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Page 1 City of Albany Albany Community Development Agency TARP Application Tenant Assistance Rehabilitation Program Revised February 28, 2017 ---PAGE BREAK--- Page 2 APPLICATION CHECKLIST FOR TARP An application is not complete and WILL NOT be accepted unless the following items are submitted ALL AT ONCE: Application Fee (in the form of a money order or a certified Check) made payable to ACDA (non-refundable) (From Property Owner) A copy of the Recorded deed to the property (From Property Owner) Copy of homeowner’s insurance policy (From Property Owner) (If property is located in a floodplain, a copy of homeowner’s flood insurance policy is also required) Copy of photo ID of 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. (From Property Owner) Property tax receipt for prior twelve months (From Property Owner) - City Hall [PHONE REDACTED] School tax receipt for prior twelve months (From Property Owner) - City School District-[PHONE REDACTED] Water and sewer receipts (last three received) (From Property Owner)-Albany Water Board-[PHONE REDACTED] Mortgage statement showing principal, interest and escrow amounts (From Property Owner) Photograph of front of property, plus photos of any extreme damage to the property (From Property Owner) Structural Engineer Report / architectural drawing if the building has been vacant for more than six months. Sketched plans are required when structural modifications are proposed or there is extensive interior fire damage. (From Property Owner) Backup documentation of all sources of the Tenants Income as listed below: Copy of photo ID of ALL Tenants (Drivers License or non-driver ID card issued by DMV) ALL documents MUST be signed EXACTLY as name appears on the picture ID. (From Tenant) Copies of their paystubs for the most recent two months AND a copy of their most recent Federal Income Tax Return with ALL attachments, including W-2 forms. (From Tenant) Self-employed applicants must submit 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. (From Tenant) Bank Statements (provide at least 2 months) for All Accounts (Must have Customer and Bank name)(From Tenant) Interest and Dividend income statements (provide at least 2 months). (From Tenant) Social Security, SSI and Pension award letters showing gross income amounts. (From Tenant) Child Support and Alimony statement from Family Court for the person making the payment. (From Tenant) Other Income not listed above must also be included with supporting documentation. (From Tenant) ---PAGE BREAK--- Page 3 CITY OF ALBANY Kathy M. Sheehan ALBANY COMMUNITY DEVELOPMENT AGENCY Michael J. Yevoli Mayor 200 HENRY JOHNSON BOULEVARD Commissioner ALBANY, NEW YORK 12210-1522 (518) 434-5240 • FAX (518) 434-5242 www.AlbanyNY.gov REHABILITATION APPLICATION FOR Tenant Assistance Rehabilitation Program (TARP) 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/Owner #1 (PLEASE PRINT CLEARLY): Applicant/Owner #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: $ Auto loan balance: $ Payment: $ Auto loan balance: $ Payment: $ Credit card balance: $ Payment: $ Credit card balance: $ Payment: $ Other debts: Other debts: ---PAGE BREAK--- Page 4 TARP APPLICATION, CONTINUED Property to be rehabilitated: Existing mortgage? Y / N Bank name: Total payment: $ Taxes included in payment? Y / N Unit #1 proposed rent: $ # of bedrooms: Occupied? Y / N Heat incl ? Y / N Util. incl.? Y / N 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 Unit #4 proposed rent: $ # of bedrooms: Occupied? Y/N Heat incl ? Y/N Util. incl ? Y/ N 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/Owner #1 Signature: Date: Applicant/Owner #2 Signature: Date: Reviewed by: Date: ---PAGE BREAK--- Page 5 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: TENANT ASSISTANCE REHABILITATION PROGRAM (TARP) 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 /Owner #1 Signature: Date: Applicant /Owner #2 Signature: Date: Rehab Property Address: ---PAGE BREAK--- Page 6 RELEASE FORM (Owner) 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/Owner Applicant/Owner Signature: Signature: Date: Date: Social Security – – Social Security – – ---PAGE BREAK--- Page 7 PROPERTY DESCRIPTION FORM (Owner) Applicant/Owner #1 (PLEASE PRINT CLEARLY): Applicant/Owner #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 be rented, if any? Please list any repairs the property needs: ---PAGE BREAK--- Page 8 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 9 Tenants, please provide info for everyone receiving income in your household. Copy/ request extra forms as needed. TYPE OF INCOME HOUSEHOLD MEMBER(S) WHO RECEIVE IT TOTAL ANNUAL AMT. Wages Overtime Commissions Fees Tips Bonuses Unemployment Social Services Net business income Cash withdrawal from business Disability Social Security Pension Workers’ Compensation Annuities Insurance policy payment Death benefit payments Armed Services payments Child support Alimony Bank interest Dividends Rental income Monetary gifts rec’d on reg. basis 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 \ INCOME & ASSET INFORMATION (THIS PAGE IS FOR THE TENANT’S HOUSEHOLD ONLY) ---PAGE BREAK--- Page 10 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 11 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. (For Lead Reduction Application Only) 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 B. Do you babysit for any children under the age of 6? YES NO 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 Tenant #1 Signature: Date: Tenant #2 Signature: Date: ---PAGE BREAK--- Page 12 RELEASE FORM (Tenant) I / We, the undersigned, hereby authorize the Albany Community Development Agency and its agents/ employees to obtain, 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. Tenant Tenant Signature: Signature: Date: Date: Social Security – – Social Security – – ---PAGE BREAK--- Page 13 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 14 Tenants, please provide info for everyone receiving income in your household. Copy/ request extra forms as needed. TYPE OF INCOME HOUSEHOLD MEMBER(S) WHO RECEIVE IT TOTAL ANNUAL AMT. Wages Overtime Commissions Fees Tips Bonuses Unemployment Social Services Net business income Cash withdrawal from business Disability Social Security Pension Workers’ Compensation Annuities Insurance policy payment Death benefit payments Armed Services payments Child support Alimony Bank interest Dividends Rental income Monetary gifts rec’d on reg. basis 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 INCOME & ASSET INFORMATION (THIS PAGE IS FOR THE TENANT’S HOUSEHOLD ONLY) ---PAGE BREAK--- Page 15 CITY OF ALBANY COMMUNITY DEVELOPMENT AGENCY LEAD–BASED PAINT HAZARD CONTROL PROGRAM (TENANT’S HOUSEHOLD) 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. ---PAGE BREAK--- Page 16 LEAD CERTIFICATION PAGE (TENANT’S HOUSEHOLD) In order for your application to be considered, you are required to certify the following: 4. I have received a copy of the lead hazard information pamphlet. 5. 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. (For Lead Reduction Application Only) 6. 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: D. Do you have any children/ grandchildren/ great grandchildren under the age of 6 who spend a significant amount of time visiting? YES NO E. Do you babysit for any children under the age of 6? YES NO F. 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 Tenant #1 Signature: Date: Tenant #2 Signature: Date: ---PAGE BREAK--- Page 17 RELEASE FORM (Tenant) I / We, the undersigned, hereby authorize the Albany Community Development Agency and its agents/ employees to obtain, 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. Tenant#1: Tenant Signature: Signature: Date: Date: Social Security – – Social Security – –