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Updated 6/1/21 1 DOMINICK PANGALLO MAYOR TOM DANIEL, AICP DIRECTOR FIRST-TIME HOMEBUYER DOWNPAYMENT ASSISTANCE APPLICATION Submit to City of Salem, DPCD, 98 Washington Street, 2nd Floor, Salem, MA 01970 APPLICANT(S) INFORMATION: For DPCD Use Only Date Received: Name: SS#: Name: SS#: Current Address: Street: City/Town: Zip Code: Home Phone: Cell Phone: Work Phone: Total Number of Persons in Household (list below, including self): Name: Age: Relationship: 1. Have you had an ownership interest in a residence in the last three years? No Yes If you answered YES to Question 1, a. Is/was the residence a mobile home or one that was not affixed to a permanent foundation? No Yes b. Is/was the residence not in compliance with building codes and cannot be brought into compliance for less than the cost of constructing a permanent structure? No Yes c. Are you a displaced homemaker or single parent who only owned with a former spouse? No Yes 2. Have you received downpayment assistance from the City of Salem in the last five years? No Yes 3. Have you completed a certified first-time homebuyer counseling course in the last year? No Yes 4. Do you have an executed Purchase and Sales Agreement? No Yes Address: Purchase Price: $ Property type: Single-Family Condominium Multi-family # of units Scheduled Closing Date: ---PAGE BREAK--- Updated 6/1/21 2 HOUSEHOLD INCOME: PART A. EMPLOYMENT/ OTHER EARNINGS Gross annual income includes all wages prior to deductions, net income from the operation of a business, SSI, AFDC, pensions, rental income, alimony and child support, and other earnings. Please provide 12 weeks of pay stubs from both full- and part-time employment, federal tax return, and verification of all other income sources. In addition, please include income anticipated in the next year for all adult (18+) household members. Household Member Employer / Source of Income Start & End Date Gross Amount $ $ $ $ Subtotal Gross Annual Household Earned Income: $ PART B. ASSETS & INTEREST: Assets are items of value, such as IRAs, CDs, checking and savings accounts. Interest received from assets are included as part of your income. Assets do not include necessary personal property such as clothing, furniture, automobiles, jewelry, etc. Please describe your assets and income or dividends from these assets in the chart below. Continue on a separate sheet if necessary. Household Member Asset Description Cash Value Annual Interest Income $ $ $ $ $ $ $ $ Total Cash Value of all Assets: $ Subtotal Annual Household Interest Income: $ TOTAL GROSS ANNUAL HOUSEHOLD INCOME (Subtotals A + OPTIONAL: For statistical purposes only, please provide the following information: 1. Are you Hispanic/Latino? No Yes *Even if you answered Yes to this ethnicity question, please answer the next question which asks about race. 2. What is your race? Please check ONE box below. One Race: White Multi Race: American Indian/Alaskan Native & White Black/African American Asian & White Asian Black/African American & White Native Hawaiian/ Other Pacific Islander American Indian/Alaskan Native & Black/African American American Indian or Alaskan Native Other Multi-Racial CERTIFICATION: In signing this application, I/we certify that all of the information provided in this application is true and correct to the best of my/our knowledge and belief and that no information has been excluded, which might reasonably affect a judgment regarding eligibility for financial assistance. I/we give the City of Salem’s Department of Planning and Community Development the right to obtain verification from any source herein and acknowledge that I/we have read Salem’s First-Time Homebuyer Downpayment Assistance Loan Program Guidelines and agree to all the program terms and requirements. Signature: Date: Signature: Date: