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Page 1 City of Albany Albany Community Development Agency HOAP Application Home Owner Assistance Program Revised January 2, 2020 ---PAGE BREAK--- Page 2 APPLICATION CHECKLIST FOR HOAP An application is not complete and WILL NOT be accepted unless the following items are submitted ALL AT ONCE: (Note: There is a reason for everything we require so please only return the requested items from the checklist. Please do not substitute items, Example: your taxes may be escrowed in your mortgage but we still need most current invoice/bill from the proper department. Copy of Recorded Deed to the property 2) Copy of Homeowner’s Insurance Declaration page. (If property is located in a floodplain, a copy of homeowner’s flood insurance policy is also required.) Most recent Property Tax invoice/bill showing current from the Treasurer’s office (Phone-[PHONE REDACTED]) Most recent School Tax invoice/bill showing current from the City School District (Phone-[PHONE REDACTED]) Most recent Water/Sewer invoice/bill showing current from the Albany Water Board (Phone-[PHONE REDACTED]) Current Mortgage statement showing principal, interest and escrow amounts (If no Mortgage, please write letter stating why there is no Mortgage) Copy of Photo ID for ALL OWNERS (Drivers License or non-driver ID card issued by DMV) ALL documents MUST be signed EXACTLY as name appears on the picture ID Photograph of front of property and any extreme damage to the property Structural Engineer Report /Architectural drawing if the building has been VACANT for more than six months is required. Sketched plans are required when structural modifications are proposed or there is extensive interior fire damage *(Please make sure ALL pages of the application are completed)* ---PAGE BREAK--- Page 3 APPLICATION CHECKLIST FOR HOAP Backup Documentation of All Sources of Income as listed below: PAYSTUBS (provide copies of each paystub for the most current 2 months) Self-employed applicants must provide SIGNED copies of their federal income tax returns with all attachments for the last three years. Eligibility will be based on the most recent year’s verifiable income. A ACDA Verification of Employment form (VOE) may be required 2) BANK STATEMENTS(provide copies of each statement (all pages) for most current 2 months) For All Accounts. Actual Bank Statements (not a debit/credit ledger) must have Customer and Bank name on them and include ALL pages SOCIAL SECURITY, DISABILITY and PENSION (provide copies of most recent award letter/documentation showing gross amount received) CHILD SUPPORT and ALIMONY Copy of documentation of amount received INTEREST and DIVIDEND income statements (provide most current 2 months) 6) Copy of most recent Federal Income Tax Return with all attachments, including W-2 forms_______ (If you do not file, please write letter why and how long it has been since you filed) OTHER INCOME not listed above must also be included with copies of supporting documentation TENANT INCOME- ALL tenants that receive income must provide copies of their paystubs for the most recent two months and a signed copy of their most recent Federal Income Tax Return with ALL attachments, including W-2 forms Proof of all other tenant household income MUST be attached, (Examples: Social Security, Disability Pension etc) ---PAGE BREAK--- Page 4 CITY OF ALBANY Kathy M. Sheehan ALBANY COMMUNITY DEVELOPMENT AGENCY Michael J. Yevoli Mayor 200 HENRY JOHNSON BOULEVARD Commissioner ALBANY, NEW YORK 12210-1522 Phone (518) 434-5265 • Fax (518) 434-5242 www.AlbanyNY.gov REHABILITATION APPLICATION FOR HOME OWNER ASSISTANCE PROGRAM (HOAP) Are you an immediate relative, employee, agent, consultant, or officer of any official of the City of Albany (either elected or appointed) or are you an employee, agent, consultant, or officer of any Neighborhood Improvement Corporation? YES / NO If yes, state name(s) & relationship(s): APPLICANT #1 (PLEASE PRINT CLEARLY): APPLICANT #2 (PLEASE PRINT CLEARLY): Full Name: Full Name: Social Security – – Social Security – – Address: Address: City / State / ZIP: City / State / ZIP: Home Telephone: Home Telephone: Work: Cell: Work: Cell: E-mail: E-mail: Employer’s Name: Employer’s Name: Employer’s Address: Employer’s Address: Years Employed: Salary: $ Years Employed: Salary: $ Other Income: Amount: $ Other Income: Amount: $ Bank Name: Bank Name: Bank Address: Bank Address: Acct. Type: Balance: $ Acct. Type: Balance: $ ---PAGE BREAK--- Page 5 HOAP APPLICATION, CONTINUED Property to be rehabilitated: # of bedrooms in owner’s unit: Existing mortgage? Y / N Bank name: Mortgage Acct Total payment: $ Taxes included in payment? Y / N Insurance included in payment? Y / N Oil supplier’s name and address: Oil cost: $ Gas: $ Electric: $ Nat. Grid budget payment: $ Unit #2 proposed rent: # of bedrooms: Occupied? Y / N Heat incl.? Y / N Util. incl.? Y / N Unit #3 proposed rent: # of bedrooms: Occupied? Y / N Heat incl.? Y / N Util. incl.? Y / N I / WE CERTIFY THAT THE PROPERTY LISTED ABOVE IS MY / OUR PRINCIPAL RESIDENCE. ANY KNOWINGLY FALSE INFORMATION SUPPLIED BY THE APPLICANT(S) WILL RENDER THIS APPLICATION NULL AND VOID. Each applicant certifies that all information in this application is true to the best of his or her knowledge and belief. Verification may be obtained from any sources named in this document. Applicant #1 Signature: Date: Applicant #2 Signature: Date: Reviewed by: Date: ---PAGE BREAK--- Page 6 MONITORING AND CERTIFICATION AGREEMENT FORM (FOR OWNER ONLY) This form must be filled out by the OWNER living in the building. All tenants should skip to page 10. Address of Building: Albany, NY ZIP Unit Floor # of Bedrooms: Is this unit currently occupied? or vacant? Is this a female head of household with child (ren)? YES NO Is anyone over age 61 in this household? YES NO Is the head of household or spouse disabled? YES NO If yes, list type(s) of disability(-ies) below: . . Which of the following do you consider your family to be? (Check ALL that apply) Black / African American White / Caucasian Hispanic Asian Native Hawaiian / Pacific Islander American Indian / Alaskan Native Other(s): HOUSEHOLD COMPOSITION: List the full legal names of all household members. “Household” is defined as all the persons who occupy a housing unit. The occupants may be a single family, one person living alone, two or more families living together, or any other group of related or unrelated persons who share living arrangements. Legal Name Relation to Head Sex Age D.O.B. Soc. Sec. # Occupation SELF ---PAGE BREAK--- Page 7 INCOME & ASSET INFORMATION (THIS PAGE IS FOR THE OWNER’S HOUSEHOLD ONLY) Please provide info for everyone receiving income in the Owner’s household separately. All tenants should skip to page 10. TYPE OF INCOME NAME OFHOUSEHOLD MEMBER(S) WHO RECEIVE THE INCOME GROSS ANNUAL INCOME AMOUNT Wages Overtime Commissions Fees Tips Bonuses Unemployment Social Services Disability Social Security Pension Workers’ Compensation Annuities Insurance policy payment Death benefit payments Child support Alimony Bank interest Dividends Rental income TYPE OF ASSET HOUSEHOLD MEMBER(S) WHO OWN IT TOTAL VALUE Additional houses / real estate Stocks, bonds, etc. Savings & checking accounts Other (specify): Under penalties of perjury, I declare that I received the above information, and to the best of my knowledge and belief, it is true and complete for all household members. I hereby authorize the Albany Community Development Agency and its agents/ employees to obtain additional information and verifications as may be necessary. ALL ADULT HOUSEHOLD MEMBERS MUST SIGN BELOW: Date: Adult Adult Adult Adult ---PAGE BREAK--- Page 8 CITY OF ALBANY COMMUNITY DEVELOPMENT AGENCY LEAD–BASED PAINT HAZARD CONTROL PROGRAM (OWNER’S HOUSEHOLD) INFORMATION SHEET As the owner of the property you have applied for federal funds to identify and control LEAD paint hazards in your home. The primary goal of this program is to reduce the hazards posed to children from LEAD paint in homes. Information on the hazards of LEAD paint is provided in the attached pamphlet. For children in your household under 6 years of age, it is necessary that they be screened for blood-LEAD levels, within 6 months of this date and within 60 days after the completion of the lead treatment. If this screening is not covered by your insurance, please contact the Albany County Health Department at (518) 447-4620 for information on blood LEAD level screening and the hazards of LEAD paint. If the property is accepted into this program, a number of activities will take place: First, LEAD staff will conduct an inspection of painted surfaces. This inspection will identify those surfaces that contain LEAD-based paint and work write-ups will be prepared. Only LEAD contractors who are trained and certified under federal requirements and approved for this program will do LEAD treatment. The LEAD program will conduct an inspection after the work is completed to measure the effectiveness of the treatments. NOTICE OF NON-DISPLACEMENT & TEMPORARY RELOCATION If assistance is provided to the property and LEAD paint hazard control work needs to be performed, you will not be permanently displaced. The Federal Uniform Relocation Assistance and Real Property Acquisition Policies of 1970, as amended, protect you from displacement. However, if you do decide to move permanently for reasons of your own, you will not be eligible for relocation assistance. It is likely that you will need to be temporarily relocated from the unit in which the LEAD paint hazard control work is being completed. If needed, the Lead program will provide a LEAD-safe temporary housing conveniently located in several neighborhoods. Depending on the size and number of dwelling units to be treated, temporary relocation may be for a period of fourteen – twenty one days. The Lead staff will provide the owner/tenant(s) with the temporary relocation information. If you have to be temporarily relocated, assistance can be provided to help cover additional reasonable living costs. It is a requirement of HUD assisted housing programs that upon project completion the property is lead safe. The Lead grant will fund up to $20,000 per unit to accomplish this requirement. For projects that are not eligible for the Lead grant this requirement will be met by these costs being covered by the funds available from ACDA’s other housing programs. Unfortunately in some cases the cost of making the home lead safe when added to the rehabilitation costs may make the project unfeasible. I have read and understood the guidelines and acknowledge that I may have to temporarily relocate while work is being performed: Applicant Applicant #2 Signature: ---PAGE BREAK--- Page 9 LEAD CERTIFICATION PAGE (OWNER’S HOUSEHOLD) All Owners must fill out and sign the Lead Certification page. In order for your application to be considered, you are required to certify the following: 1. I have received a copy of the lead hazard information pamphlet. 2. For children in my household under 6 years of age, I agree that I will have them screened for blood-Lead levels within 6 months before this application and within 60 days after completion of the Lead treatment. 3. The Agency is required to report to the U.S. Department of HUD the number of children under age 6 that will be protected in all units receiving LEAD Assistance. Please answer the following questions: A. Do you have any children/ grandchildren/ great grandchildren under the age of 6 who spend a significant amount of time visiting? YES NO Ages B. Do you babysit for any children under the age of 6? YES NO Ages C. Do you have any nieces/ nephews/ cousins or other relatives under the age of 6 who spend a significant amount of time visiting? YES NO Ages D. Is anyone in the household currently pregnant? YES NO Applicant #1 Signature: Date: Applicant #2 Signature: Date: ---PAGE BREAK--- Page 10 MONITORING AND CERTIFICATION AGREEMENT FORM (FOR TENANT ONLY) This form must be filled out by each Tenant of the building (one form per unit) (Copy/request extra forms as needed) Address of Building: Albany, NY ZIP Unit Floor # of Bedrooms: Is this unit currently occupied? or vacant? How much is your rent? $ Does rent include heat? YES NO Is your rent paid by Section 8? YES NO Does rent include electric? YES NO Is your rent paid by Social Services? YES NO HEAD OF HOUSEHOLD’S TELEPHONE NUMBERS: HOME: WORK: CELL: Is this a female head of household with child(ren)? YES NO Is anyone over age 61 in this household? YES NO Is the head of household or spouse disabled? YES NO If yes, list type(s) of disability(-ies) on next line: . Which of the following do you consider your family to be? (Check ALL that apply) Black / African American White / Caucasian Hispanic Asian Native Hawaiian / Pacific Islander American Indian / Alaskan Native Other(s): HOUSEHOLD COMPOSITION: List the full legal names of all household members. “Household” is defined as all the persons who occupy a housing unit. The occupants may be a single family, one person living alone, two or more families living together, or any other group of related or unrelated persons who share living arrangements. Legal Name Relation to Head Sex Age D.O.B. Soc. Sec. # Occupation SELF ---PAGE BREAK--- Page 11 INCOME & ASSET INFORMATION (THIS PAGE IS FOR THE TENANT’S HOUSEHOLD ONLY) Tenants, please provide info for everyone receiving income in your household. (Copy/ request extra forms as needed) TYPE OF INCOME NAME OF HOUSEHOLD MEMBER(S) WHO RECEIVE THE iNCOME GROSS ANNUAL INCOME AMOUNT Wages Overtime Commissions Fees Tips Bonuses Unemployment Social Services Disability Social Security Pension Workers’ Compensation Annuities Insurance policy payment Death benefit payments Child support Alimony Bank interest Dividends Rental income TYPE OF ASSET HOUSEHOLD MEMBER(S) WHO OWN IT TOTAL VALUE Additional houses / real estate Stocks, bonds, etc. Savings & checking accounts Other (specify): Under penalties of perjury, I declare that I received the above information, and to the best of my knowledge and belief, it is true and complete for all household members. I hereby authorize the Albany Community Development Agency and its agents/ employees to obtain additional information and verifications as may be necessary. ALL ADULT HOUSEHOLD MEMBERS MUST SIGN BELOW: Date: Adult Adult Adult Adult ---PAGE BREAK--- Page 12 INFORMATION SHEET The owner of the property where you live has applied for federal funds to identify and control LEAD paint hazards in your home. The primary goal of this program is to reduce the hazards posed to children from LEAD paint in homes. Information on the hazards of LEAD paint is provided in the attached pamphlet. For children in your household under 6 years of age, it is necessary that they be screened for blood- LEAD levels, within 6 months of this date and within 60 days after the completion of the lead treatment. If this screening is not covered by your insurance, please contact the Albany County Health Department at (518) 447-4620 for information on blood LEAD level screening and the hazards of LEAD paint. If the property is accepted into this program, a number of activities will take place: First, LEAD staff will conduct an inspection of painted surfaces. This inspection will identify those surfaces that contain LEAD-based paint and work write-ups will be prepared. Only LEAD contractors who are trained and certified under federal requirements and approved for this program will do LEAD treatment. The LEAD program will conduct an inspection after the work is completed to measure the effectiveness of the treatments. Residents may contact the owner if they wish to review the work to be done. NOTICE OF NON-DISPLACEMENT & TEMPORARY RELOCATION If assistance is provided to the property and LEAD paint hazard control work needs to be performed, you will not be permanently displaced. The Federal Uniform Relocation Assistance and Real Property Acquisition Policies of 1970, as amended, protect you from displacement. However, if you do decide to move permanently for reasons of your own, you will not be eligible for relocation assistance. It is likely that you will need to be temporarily relocated from the unit in which the LEAD paint hazard control work is being completed. If needed, the Lead program will provide a LEAD-safe temporary housing conveniently located in several neighborhoods. Depending on the size and number of dwelling units to be treated, temporary relocation may be for a period of fourteen – twenty one days. The Lead staff will provide the owner/tenant(s) with the temporary relocation information. If you have to be temporarily relocated, assistance can be provided to help cover additional reasonable living costs. All tenants must fill out and sign the Lead Certifications on the following page. CITY OF ALBANY COMMUNITY DEVELOPMENT AGENCY LEAD–BASED PAINT HAZARD CONTROL PROGRAM (TENANT’S HOUSEHOLD) ---PAGE BREAK--- Page 13 LEAD CERTIFICATION PAGE (TENANT’S HOUSEHOLD) In order for your application to be considered, you are required to certify the following: 1. I have received a copy of the lead hazard information pamphlet. 2. For children in my household under 6 years of age, I agree that I will have them screened for blood-Lead levels within 6 months before this application and within 60 days after completion of the Lead treatment. 3. The Agency is required to report to the U.S. Department of HUD the number of children under age 6 that will be protected in all units receiving LEAD Assistance. Please answer the following questions: A. Do you have any children/ grandchildren/ great grandchildren under the age of 6 who spend a significant amount of time visiting? YES NO Ages B. Do you babysit for any children under the age of 6? YES NO Ages C. Do you have any nieces/ nephews/ cousins or other relatives under the age of 6 who spend a significant amount of time visiting? YES NO Ages D. Is anyone in the household currently pregnant? YES NO Adult #1 Signature: Date: Adult #2 Signature: Date: ---PAGE BREAK--- Page 14 TENANT DISPLACEMENT FORM / RECEIPT OF PROGRAM GUIDELINES CERTIFICATION Dear Landlord(s): (This page is to be filled out by the Owner/Landlord) Since you have applied to this agency for financial and technical assistance to rehabilitate your house, you have certain responsibilities. One of these concerns any tenants living in your building. It is general policy of the Albany Community Development Agency to avoid displacement of existing tenants. However, in some cases, permanent displacement of tenants may be necessary due to substantial or “gut” rehabilitation. In such cases, you must assume responsibility for aiding the displaced tenants in finding safe, sanitary and decent housing at a price the tenant can afford. If displacement does occur, the tenants are eligible for moving expenses according to a fixed schedule. Whether or not tenants are being displaced, the agency requires you to inform the tenants of the fact that you have applied for rehab assistance and of their rights. Please check one of the following boxes to show what you intend to do with your building: I have no tenants in the building I wish to rehabilitate; therefore no tenants will be displaced. As a recipient of Community Development funds to aid in rehabilitating my property. I hereby certify I have no intention on displacing any of my tenants due to the work being done on the property. I further understand that a false statement may result in forfeiture of any and all assistance received. As a recipient of Community Development Funds to aid in rehabilitating my property, it will be necessary to permanently relocate existing tenant(s) of the property due to work and I hereby promise to do all that I reasonably can to aid the displaced tenant(s) in finding safe, sanitary and decent housing at a price they can afford. By signing below, I/we confirm that I/we have received, read, and understand the program guidelines relating to: HOME OWNER ASSISTANCE PROGRAM (HOAP) LEAD For houses built prior to January 1, 1978: I / we understand that since I / we have applied to this Agency for assistance from one or more of the above programs, based on HUD requirements (24CFR, Part 35), ACDA will perform an initial lead hazard inspection and clearance testing for lead based paint hazards. Based on this inspection, the appropriate procedures for lead abatement will be required. Applicant #1 Signature: Date: Applicant #2 Signature: Date: Rehab property address: ---PAGE BREAK--- Page 15 RELEASE FORM I / We, the undersigned, hereby authorize the Albany Community Development Agency and its agents/ employees to obtain credit, financial, income tax and any additional information necessary to process this application. I / We also authorize the Social Security Administration to disclose information relative to the amount of my gross benefit to the Albany Community Development Agency. APPLICANT APPLICANT Signature: Signature: Date: Date: Social Security – – Social Security – – ---PAGE BREAK--- Page 16 PROPERTY DESCRIPTION FORM APPLICANT #1 (PLEASE PRINT CLEARLY): APPLICANT #2 (PLEASE PRINT CLEARLY): Full Name: Full Name: Home Telephone: Home Telephone: Work: Cell: Work: Cell: E-mail: E-mail: Property address: PERSON(S) WE SHOULD CONTACT TO ARRANGE AN INSPECTION OF THE PROPERTY (IF DIFFERENT THAN ABOVE): Name: Home phone Cellphone PROPERTY CONDITION: FLOOR # APT. # CURRENTLY OCCUPIED? EXISTING # OF BEDROOMS PROPOSED # OF BEDROOMS YES NO YES NO YES NO YES NO YES NO Which floor(s) / unit(s) will the owner(s) occupy? Which floor(s) / unit(s) will be rented, if any? Please list any repairs the property needs: