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1 CITY OF LEWISTON HOMEOWNER REHABILITATION PROGRAM APPLICATION CHECKLIST When you apply for the Lewiston Homeowner Rehabilitation Program, we need the following information to start the application process: Verification of Income: Past 2 years Federal Tax Form 1040, Pay stubs, benefit statements, other proof of income Assets: Please provide us a copy of: checking, savings, and/or retirement account statements For the past two months Mortgage: Provide a recent mortgage statement or copy of your promissory note Mortgage Deed: A copy of the deed showing ownership for the property which is available for a fee at the Androscoggin Registry of Deeds Homeowner’s Insurance: Provide current proof of homeowner’s insurance Return to: Jayne Jochem, Community Development Coordinator City of Lewiston Economic and Community Development Department 27 Pine Street Lewiston, ME 04240 Telephone 513-3126 ext. 3233 Email: [EMAIL REDACTED] OFFICE USE ONLY Date Received: ---PAGE BREAK--- 2 HOMEOWNER REHABILITATION PROGRAM Applicant’s Date of Name Co-applicant’s Date of Name Applicant's Social Security # ________________Co-applicant’s Social Security # Mailing Address Email Address Phone: Home Cell Number of people who live in the applicant(s) Please provide additional information: Name Relationship Age RACE: The Economic and Community Development Department reports certain information to the federal government. Please provide the race and ethnicity of the head of household (check one box): White American Indian/Alaskan Native & White Black/African American Black/African American & White Asian Asian & White American Indian or Alaskan Native American Indian/Alaskan Native & Black Native Hawaiian/Other Pacific Islander Other Multi-Racial ETHNICITY: Hispanic Not Hispanic PROPERTY TO BE REHABILITATED Property address (if different from mailing address): Describe work to be done: ---PAGE BREAK--- 3 Heat Source: Oil Natural Gas Bottled Gas Wood INCOME: Check yes or no for each type of income. Enter the amount of all money that household members have received for the past 30 days, or money that you expected to receive. Provide a copy of your most recent check stub or benefit statement with this application. Source of Income Yes No Money Received by Applicant Other Household Members Applicant Employment $ $ Temporary Assistance to Needy Families $ $ Social Security $ $ Military/Veterans Benefits $ $ Retirement or Pension Plan $ $ Unemployment Benefits $ $ Worker’s Compensation $ $ Child Support/Alimony $ $ SSI/Supplemental Security $ $ Interest/Dividends Income $ $ Earned Income Credit $ $ Other $ $ Other $ $ ASSETS: Type Balance/Value Type Balance/Value Checking Account $ Stocks/Bonds $ Savings Account $ Real Estate $ Other $ Retirement Account $ **Please provide copies of statements verifying asset information listed above PERSONAL EXPENSES: Mortgage Payment $ Auto Loan $ Property Insurance $ Life Insurance $ Taxes $ Medical Insurance $ Heat $ Medical Expenses $ Water/Sewer $ Child Care $ Electricity $ Food $ Telephone $ Food Stamp Benefit $ Cable/Internet $ Credit Card $ Auto Operating Expenses $ Credit Card $ Auto Insurance $ Other $ ---PAGE BREAK--- 4 Mortgage Current Balance Interest Rate Fixed Variable Other Loans or Liens on this Property 1. Balance 2. Balance EMPLOYMENT: Applicant's Employer of Years Employed Employer’s Address Co-applicant’s Employer Number of Years Employed Employer’s Address Have you applied for credit within the last 3 months? ___yes ___no If yes, were you approved ____denied APPLICANT'S CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION: I/we understand that all information in this application is given for the purpose of evaluating eligibility for the City of Lewiston's Homeowner Rehabilitation Program. I/we authorize the City of Lewiston to obtain verification of all sources named to verify income and employment, and to obtain a credit report. I/we understand that by signing this application I/we authorize release of this information to the City of Lewiston. Client information will be shared with only those individuals, entities, or committee members designated or acknowledged by the City as an interested party to the client’s application process excluding information declared as public records pursuant to M.R.S.A. Title 1 §401, Public Records and Proceedings. Otherwise, the information furnished will be held in strict confidence. I/we hereby certify the information contained in this application is accurate and complete to the best of my/our knowledge and belief. If I/we have intentionally falsified any of this information or omitted information necessary to prevent statements from being misleading, I/we understand that I/we will be liable to the City of Lewiston and that such falsification or omission(s) would be considered a Class D Crime. Date Applicant's Signature Co-Applicant's Signature