henry county community development department · 2020. 5. 4. · henry county community development...

Henry County Community Development Department 140 Henry Parkway McDonough, GA 30253

CDBG HOME/SEPTIC REPAIR PROGRAM APPLICATION

1

APPLICATION #

Section 1 – Applicant

First Name Last Name

AGE Home /Cell Phone

Work Phone E-Mail

Social Security # DOB:

Married Status: □ Unmarried

□ Married

□ Female

□ Male

Co- Applicant

First Name Last Name

AGE Home/Cell Phone

Work Phone E-mail

Social Security # DOB:

Section 2 – Property

Address

City Zip Code

Principal Residence

(Y/N)

Number of Bedrooms :

Number of Bathrooms :

Year House Built _____



2

Section 3- Household

Members

Number of Occupants ________

Full Name Relationship S.S. # Birthdate AGE SEX DISABLED ( (Y/N)



Section 4 – Income

WAGES/SALARIES

Household Member Name Employer Name

How Long?

Paid How Frequently?

Gross Amount

1. Weekly________

Bi-Weekly________

Semi-Monthly________

Monthly ________

$

2. Weekly_________

Bi-Weekly_________

Semi-Monthly_________

Monthly _________

$



3

Section 5- Other Income

SOCIAL SECURITY/PENSIONS/ PUBLIC ASSISTANCE/OTHER INCOME

Household Member Name

Monthly Income Type

Pension Source

{Name of Company}

Public Assistance

Public Assistance

Source

Other Income*

1. $ $ $

2. $ $ $

3. $ $ $

Source of Other Income: (*Child Support, Alimony, Annuity)

Section 6-Other

Real Estate Owned

Property Address Date

Purchased

Mortgage Company Estimated

Market Value

Date Built Home Owners

Insurance

Street:

City:

State:

Zip:

Street:

City:

State:

Zip:



4

The following information is used for statically reporting only. This information is not considered when considering eligibility for assistance. This information is required as per the funding source of this program. Please check all that apply.

Section 7- Assets/Accounts

Type Name of Bank or

Credit Union

Account # Cash or market Value

Checking Account

Savings Account

Credit union

Stocks, Bonds

Mutual Funds

IRA Account/Pensions

Other

Section 8- Family Characteristics

Elderly

Female head of household

Small Family (1-4)

Large Family (5+)

Handicapped/Disabled

Black/African American

White

Native American

American Indian/Alaskan Native

Asian

Black/African & White

Asian & White

American Indian/Alaskan Nat. & White

Native Hawaiian/Other Pacific Islander

American Ind./Alaskan Native/Black/African American

Other Multi-racial



5

APPLICANTS CERTIFICATION:

I, THE UNDERSIGNED, CERTIFY THAT ALL INFORMATION IN THIS APPLICATION AND ALL

INFORMATION FURNISHED IN SUPPORT OF THIS APPLICATION IS TRUE AND COMPLETE TO

THE BEST OF MY KNOWLEDGE AND BELIEF. VERIFICATION MAY BE OBTAINED FROM

ANY SOURCE NAMED HEREIN. I HAVE RECEIVED A COPY OF THE TERMS AND

CONDITIONS AND AGREE TO ABIDE BY THOSE REQUIREMENTS IN CONNECTION WITH

ANY LOAN AND/OR GRANT THAT MAY BE MADE BY THE HENRY COUNTY COMMUNITY

DEVELOPMENT PROGRAM PURSUANT TO THIS APPLICATION.

I HEREBY AUTHORIZE ALL STAFF, WORKERS AND CONTRACTORS AUTHORIZED BY

HENRY COUNTY TO MAKE REPAIRS TO THE ABOVE DWELLING. I HEREBY RELEASE AND

PLEDGE TO HOLD HARMLESS ALL STAFF, WORKERS AND CONTRACTORS FROM ANY

LIABILITY WHATSOEVER IN THE PERFORMANCE OF THE AUTHORIZATION OR

EVENTUALLY ARISING THEREFROM. I CERTIFY THAT I AM THE OWNER-OCCUPANT AND

THIS IS MY PRINCIPAL RESIDENCE AND THAT I HOLD FEE SIMPLE TITLE TO THE ABOVE

PROPERTY. FAILURE TO DISCLOSE ALL INCOME, OR REPORTING OF INACCURATE

OR FALSE INFORMATION WILL RESULT IN DISAPPROVAL OF ASSISTANCE AND

WILL BE CONSIDERED FRADULENT.

I HEREBY AUTHORIZE HENRY COUNTY PROGRAM PERSONNEL TO TAKE PHOTOGRAPHS

AND VIDEO FOOTAGE OF MY HOME AND PROPERTY, WHERE NECESSARY IN ORDER TO

ASSIST IN THE SPECIFICATION WRITING AND THE EVALUATION OF THE ACTUAL

REHABILITATION WORK PERFORMED ON THE PROPERTY

WARNING: SINCE THESE FUNDS ARE FROM THE FEDERAL HUD PROGRAM, SECTION

1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE

WILLFUL FALSE STAEMENTS OR MISREPRESENTATION TO ANY DEPARTMENT OR

AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.

______________________________ ________________

APPLICANT DATE

_______________________________ _________________

CO-APPLICANT DATE

SENIOR HOME REPAIR PROGRAM APPLICATION

GENERAL AUTHORIZATION

TO WHOM IT MAY CONCERN:

I/WE HEREBY AUTHORIZE YOU TO RELEASE ANY INFORMATION

CONCERNING MY CREDIT, INCOME, SOCIAL SECURITY, RETIREMENT,

EMPLOYMENT, ASSETS OR MORTGAGE IN CONNECTION WITH THE

PROCESS OF OBTAINING A HOUSING REPAIR GRANT TO:

HENRY COUNTY

COMMUNITY DEVELOPMENT

140 HENRY PARKWAY

MCDONOUGH, GA 30253

A COPY OF THIS RELEASE IS ALSO AN ACCEPTABLE AUTHORIZATION.

___________________________________ _________________________

APPLICANT DATE

___________________________________ _________________________

CO-APPLICANT DATE


DOCUMENTATION CHECKLIST

NAME________________________________________________________

ADDRESS______________________________________________________

REQUIRED DOCUMENTS FOR SENIOR HOME REPAIR PROGRAM

___1. Minor Repair Program Application

___2. Copy of Deed

___3. Receipt for current property taxes

___4. Homeowner’s Insurance verification

___5. Mortgage Statement (if applicable)

___6. Proof of income for ALL household members (see below)

___7. Three (3) Months checking and /or savings account statements for ALL

members of the household.

___8. Copy of most recent Social Security Benefits statement

___9. Copy of most recent pension benefits statements, if applicable

___10. Copy of three (3) Months (90 DAYS) pay stubs

___11. Proof of 12 months unemployment, disability benefits, veterans benefits,

pensions

___12. Copy of social security card and driver’s license for all household members

___13. Copy of last year’s taxes and W-2’s for all household members


Repair Needs

Property Address:______________________________________

Please check applicable repair needs:

_________ Roof

_________ Heat and Air

_________ Plumbing

_________ Electrical

_________ Handicap accessible improvements (ADA)

_________ Smoke/Co Detectors

_________ Septic System Repair or Replace


HENRY COUNTY COMMUNITY DEVELOPMENT

DEPARTMENT

Senior Home Repair Program

Borrower’s Affidavit STATE OF GEORGIA, COUNTY OF HENRY

BEFORE ME came in person, _______________________________ who having been duly sworn on oath depose(s) and say(s) as follows: That deponent(s) are the owner(s) of _______________________________________

(Property Address) Deponent(s) further say(s):

1. That there are no unpaid or unsatisfied security deeds, mortgages, claims of lien, specialassessments for sewage or treatment improvement, or taxes which could constitute a lienagainst said property, except:

2. That they own or have owned the fee simple title to the above described property for aminimum of one (1) year and that no other party has any claim or interest in said property;

3. That there is no outstanding indebtedness for equipment, appliance or other fixturesattached to said property;

4. That the lines and corners of said property are clearly marked and there are no disputesconcerning the location of said lines and corners;

5. That there are no pending suits, proceedings, judgments, bankruptcies, liens, or executionsagainst said owner(s) either in the aforesaid county or in any other county in the State ofGeorgia;

6. That no improvements have been made on the above described property within three (3)months prior to the date of this Affidavit;

7. That there has been no outstanding debt incurred for the labor or materials or services ofany kind including services of architects, surveyors or engineers in connection therewith.

This Affidavit is given for the purpose of inducing the Henry County Housing Rehabilitation Program to grant a loan on the above described property.

____________________________ Homeowner Homeowner

Property Owner(s) Sworn to and subscribed before me on this day of

Seal of Notary



CDBG SENIOR HOME REPAIR PROGRAM

DECLARATION OF CITIZENSHIP STATUS

FOR HOUSEHOLD MEMBER 18 YEARS OF AGE OR OLDER

NOTICE TO APPLICANTS AND TENANTS: Section 214 of the Housing and Community Development Act of 1980, as amended, prohibits the Secretary of HUD from making financial assistance available, through the department’s programs, to persons other than United States citizens, nationals, or certain eligible non-citizens. In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the United States. Please read this Declaration statement carefully, sign and return to the Department’s office. Please feel free to consult with an immigration lawyer or other immigration expert of your choice.

A complete Declaration must be provided for each member of the household.

I, ____________________________________, certify under penalty of perjury, that, to the best of my knowledge, I am lawfully within the United States because (please check appropriate box):

( ) I am a citizen by birth, a naturalized citizen, or a national of the United States; or

( ) I have eligible immigration status and I am 62 years of age or older (Attach proof of age); or

( ) I have eligible immigration status as checked below (see reverse side of this form for explanations).

Attach INS documents(s) evidencing eligible immigration status and signed verification consent form.

[ ] Immigration status under 101(a or 1010(a) (20) of the INA 3/; or

[ ] Permanent residence under 249 of INA/4; or

[ ] Refugee, asylum, or conditional entry status under 207, 208, of 203 of the INA /5; or

[ ] Parole status under 212(d) (5) of the INA/6; or

[ ] Threat to life or freedom under 243(h) of the INA /7; or

[ ] Amnesty under 245A of the INA 8/.

_________________________________________ ____________________

Signature Date

_________________________________________

Printed Name


Eligible immigration status may be confirmed by providing one of the following forms of documentation:

(1) A noncitizen lawfully admitted for permanent residence, as defined by section 101 (a) (20) of the Immigration andNationality Act (INA), as an immigrant, as defined by section 101 (a) (15) of the INA (8 U.S.C. 1001(a) (20) and 1101 (a) (15), respectively [immigrants]. (This category includes a noncitizen admitted under section 210 or 210A of the NA (8U.S.C. 1160 OR 1161) [special agricultural worker], who has been granted lawful temporary resident status).

(2) A noncitizen who entered the United States before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the United States since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney Generalunder Section 249 of the INA (8 U.S.C. 1259).

(3) A noncitizen who is lawfully present in the United States pursuant to an admission under section 207 of the INA (8 S.S.C.1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under section 208 of the Ina (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under section 203 (a) (7) of the INA (8 U.S.C. 1153 (A) (7)).

Page 2 of 2 CC-3



CDBG SENIOR HOME REPAIR PROGRAM

DECLARATION OF CITIZENSHIP STATUS

FOR HOUSEHOLD MEMBER UNDER 18 YEARS OF AGE

NOTICE TO APPLICANTS AND TENANTS: Section 214 of the Housing and Community Development Act of 1980, as amended, prohibits the Secretary of HUD from making financial assistance available, through the department’s programs, to persons other than United States citizens, nationals, or certain eligible non-citizens. In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the United States. Please read this Declaration statement carefully, sign and return to the Department’s office. Please feel free to consult with an immigration lawyer or other immigration expert of your choice.

A complete Declaration must be provided for each member of the household. A PARENT/GUARDIAN must sign for family members under age 18. DO NOT SIGN CHILD’S NAME.

I, ____________________________________________, certify under penalty of perjury, that, to the best of my

knowledge, ________________________________________, a minor child, is lawfully within the United States

because (please check appropriate box):

( ) He/She is a citizen by birth, a naturalized citizen, or a national of the United States; or

( ) He/She has eligible immigration status and I am 62 years of age or older (Attach proof of age); or

( ) He/She has eligible immigration status as checked below (see reverse side of this form for explanations).

Attach INS documents(s) evidencing eligible immigration status and signed verification consent form.

[ ] Immigration status under 101(a or 1010(a) (20) of the INA 3/; or

[ ] Permanent residence under 249 of INA/4; or

[ ] Refugee, asylum, or conditional entry status under 207, 208, of 203 of the INA /5; or

[ ] Parole status under 212(d) (5) of the INA/6; or

[ ] Threat to life or freedom under 243(h) of the INA /7; or

[ ] Amnesty under 245A of the INA 8/.

_________________________________________ _____________________________

Signature Date

_________________________________________

Printed Name


Eligible immigration status may be confirmed by providing one of the following forms of documentation:

(1) A noncitizen lawfully admitted for permanent residence, as defined by section 101 (a) (20) of the Immigration andNationality Act (INA), as an immigrant, as defined by section 101 (a) (15) of the INA (8 U.S.C. 1001(a) (20) and 1101 (a) (15), respectively [immigrants]. (This category includes a noncitizen admitted under section 210 or 210A of the NA (8U.S.C. 1160 OR 1161) [special agricultural worker], who has been granted lawful temporary resident status).

(2) A noncitizen who entered the United States before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the United States since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney Generalunder Section 249 of the INA (8 U.S.C. 1259).

(3) A noncitizen who is lawfully present in the United States pursuant to an admission under section 207 of the INA (8 S.S.C.1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under section 208 of the Ina (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under section 203 (a) (7) of the INA (8 U.S.C. 1153 (A) (7)).

HENRY COUNTY COMMUNITY DEVELOPMENT DEPARTMENT

Senior Home Repair Program

INCOME VERIFICATION STATEMENT AND CERTIFICATE OF OCCUPANCY

SELF-DECLARATION FROM

TO: Henry County Community Development Department

140 Henry Parkway

McDonough, GA 30253

A. Are you currently receiving income? Yes No

B. If the answer to (A) is yes, indicate the amount received in

2018 $____________________ 2019 $_______________________, 2020 $____________

C. Specify source of income: ________________________________________________________

D. If the total 2020 income listed above is less than $4,000, please explain how living expense are being paid.________________________________ _______________________________ ________________________________

E. My current principal residence is ______________________________________________

F. How long have you lived at current address_________________________________

By signing this form, I certify that all information reported on this form and any attachments are true, complete, and accurate to the

best of my knowledge. I understand that any false statement or misrepresentations in regards to the owner applying for housing

rehabilitation assistance will be cause for denial of such assistance for the Owner. I understand that it my and or the Owner’s

responsibility to report any change in income to the Henry County Community Development Department.

WARNING: SECTION 1001 OF TITLE 18 OF THE UNITED STATES CODE MAKES IT A CRIMINAL OFFENSE TO

WILLFULLY MAKE A FALSE STATEMENT OR MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF

THE UNITED STATES AS TO ANY MATTER WITHIN ITS JURISDICTION.

PRINT NAME OF APPLICANT SIGNATURE

DATE

PRINT NAME OF OCCUPANT SIGNATURE

Henry County

CDBG Housing Repair Program

Certification as to Conflict of Interest

The Conflict of Interest prohibition at 24 CFR Part 570.611 is applicable to all CDBG grants and

activities. This rule generally prohibits elected officials, and staff who are in a position to

influence decisions, from receiving any benefit in a CDBG-assisted project.

Conflicts prohibited: No covered persons, who exercise or have exercised any functions or responsibilities with

respect to CDBG activities assisted under this part, or who are in a position to participate in a decision making

process or gain inside information with regard to such activities, may obtain a financial interest or benefit from

a CDBG-assisted activity, or have a financial interest in any contract, subcontract, or agreement with respect to

a CDBG-assisted activity, or with respect to the proceeds of the CDBG-assisted activity, either for themselves

or those with whom they have business or immediate family ties, during their tenure or for one year thereafter.

Persons covered: The conflict of interest provisions above apply to any person who is an

employee, agent, consultant, officer, or elected official or appointed official of the State of

Georgia, or of a unit of general local government, or of any designated public agencies, or

subrecipients which are receiving or administering CDBG funds.

Definition of Family or Business ties:

• Family – “A group of people related by ancestry or marriage; relatives.”

• Business – “The buying and selling of commodities and services; commerce, trade.”

• Ties – “Something that connects, binds, or joins; bond, link.”

Having read and understood the Conflict of Interest prohibition as summarized above:

____ I (or we) acknowledge and disclose the

potential of a Conflict of Interest, due to my (or

our):

____ being a covered person (Employee,

Agent, Consultant, Elected or Appointed

Official)

OR

____ having a Family or Business tie to a

covered person (Employee, Agent,

Consultant, Elected or Appointed Official)

In the following space provided describe the

Conflict of Interest or potential of a Conflict of

Interest. Specify the source of the Conflict, such as

name of department for which you are employed

and job title or name of person(s) for which you

have family of business ties.

____ I (or we) certify, that I (or we) are not aware

of any Conflict of Interest or potential Conflict of

Interest that exists of myself (or ourselves) no are

between myself (or ourselves) and any person who

is an employee, agent, consultant, officer, or elected

official or appointed official of Henry County or the

State of Georgia who are in a position to participate

in a decision making process or are responsible for

the administration or oversight of the CDBG

Housing Repair Program.

OR

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Signed:

_____________________________________________________________

Applicant Date

_____________________________________________________________

Co-Applicant Date

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ______ DAY OF _________________, 20____.

_________________________________

NOTARY PUBLIC

My Commission Expires:

_________________________________

SeniorSepticRepairApplicationSRHP Application 2019CurrentlyUpdating

SHRP Homeowner Handbook 2020-2021SeniorSepticRepairApplicationCDBG Conflict of Interest certificationUPDATED

aFirstName: aLastName: aAge: aHomeCellPhone: aWorkPhone: aEmail: aSSN: aDOB: cFirstName: cLastName: cAge: cHomeCellPhone: cWorkPhone: cEmail: cSSN: cDOB: pAddress: pCity: pZip: MarriedStatus: UnmarriedGender: MalePrincipal Residence: [-----Select-----]pBedrooms: pBathrooms: Year House Built: Occupants: 1Name: 1Relationship: 1SSN: 1dob: 1Age: 1Gender: [-Select-]1Disabled: [-Select-]2Name: 2Relationship: 2SSN: 2dob: 2Age: 2Gender: [-Select-]2Disabled: [-Select-]3Name: 3Relationship: 3SSN: 3dob: 3Age: 3Gender: [-Select-]3Disabled: [-Select-]1Household Member Name: Employer Name1: How Long1: 1Gross: 2Household Member Name: Employer Name2: How Long2: 2Gross: 1FrequentlyPaid: Bi-Weekly2FrequentlyPaid: Bi-Weekly51HouseholdMemberName: 51Monthly: 51Income Type: 51Pension Source Name of Company: 51Public Assistance Source: 51OtherIncome: 52HouseholdMemberName: 52Monthly: 52Income Type_2: 52Pension Source Name of Company_2: 52Public Assistance Source_2: 52OtherIncome: 53HouseholdMemberName: 53Monthly: 53Income Type_3: 53Pension Source Name of Company_3: 53Public Assistance Source_3: 53OtherIncome: 61Street: 61City: 61State: 61Zip: Date PurchasedStreet City State Zip: Mortgage CompanyStreet City State Zip: 61EstimatedMarketValue: 61DateBuilt: 61HomeOwnerInsurance: Date PurchasedStreet City State Zip_2: Mortgage CompanyStreet City State Zip_2: 51PublicAssistance: 52PublicAssistance: 53PublicAssistance: 62Street: 62City: 62State: 62Zip: 62EstimatedMarketValue: 62DateBuilt: 62HomeOwnerInsurance: Name of Bank or Credit UnionChecking Account: Account Checking Account: Cash or market ValueChecking Account: Name of Bank or Credit UnionSavings Account: Account Savings Account: Cash or market ValueSavings Account: Name of Bank or Credit UnionCredit union: Account Credit union: Cash or market ValueCredit union: Name of Bank or Credit UnionStocks Bonds: Account Stocks Bonds: Cash or market ValueStocks Bonds: Name of Bank or Credit UnionMutual Funds: Account Mutual Funds: Cash or market ValueMutual Funds: Name of Bank or Credit UnionIRA AccountPensions: Account IRA AccountPensions: Cash or market ValueIRA AccountPensions: Name of Bank or Credit UnionOther: Account Other: Cash or market ValueOther: Elderly: OffFHeadOHouse: OffSmallFam: OffLargeFam: OffDisabled: OffBlack/AfricanAmerican: OffWhite: OffNativeAmerican: OffAmericanIndianAlaskanNative: OffAsian: OffBlack/AfricanWhite: OffAsianWhite: OffAmericanIndianAlaskanNatWhite: OffNativeHawaiianOtherPacificIslander: OffAmericanInd: AlaskanNative: Black: AfricanAmerican: Off

OtherMultiRacial: OffAPPLICANT: COAPPLICANT: DATE: DATE_2: APPLICANT_2: COAPPLICANT_2: DATE_3: DATE_4: NAME: ADDRESS: Property Address_2: Roof: OffHeatAndAir: OffPlumbing: OffElectrical: OffADA: OffSmokeCoDetectors: OffSepticRepairReplace: OffProperty Address_3: PersonNAme: NameDeclaration: certify under penalty of perjury that to the best of my: a minor child is lawfully within the United States: acknowledge: Offcoveredperson: Offfamily/business: Offcertify: OffText54: ReceivingIncome: Yesb2017: b2019: b2018: SourecOfIncome: Text61: PrincipleResidence: LivedAt:

henry county community development department · 2020. 5. 4. · henry county community development...

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