Full Text
The Housing Rehabilitation and Get the Lead Out programs do not discriminate on the basis of race, color, national origin, gender or gender identity, age, religion, familial status, sexual orientation or disability. These programs are funded through the United States Department of Housing and Urban Development (HUD), utilizing Community Development Block Grant (CDBG), HOME, and MassHousing funds. Updated 5.31.18 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 TENANT APPLICATION INSTRUCTIONS Please complete all items on this application. If the information requested does not apply to you, please write “not applicable” or Please submit your completed Application with the required documentation in a sealed envelope either to your landlord or directly to our office at the above address. Please contact our office at (978) 617-5685 if you have any questions. All information will be kept confidential. PROPERTY INFORMATION Property Address: Apartment Number: Telephone Number: Number of Bedrooms: TENANT INFORMATION Tenant Name: Co-Tenant Name: Marital Status: Marital Status: Age: Age: Please list names, ages, and relationship of other household members below: Name: Age: Relationship: Is the head of the household a handicapped person? ❑ No ❑ Yes Is anyone else in the household a handicapped person? ❑ No ❑ Yes ---PAGE BREAK--- The Housing Rehabilitation and Get the Lead Out programs do not discriminate on the basis of race, color, national origin, gender or gender identity, age, religion, familial status, sexual orientation or disability. These programs are funded through the United States Department of Housing and Urban Development (HUD), utilizing Community Development Block Grant (CDBG), HOME, and MassHousing funds. Updated 5.31.18 ---PAGE BREAK--- The Housing Rehabilitation and Get the Lead Out programs do not discriminate on the basis of race, color, national origin, gender or gender identity, age, religion, familial status, sexual orientation or disability. These programs are funded through the United States Department of Housing and Urban Development (HUD), utilizing Community Development Block Grant (CDBG), HOME, and MassHousing funds. Updated 5.31.18 RENTAL INFORMATION Amount of rent you pay per month? $ What utilities are you responsible to pay? ❑ electricity ❑ heat ❑ water Total cost of utilities? $ Do you receive rental assistance? ❑ No ❑ Yes Amount of rental assistance per month: $ What type of rental assistance do you receive? ❑ Section 8 Voucher ❑ Tenant Based Rental Assistance (through NSCAP, HAWC, or Salvation Army) ❑ Other (Specify): SOURCES OF INCOME A. EMPLOYMENT INFORMATION Please complete this section for ALL household members age 18 and over. You must include tips, bonuses, and overtime for both full and part time employment. (Please list additional employers on a separate sheet.) 1. Name: Employer: Gross Annual Earnings: $ 2. Name: Employer: Gross Annual Earnings: $ 3. Name: Employer: Gross Annual Earnings: $ B. OTHER SOURCES OF INCOME: (Include income for all household members.) Source Gross Amount Received per Year Source Gross Amount Received per Year Social Security: $ Welfare: $ Social Security Disability: $ Worker’s Compensation: $ Pension: $ Unemployment: $ Retirement: $ Alimony: $ Veterans Benefits: $ Child Support: $ Other: $ ---PAGE BREAK--- The Housing Rehabilitation and Get the Lead Out programs do not discriminate on the basis of race, color, national origin, gender or gender identity, age, religion, familial status, sexual orientation or disability. These programs are funded through the United States Department of Housing and Urban Development (HUD), utilizing Community Development Block Grant (CDBG), HOME, and MassHousing funds. Updated 5.31.18 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 ACKNOWLEDGEMENT AND AGREEMENT I/we certify that the information provided in this application is true and correct as of the date set forth opposite my/our signatures on this application and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both 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, which I/we have made on this application. Signing this document gives the City of Salem’s Department of Planning and Community Development the authorization to obtain verification from any source herein. ALL APPLICANTS MUST SIGN BELOW. Applicant’s Signature: Date: Co- Applicant’s Signature: Date: IMPORTANT: ALL APPLICANTS MUST PROVIDE THE REQUIRED INCOME DOCUMENTATION (SPECIFIED ON THE ENCLOSED CHECKLIST) WITH THEIR APPLICATION. ---PAGE BREAK--- The Housing Rehabilitation and Get the Lead Out programs do not discriminate on the basis of race, color, national origin, gender or gender identity, age, religion, familial status, sexual orientation or disability. These programs are funded through the United States Department of Housing and Urban Development (HUD), utilizing Community Development Block Grant (CDBG), HOME, and MassHousing funds. Updated 5.31.18 KIMBERLEY DRISCOLL 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 TENANT ACKNOWLEDGMENT OF OWNER’S APPLICATION FOR ASSISTANCE I/we, and resident(s) of (Tenant) (Co-Tenant) Salem, Massachusetts, certify awareness that the owner of this rental (Street Address) unit is submitting an application to the City of Salem’s Housing Rehabilitation Loan Program. I/we understand that: • I will be required to submit household income information to the City of Salem as part of the application process. All of the income information given to the City of will be kept confidential. • During construction, I may be asked to comply with certain reasonable requests to accommodate construction. I am willing to comply with such requests. • During construction, I may be required to temporarily relocate for a period of time to accommodate construction and/or deleading. If temporary relocation is required, relocation assistance will be made available through the City. • I will be required on an annual basis to provide information about the amount of rent and utilities that I pay and my gross annual household income. Tenant’s Signature: Date: Co-Tenant’s Signature: Date: