City of tuscaloosa

CITY OF TUSCALOOSA
City Wide Emergency Home Repair Program

Application

Community Development Block Grant
Office of Federal Programs

2201 University Boulevard Tuscaloosa, Alabama 35401 I 205)248-5080 I www.tuscaloosa.com

City of Tuscaloosa

COUNCIL

Phyllis Odom

District 1

Harrison Taylor

District 2

President Pro Tem

Cynthia Lee Almond

District 3



COUNCIL

Matt Calderone

District 4

Kip Tyner

District 5

Eddie Pugh

District 6

Sonya McKinstry

District 7

WALTER MADDOX

Mayor

Thank you for your interest in the City of Tuscaloosa’s City Wide Emergency Home Repair Program!

By completing this application packet, you’re taking the first step towards receiving rehabilitation assistance and improving the quality of life for you and your family.
The City’s mission is to ensure that all Tuscaloosa families have decent, safe, and sanitary housing. To further this mission, the City has created the City Wide Emergency Home Repair Program. This program is a federally funded, minor to moderate rehabilitation program that provides free rehabilitation services to eligible homeowners living within Tuscaloosa City limits.
In order to be eligible for services, the applicant must meet the two components of eligibility: Applicant and Property Eligibility
Applicant Eligibility—the applicant must

1. 
   be income eligible as defined by the FY 2015 HUD Income Limits
   
2. 
   own the home and must be able to show proof of ownership through a valid deed of trust, Warranty Deed, Record of Mortgage, or Quit Claim Deed
   
3. 
   must reside in the home at the time of application and assistance
   

Property Eligibility—the property must

1. 
   be within Tuscaloosa City limits
   
2. 
   be owner –occupied. Rental property is not eligible.
   
3. 
   be the primary residence of the applicant
   
4. 
   be insured
   
5. 
   meet condition requirements
   

The applicant must remain in the home for a minimum of five (5) years after the completion of the rehabilitation. If the applicant moves or sales the home, the home enters into immediate repayment.

The staff of the Office of Federal Programs is available to assist you through the application and rehabilitation processes. Please contact Margaret Jones or Sherry King at [phone] with any questions or concerns.

Again, thank you for your interest. We look forward to working with you!

City Wide Emergency Home Repair Program

Required Documentation Checklist
(Please note: additional documentation may be needed if you are approved)
Please provide all documents when you submit your application. Failure to provide all documents will result in the ineligibility of the application.

• 
  Verification of income and/or employment of all persons living in the home. (Two (2) recent paycheck stubs, Social Security certification letter, unemployment, child support, alimony, AFDC, FEMA, etc.)
  

• 
  Proof of ownership for property in question (Warranty Deed, Deed of Trust, Quit Claim Deed, Record of Mortgage)
  
• 
  Certified Consent Form for Non-Resident Property Owners (if applicable)
  
• 
  Certified Residency Statement( included in application packet)
  

The statement must be notarized

• 
  Lead Notification Statement
  
• 
  Copy of TWO current utility bills
  

The bills must be issued within the 30 days prior to application and the utility bills must be for different utilities (e.g. power bill and water bill or water bill and gas bill)

• 
  Copy of Homeowners Insurance
  
• 
  Copy of Special Area Flood Hazard Insurance (If applicable)
  
• 
  Copy of Income Tax Records for previous year
  
• 
  Copy of Social Security cards for applicant and co-applicant
  
• 
  Copy of Driver’s License/ID card for applicant and co-applicant
  

The DEADLINE to submit documents and application is AUGUST 7^th, 2015 at 5:00PM. Applications mailed to the Office of Federal Programs must be postmarked by AUGUST 7^th, 2015.

Please return the application and supporting documents to the Office of Federal Programs located at 2201 University Boulevard on the second floor of the City Hall Building.
Please mail completed application packets to City of Tuscaloosa Office of Federal Programs P.O. Box 2089 Tuscaloosa, AL 35403.
If you have any questions, please contact the Office of Federal Programs at [phone].


CITY OF TUSCALOOSA

City Wide Emergency Home Repair Program

Application
This application will be used to determine applicant(s) eligibility to receive assistance through the City of Tuscaloosa’s City-wide Emergency Home Repair Program. The information provided will not be disclosed outside of the Office of Federal Programs without prior consent of the applicant(s) except under the following conditions: verification of employment, mortgage, bank account, and previous housing assistance. Applicants may refuse to provide requested information; however, refusal to provide information and/or documentation will result in the rejection of the application for assistance.

Property Address:
______________________________________________________________________________________________________

Street City State Zip Code
Neighborhood/Subdivision Name ___________________________________________________________________
Work proposed to be rehabilitated:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________



Please fill in the following information completely. If it does not apply to you, please write N/A in the blank space. Please use blue or black ink.
Primary Applicant

Name:_________________________________ Date of Birth: _______________________

SSN#: ______ - ______ -________ Race: ______________

Home number: ______________________ Alternate number: ______________________

Marital Status: Single:____ Married:____ Divorced:____ Widowed:____ Separated:____

Employer _____________________________ Job Title: __________________________

Employer Phone: ( )________________ Number of years on job ___________

Employer Address: __________________________________________________________________________

Co-Applicant

Name:_________________________________ Date of Birth: _______________________

SSN#: ______ - ______ -________ Race: ______________

Home number: ______________________ Alternate number: ______________________

Marital Status: Single:____ Married:____ Divorced:____ Widowed:____ Separated:____

Employer _____________________________ Job Title: __________________________

Employer Phone: ( )________________ Number of years on job ___________

Employer Address: __________________________________________________________________________

HOUSEHOLD COMPOSITION

(If additional household members please include on a separate sheet of paper)

Name	Relationship to Applicant	DOB	Age	Sex	Race/Ethnicity

GROSS ANNUAL INCOME

Please provide all income for adult members of household. If an adult is a student, please attach proof of enrollment.

Source	Applicant	Co-Applicant	Household members (18 and older)	Total
Salary (including overtime)
SS/SSD/SSI/VA Retirement
AFDC
Child Support
Alimony
Unemployment
Business/Rental
Other

$

*Please include the supporting documentation with application ( e.g income tax records, mortgage/deed, payroll check stubs, Social Security letter, VA letter, Child Support award letter, etc.) *
The information provided above is true and complete to the best of my/our knowledge and belief. I/we consent to the disclosure of such information for purposes of income and data verification related to my/our application for assistance. I/We understand that my willful misstatement of relative facts will result in my/our disqualification for the assistance requested.
I/We understand that the competition of this application in no way guarantees assistance of any type by the City of Tuscaloosa.
_______________________________________ _________________________

Signature of Applicant Today’s Date

_______________________________________ _________________________

FOR OFFICE USE ONLY App received DATE__________________ Supporting documentation________________ Absent Forms______________________________________________________________ Application reviewed___________ (initials) DATE_____________ Applicant eligible_____________ not eligible________

Signature of Co-Applicant Today’s Date
City of Tuscaloosa

Office of Federal Programs

City Wide Emergency Home Repair Program


Non- Resident Property Owner Consent Form
If there are additional persons listed on the property deed, then these persons must complete this form to provide consent for rehabilitation services. This form must be submitted with the City Wide Emergency Home Repair application.
I, ___________________________________________________________, hereby acknowledge that I have inherited property located in Tuscaloosa County and that I am or are presented as an heir to this property: ____________________________________________

_________________________________________________________________________________.

I am aware that an additional owner of the property, __________________________________, currently resides in the home and has applied for rehabilitation services under the City Wide Emergency Home Repair Program.
I understand the residency requirement mandates that this additional owner must remain in the home until the end of residency period. If the person should vacate the premises prior to the end of this period, the full amount of the rehabilitation services provided will become payable immediately. This could mean that the home could be leveraged to satisfy the cost of the rehabilitation.
I have reviewed the proposed rehabilitation and agree to all the conditions and standards required for rehabilitation assistance under the City Wide Emergency Home Repair Program. I, __________________________________________________________, hereby provide my consent to the rehabilitation of the property located at
______________________________________________________________________________.
________________________________________ ____________________

Non-Resident Property Owner Date

________________________________________ ____________________

Witness Date

City of Tuscaloosa

Office of Federal Programs

City Wide Emergency Home Repair Program

Certification of Principle Place of Residence

I (we),_______________________________, hereby certify that my (our) place of residence is ____________________________________________, and further certify that I(we) legally own the property as evidenced by an appropriately executed property deed filed in the Tuscaloosa County, Alabama.

_________________________ __________________________

Printed Name of Homeowner Signature

__________________________ ____________________________

Printed Name of Homeowner Signature

__________________________

Witness
Sworn to and subscribed before me this ____________________ day of _________, 20____.

Notary Public

My Commission Expires:________________________________


City of Tuscaloosa

Office of Federal Programs

City Wide Emergency Home Repair Program

NOTIFICATION

Watch Out for Lead-Based Paint Poisoning!

This is to acknowledge that I have received and read a lead hazard information booklet entitled: The Lead-Safe Certified Guide to Renovate Right.

_____________________ _______________

Signature Date

_____________________ _______________

Signature Date