Full Text
This program does not discriminate on the basis of race, color, national origin, religion, gender or gender identity, familial status, disability, ancestry, age, marital status, public assistance status, sexual orientation, veteran history/military status or genetic information. This program is funded through the United States Department of Housing and Urban Development (HUD), utilizing HOME and Community Development Block Grant (CDBG) funds. DOMINICK PANGALLO MAYOR TOM DANIEL, AICP DIRECTOR CITY OF SALEM, MASSACHUSETTS DEPARTMENT OF PLANNING AND COMMUNITY DEVELOPMENT 98 WASHINGTON STREET, 2ND FLOOR ♦ SALEM, MASSACHUSETTS 01970 TELE: [PHONE REDACTED] HOUSING REHABILITATION LOAN PROGRAM PRE-QUALIFICATION FORM OWNER’S INFORMATION For Office Use: Name(s): Address: City: Zip Code: Home Phone: Cell Phone: REQUIRED: Pre-Qualification Form will NOT BE ACCEPTED without income and household size information. Please provide your gross annual household income (for all persons over age 18) including: Wages, SSI, AFDC, Pensions, Rental Income, Interest, and extra income you expect to receive next year. ESTIMATED HOUSEHOLD INCOME: HOUSEHOLD SIZE: PROPERTY INFORMATION Address of property to be rehabilitated: Does the owner occupy this address as his/her primary residence? ❑ No ❑ Yes Current appraised value: $ Mortgage amount: $ Is there Lead Paint in the home? ❑ No ❑ Yes ❑ Unknown Year house was built: Number of units: Number of occupied units: Has the property been cited for Code Violations that have not been corrected? ❑ No ❑ Yes If yes, mark the type of Code Violation: ❑ Building ❑ Health ❑ Electrical ❑ Plumbing ❑ Fire Please list needed repairs: DO YOU NEED EMERGENCY REPAIRS? (such as for an actively leaking roof or no heat in the winter) ❑ No ❑ Yes If Yes, please describe: ---PAGE BREAK--- This program does not discriminate on the basis of race, color, national origin, religion, gender or gender identity, familial status, disability, ancestry, age, marital status, public assistance status, sexual orientation, veteran history/military status or genetic information. This program is funded through the United States Department of Housing and Urban Development (HUD), utilizing HOME and Community Development Block Grant (CDBG) funds. HOUSEHOLD INFORMATION Please provide the information requested in the table below: Please circle unit occupied by owner. Unit 1 Unit 2 Unit 3 Unit 4 Number of occupants Number of occupants over 62 years of age Number of handicapped individuals Number of bedrooms rent paid (if a rental unit) Rental subsidies received (Section 8 or 707)? APPLICANT CERTIFICATION I understand that this Pre-Qualification form will be used to determine income eligibility for Housing Rehabilitation Assistance. Should I pre-qualify, based on the information provided, the property will be placed on a waiting list for the Housing Rehabilitation Loan Program. I will be notified by the City of Salem when funds are available to rehabilitate the property. At that time, I will be required to complete a full Application for assistance. I understand that final eligibility for the Housing Rehabilitation Loan Program will be determined only after the full Application and required documentation have been submitted. Owner’s Signature Date Co-owner’s Signature Date All Information will be kept confidential. PLEASE RETURN PRE-QUALIFICATION FORM TO: City of Salem, Department of Planning & Community Development 98 Washington Street, 2nd Floor Salem, MA 01970 Attention: Housing Rehab Program For more information, please call (978) 619-5685. Para información en español, favor de llamar: (978) 619-5685.