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Application KIMBERLEY DRISCOLL MAYOR TOM DANIEL, AICP DIRECTOR CITY OF SALEM, MASSACHUSETTS DEPARTMENT OF PLANNING AND COMMUNITY DEVELOPMENT 98 WASHINGTON STREET, SECOND FLOOR ♦ SALEM, MASSACHUSETTS 01970 TEL: [PHONE REDACTED] DATE RECEIVED STAMP HOUSING REHABILITATION LOAN PROGRAM APPLICATION APPLICANT INFORMATION: Owner: Co-Owner: Address: Home Phone Other Preferred Contact Email Address: Total Number of Household Members (including YOURSELF and any unrelated individuals): List All Household Members Age Social Security # Relationship to Applicant PROPERTY INFORMATION: Year house was built: Number of Units*: Number of Units Occupied: Are you up-to-date with your property taxes and water/sewer payments? No Yes Is there flaking Lead Paint in the home? No Yes Unknown Previously deleaded Has any child under the age of 6 tested positive for lead blood poisoning? No Yes Unknown 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 Check Needed Repairs: Roof Electrical Plumbing Heating Windows Insulation Stairs Painting Deleading Asbestos Removal Other: Has this Program assisted the property before? No Yes If yes, in what year? Unknown Is there an EMERGENCY CONDITION that threatens the health and safety of the property’s residents (such as an actively leaking roof or lack of heat in the winter)? No Yes Specify: Does anyone require accessibility modifications in order to continue to live in the home? No Yes * If the property has more than one unit, please have each tenant complete a Tenant Application and submit income documents. Rev. 1/10/17 ---PAGE BREAK--- If the property has multiple units, please complete this page. Otherwise, skip this page and proceed to Page 3. UNIT & TENANT INFORMATION: EACH TENANT MUST ALSO SUBMIT A TENANT APPLICATION. Unit # 1 2 3 4 Location of Unit (Floor): 1st 2nd 3rd 4th Other Number of bedrooms: 1 2 3 4 Other Lead paint in the unit: Yes No Unknown Is the unit occupied? No Yes Number of people residing in the unit: Check all that apply to anyone living in the unit under 6 years of age age 62 or over handicapped Are you requesting repairs in this unit? No Yes Name of head of household: Telephone Does the tenant receive a rental subsidy? (Section 8, 707 Certificate etc.)? No Yes Current rent: $ Proposed rent after rehabilitation: $ Unit # 1 2 3 4 Location of Unit (Floor): 1st 2nd 3rd 4th Other Number of bedrooms: 1 2 3 4 Other Lead paint in the unit: Yes No Unknown Is the unit occupied? No Yes Number of people residing in the unit: Check all that apply to anyone living in the unit under 6 years of age age 62 or over handicapped Are you requesting repairs in this unit? No Yes Name of head of household: Telephone Does the tenant receive a rental subsidy? (Section 8, 707 Certificate etc.)? No Yes Current rent: $ Proposed rent after rehabilitation: $ Unit # 1 2 3 4 Location of Unit (Floor): 1st 2nd 3rd 4th Other Number of bedrooms: 1 2 3 4 Other Lead paint in the unit: Yes No Unknown Is the unit occupied? No Yes Number of people residing in the unit: Check all that apply to anyone living in the unit under 6 years of age age 62 or over handicapped Are you requesting repairs in this unit? No Yes Name of head of household: Telephone Does the tenant receive a rental subsidy? (Section 8, 707 Certificate etc.)? No Yes Current rent: $ Proposed rent after rehabilitation: $ Unit # 1 2 3 4 Location of Unit (Floor): 1st 2nd 3rd 4th Other Number of bedrooms: 1 2 3 4 Other Lead paint in the unit: Yes No Unknown Is the unit occupied? No Yes Number of people residing in the unit: Check all that apply to anyone living in the unit: under 6 years of age age 62 or over handicapped Are you requesting repairs in this unit? No Yes Name of head of household: Telephone Does the tenant receive a rental subsidy? (Section 8, 707 Certificate etc.)? No Yes Current rent: $ Proposed rent after rehabilitation: $ ---PAGE BREAK--- SOURCES OF INCOME: A. EMPLOYMENT INCOME Please complete this section for ALL household members age 18 and over. You must include all current full- time and part-time employment. Please continue on a separate sheet if necessary. Household Member Employer / Source of Income Start Date Annual Gross Amount (before taxes) $ per Year $ per Year $ per Year $ per Year Total: $ per Year Has anyone’s employment situation changed in the past year or do you anticipate a change in the coming year? No Yes If yes, please describe: B. OTHER INCOME OTHER HOUSEHOLD INCOME Household Member’s Name: Social Security: (Including Benefits for Children) $ $ $ Pension/Annuity: $ $ $ Veterans Benefits: $ $ $ Disability: $ $ $ Welfare: $ $ $ Worker’s Compensation: $ $ $ Unemployment: $ $ $ Alimony: $ $ $ Child Support: $ $ $ Rental Income: $ $ $ TOTAL: $ $ $ ---PAGE BREAK--- C. INCOME FROM ASSETS - An asset is a cash or non-cash item that can be converted to cash. 1. SAVINGS & CHECKING ACCOUNT(S): Please attach copies of most recent 6 months of statements. Household Member Name of Bank or Institution Account # Type of Account (Checking or Savings) Current Balance $ $ $ $ 2. INVESTMENT PROPERTY: Address: Value: $ (other than your primary residence) Address: Value: $ 3. OTHER INVESTMENTS: Include: stocks, bonds, savings certificates, money market funds, CDs, IRAs, Keoghs or other investment accounts, contributions to company retirement or pension funds that can be withdrawn without retiring or terminating employment, lump-sum receipts such as inheritances, capital gains, lottery winnings, insurance settlements and other claims, and cash value of life insurance policies. Please attach a copy of most recent statement for each. Household Member Asset Description Cash Value Income from Assets TOTAL $ $ HOUSING EXPENSES: A. MORTGAGE Please attach a copy of most recent mortgage bill/statement. Lender Name Current Loan Amount Payment Primary: $ $ Secondary: $ $ Other: $ $ TOTAL $ B. QUARTERLY EXPENSES C. EXPENSES (not included in mortgage payment) Heat: $ Insurance: $ Electricity: $ Property Taxes: $ D. OTHER EXPENSES Water & Sewer: $ Credit Cards: $ Total: $ Car Payment: $ $ Office Use Only: If Moderate: Mtg Pymt + Qtr Exp/4 + H & E = Expenses Housing Cost Burden: Housing Expenses/ Income = Greater than 30%? Yes No ---PAGE BREAK--- KIMBERLEY DRISCOLL MAYOR TOM DANIEL, AICP DIRECTOR CITY OF SALEM, MASSACHUSETTS DEPARTMENT OF PLANNING AND COMMUNITY DEVELOPMENT 98 WASHINGTON STREET, SECOND FLOOR ♦ SALEM, MASSACHUSETTS 01970 TEL: [PHONE REDACTED] HOUSING REHABILITATION LOAN PROGRAM REQUEST FOR CONSUMER CREDIT INFORMATION In connection with a credit transaction initiated by the undersigned consumer or consumers involving the extension of credit, and in accordance with Civil Code section 1785.11 and 1785.12, the undersigned hereby instructs you to provide the following information to the Housing Rehabilitation Loan Program administered by and through the City of Salem’s Department of Planning and Community Development. A photocopy of my signature may be used to obtain any or all of the information stated below: All information regarding the matters indicated below: 1. My/our employment, (including salary or wages); 2. Savings and checking accounts; 3. Mortgages; 4. Brokerage accounts; 5. Any previous or present credit, whether on closed or open status; 6. A full credit report on my/our previous and present credit history. All information regarding the amounts received by the undersigned (including any ending date for payments) under the following categories: 7. Public assistance (including AFDC, SSI, SSA, SSD and SDI); 8. Annuities, pension or retirement plans including PERS); 9. Court-ordered payments, including child support and spousal support; 10. Workers’ compensation; 11. Unemployment. This authorization shall remain in effect for 6 months from the date of my signature. Print Name: Social Security Date of Birth: Signature: Date: Print Name: Social Security Date of Birth: Signature: Date: ---PAGE BREAK--- INFORMATION FOR GOVERNMENT MONITORING PURPOSES The following information is requested by the Federal Government for certain types of loans in order to monitor the City of Salem’s compliance with equal credit opportunity and fair housing laws. While you are not required to supply this information, you are encouraged to do so. The law provides that a lender may neither discriminate on the basis of the information, nor on whether you chose to supply it. Under Federal regulations, the City of Salem is required to note race and sex on the basis of visual observation or surname. If you do not wish to furnish this information, please check the box below. I do not wish to provide this information. HEAD OF HOUSEHOLD: 1. What is your gender? Male Female 2. Are you Hispanic/Latino? Yes* No * Even if you checked Yes to this question on ethnicity, please answer Question 3 which asks about race. 3. What is your race? Please check only ONE box. White Black/African American & White Black/African American Asian & White Asian American Indian/Alaskan Native & White American Indian or Alaskan Native American Indian/Alaskan Native & Black/African American Native Hawaiian or Pacific Islander Other multi-racial CONFLICT OF INTEREST STATEMENT Are you presently or have you been in the last twelve months, an employee, agent, consultant, or elected appointed official of any agency (including the City of Salem or the Salem Department of Planning and Community Development) receiving CDBG and/or HOME funds directly or indirectly? No Yes ACKNOWLEDGEMENT AND AGREEMENT In signing this application, I certify that all of the information provided in this application is true and correct to the best of my knowledge and belief and that no information has been excluded, which might reasonably affect a judgment regarding eligibility for financial assistance. I 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 agree to all the program terms and requirements. My signature below acknowledges my understanding that any intentional or negligent misrepresentation(s) of information contained in this application may result in civil liability and/or criminal penalties under the provisions of Title 18, United States Code, Section 1001, and liability for monetary damages to the City of Salem, its agents’ successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation I have made on this application. Applicant’s Signature Date: Applicant’s Signature Date: **Please Submit all Required Documents listed on the Checklist with your Application.