSEHOLD MEMBERS DATA Write in the Total # of All Persons in your Household for each category below: BY RACE: American Indian # Asian # Black # Mixed # White # Other # BY ETHNICITY : Hispanic # Non-Hispanic # BY AGE : 0-25 # 26-40 # 41-61 # 62+ # EMPLOYMENT STATUS : Full-Time # Part-time # Retired # Unemployed # Business Owner # Independent Worker # # of Developmentally Disabled # of Persons Receiving Disability # of Farm workers # Full Time Students # Part Time Students Page 18 of 18 Applicant s Initials: CO-Applicant s Initials: