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Page I 1 City of Albany Albany Community Development Agency 200 Henry Johnson Blvd, 2 FL Albany, NY 12210 LEAD-BASED Paint Hazard Control Program Application ( LEAD ONLY ) Revised 7/31/2019 ---PAGE BREAK--- Page I 2 An application is not complete and WILL NOT be accepted unless the following items are submitted ALL AT ONCE with copies included: Application Fee (in the form of a money order or a certified Check) made payable to ACDA(non-refundable) (From Property Owner) 2. A copy of the Recorded deed to the property (From Property Owner) ______3.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) ______4.Copy of photo ID of ALL OWNERS (Driver’s 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) ______5.Property tax receipt for prior twelve months (From Property Owner) City Hall [PHONE REDACTED] ______6.School tax receipt for prior twelve months (From Property Owner)City School District [PHONE REDACTED] ______7.Water and sewer receipts (last 3 received)(From Property Owner) Albany Water Board [PHONE REDACTED] ______8.Mortgage statement showing principal, interest and escrow amounts (From Property Owner) ______9.Signed and completed Monitoring and Certification Form and Lead Information Form for the Owner’s unit and Tenant’s unit in the property. Completed Application (please make sure ALL pages of the application are complete) Additional Tenant Monitoring & Certification Forms can be provided upon request as needed! Additional Verification of Employment Forms can be provided upon request as needed! Application Checklist for LEAD-BASED Paint Program Application Checklist for LEAD-BASED Paint Program ---PAGE BREAK--- Page I 3 Application Checklist for LEAD-BASED Paint Program Backup documentation of all sources of the Tenants Income as listed below: Copy of photo ID of ALL Tenants (Driver’s License or non-driver ID card issued by DMV) ALL documents MUST be signed EXACTLY as name appears on the picture ID. (From Tenant) 2. Copies of tenants 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) 3. Completed Verification of Employment Form (VOE) (Federal Regulations require us to verify Employment Income of all members of the household applying and all tenants participating in any of our programs) 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) ______8.Child Support and Alimony statement from Family Court for the person making the payment. (From Tenant) ______9.Other Income not listed above must also be included with supporting documentation. (From Tenant) ---PAGE BREAK--- Page I 4 CITY OF ALBANY ALBANY COMMUNITY DEVELOPMENT AGENCY 200 HENRY JOHNSON BOULEVARD Commissioner ALBANY, NEW YORK 12210-1522 (518) 434-5265 • FAX (518) 434-5242 Application for LEAD-BASED Paint Hazard Program 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: 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: Kathy M. Sheehan Mayor Faye C. Andrews Director ---PAGE BREAK--- Page I 5 OFFICE USE ONLY Housing Affordability Determination: 1. Below 30% of 80% of median income. 2. Below 30% of 50% of median income. 3. Not affordable to low-income households without housing assistance 4. Unit(s) are currently vacant Agency Signature Date Application for LEAD-BASED Paint Hazard Program - Continued Property to be Lead Abated: Existing Mortgage? Y/ N 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 I 6 Application Certifications/ Release Form (Owner) Please Circle One of the following statements and then sign this certification showing what you intend to do with your building: I hereby certify I have no intention on displacing any of my tenants due to the work being done on the property. I have units in the building which are currently vacant but were occupied at some point during the six months prior to this application. I certify that the occupants were not displaced due to the proposed work on my property. There are no tenants in this building; therefore no tenants will be displaced. For this LEAD-BASED Paint grant made to assist rental units in this property; I agree that those units shall be made available to families with incomes below 50% of the Albany area median income for not less than 3 years following the completions of LEAD abatement activities and shall give priority to families with children under 6 years of age. Received By Date Applicant Date Applicant Date 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 I 7 LEAD-BASED PAINT HAZARD CONTROL PROGRAM Resident Information – Application Notice The Owner of the property where you live has applied for Federal funds to identify and control LEAD paint hazards in your home. To determine whether your home is eligible for funds under the Program, we need you to complete the attached Resident Information Form. This information will be kept strictly confidential and will be used only to determine eligibility. 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 with this letter. 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 447-4620 for information on blood LEAD screening and the hazards of LEAD paint. If your home is accepted into this Program, a number of activities will take place. First, the Agency will conduct an inspection of painted surfaces. This inspection will identify those surfaces that contain LEAD-based paint. For surfaces that contain excessive LEAD paint, a work write-up will be prepared. Only LEAD contractors who are trained and certified under Federal requirements and approved for this program will do LEAD treatment. The Agency 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 owner and the unit or building in which are you living has LEAD paint hazard control work undertaken, you will not be permanently displaced. You are protected from displacement by the Federal Uniform Relocation Assistance and Real Property Acquisition Policies of 1970, as amended. 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 which the LEAD paint hazard control work is being completed. Someone from the LEAD program and the owner will contact you to discuss the need and timing of temporary relocation. If you have to be temporarily relocated, assistance will be provided to help cover additional reasonable living costs. The Agency will provide LEAD Safe temporary housing at convenient locations in several neighborhoods. Depending on the size and number of dwelling units to be treated, temporary relocation may be for fourteen to twenty one days. In order to proceed with this application, please complete the attached Resident Information Form and return it to your landlord or directly to: Albany Community Development Agency 200 Henry Johnson Boulevard Albany, NY 12210 If you have any questions about completing the attached form or about the LEAD Program, please call (518) 434-5265. KEEP THIS RESIDENT INFORMATION SHEET FOR YOUR RECORDS Tenant Displacement Form / Receipt Of Program Guidelines Certification ---PAGE BREAK--- Page I 8 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? ---PAGE BREAK--- Page I 9 Monitoring & Certification Agreement Form (OWNER ONLY) This form must be filled out by the OWNER of the property. Address of Building: 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 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 I 10 Income & Asset Information Form (OWNER’S HOUSEHOLD ONLY) Please provide names for everyone receiving income in the Owner’s household separately. TYPE OF INCOME HOUSEHOLD MEMBER(S) First & Last Name Gross Annual Income (Dollar Amount Wages Overtime Unemployment Disability Social Security Pension Workers’ Compensation Rental Income Death benefit payments OTHER Child support Alimony Social Services Benefits Bank Interest Dividends 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 I 11 Monitoring & Certification Agreement Form (TENANT ONLY This form must be filled out by each Tenant of the building (one form per unit). Address of Building: 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 Tenants Telephone Numbers: Home Phone: Cell Phone: 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 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 I 12 Income & Asset Information Form (TENANT ONLY Please provide names for everyone receiving income in the Tenants household separately. TYPE OF INCOME TENANT MEMBER(S) First & Last Name Gross Annual Income (Dollar Amount Wages Overtime Unemployment Disability Social Security Pension Workers’ Compensation Rental Income Death benefit payments OTHER Child support Alimony Social Services Benefits Bank Interest Dividends TYPE OF ASSET TENANT 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 I 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. YES NO 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 Age(s): B. Do you babysit for any children under the age of 6? YES NO Age(s): 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 Age(s): Tenant #1 Signature: Date: Tenant #2 Signature: Date: ---PAGE BREAK--- Page I 14 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 I 15 Monitoring & Certification Agreement Form (TENANT ONLY This form must be filled out by each Tenant of the building (one form per unit). Address of Building: 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 Tenants Telephone Numbers: Home Phone: Cell Phone: 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 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 I 16 Income & Asset Information Form (TENANT ONLY Please provide names for everyone receiving income in the Tenants household separately. TYPE OF INCOME TENANT MEMBER(S) First & Last Name Gross Annual Income (Dollar Amount Wages Overtime Unemployment Disability Social Security Pension Workers’ Compensation Rental Income Death benefit payments OTHER Child support Alimony Social Services Benefits Bank Interest Dividends TYPE OF ASSET TENANT 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 I 17 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 I 18 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 – –