Lead Homeowner's Application FY13

LYNN LEAD ABATEMENT PROGRAM

~HOMEOWNER APPLICATION~
(1) Applicant
Applicant Name *

First NameMiddle NameLast Name
Social security number *
Date of Birth*
Is there anybody who is 18 years or older in your household who is not currently employed? (Note, if the answer is "yes," you will be directed to fill out a No Income Statement after submitting this form).*

YesNo
Are you married?*

YesNo
Spouse Name *

First NameLast Name
Spouse social security number *
Spouse's Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email*
example@example.com

(2) Household Information

Rows	Name	D.O.B	College Student (Yes or No)	Annual Income	Relationship to Applicant
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7

(3) Property
Home Type*

Single FamilyMulti-Family
How many units?*

1-4 units4-8 units
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year Built*
Subject Property Contact Person's #*
Do you own the subject property solely or in partnership?*

SolelyPartnership

Rows	Name	Address
Person 1
Person 2
Person 3

FOR OWNERS’ UNIT:
Ethnicity*

Hispanic/LatinoNon-Hispanic/Non-LatinoPrefer not to answer
Race*

WhiteBlack/African-AmericanNative Hawaiian/Pacific IslanderAsianAmerican Indian/Alaska NativePrefer not to answer

EMPLOYMENT INFORMATION
1. Head of Household's Full time Occupation*
Employer's Name:*
Length of time at this job:*
Does the head of the household also have a part time occupation?*

YesNo
Part time Employer's Name:*
Length of time at this job:*
2. Other Member's Full and/or Part time Occupation
Household members’ name:
Employer's Name:
Length of time at this job:
Part time Employer's Name:
Length of time at this job:
3. Other Member's Full and/or Part time Occupation
Household members’ name:
Employer's Name:
Length of time at this job:
Part time Employer's Name:
Length of time at this job:

SOURCES OF FIXED INCOME
Do you receive Retirement Income (Pension) or a Disability Award?*

YesNo
Retirement Income (PENSION) or Disability Award: Name(s) of Recipient(s):*

First NameLast Name
Company Providing Pension:*
Amount of gross monthly income:*

Do you receive Social Security?*

YesNo
B. Social Security Income: Name of Recipient(s):*

First NameLast Name
Amount of gross monthly award:*

Are you a veteran?*

YesNoPrefer not to answer
Do you receive Veterans Assistance?*

YesNo
C. Veterans Assistance: Name of Recipient(s):*

First NameLast Name
Amount of gross monthly award:*

Do you receive Public Assistance?*

YesNo
D. Public Assistance: Name of Recipient(s): *

First NameLast Name
Amount of gross monthly award:*

Do you receive Unemployment Assistance?*

YesNo
E. Unemployment: Name of Recipient(s) *

First NameLast Name
Amount of Biweekly award:*
When did benefits start?*

LIST ALL CURRENT ASSETS:

Rows	Interest Rate	Amount in Dollars
1. Average 6 month balance of Checking Account
2. Actual balance of Saving Accounts
3. FSS Escrow Account
4. Mutual Funds, Bonds & Annuities
5. Certificates of Deposit
6. Cash Value of Life Insurance Policies
7. Retirement and Pension Funds (current cash value)
8. Value of Stocks
9. Cash value from Trust
10. Investments such as jewelry, antiques cars, collections
11. Inheritances, lottery winnings, capital gains, insurance settlements
12. Mortgages or deeds held by applicants

Did any member of the household dispose of any assets for less than the fair market value within the past two years?*

YesNo
Were the assets either given away or sold at less than the allotted market value?*

YesNo

INCOME and ASSET DOCUMENTATION CHECKLIST

The following documentation applies to ALL persons who will reside in the household and must be included with your application to determine your income eligibility: Documentation for all sources of income for all household members must be emailed to... after submitting this application
Most recent 4 (four) consecutive paystubs*

Cancelof

Current Social Security Award Letter*

Cancelof

Do you receive a pension?*

YesNo
Current Pension Award Letter (indicating monthly gross income for the current year) *

Cancelof

Complete copy of the applicant’s most recent 3 (three) years federal Income Tax form 1040, with all schedules *

Cancelof

Veteran Benefits Certificate*

Cancelof

Federal Income Tax form 1040, with all schedules*

Cancelof

Are you self-employed?*

YesNo
Profit & Loss Statement year-to-date (If self-employed)*

Cancelof

Do you receive Child Support or Alimony?*

YesNo
Child Support and/or Alimony Statement (Court statement)*

Cancelof

Are you unemployed?*

YesNo
Unemployment Documentation (Computer run-off sheet from Unemployment Office)*

Cancelof

Do you receive other income?*

YesNo
Other income (acceptable forms of current income verification)*

Cancelof

Most recent 3 (three) consecutive months of bank statement for all bank accounts in the household.*

Cancelof

REPRESENTATIONS AND CERTIFICATIONS OF THE PROPERTY OWNER/S

The undersigned hereby represents and certifies under the pains and penalties of perjury respective to the Property located at:
Signature

Clear
A. CONFLICT OF INTEREST: Is the Owner or any member of his/her immediate family, or any business associate, employed by the City of Lynn?*

YesNo
If yes, please explain:*
B. DECLARATION OF OTHER REAL ESTATE OWNED: Are you an owner or part owner of any other real estate in the City of Lynn?*

YesNo
If yes, please list addresses:*

C. TAX AND CONTRIBUTION COMPLIANCE:

The Owner is in full compliance with all laws of the Commonwealth of Massachusetts and ordinances of the City of Lynn relating to taxes and to contributions and payments in lieu of the contributions
D. NON-DISCRIMINATION COMPLIANCE:

The undersigned agrees that there will be no discrimination on the basis of race, color, national origin, ancestry, age, sex, religion, disability, sexual orientation, presence of children, marital status, source of income or military status, in the sale, lease, rental use, advertisement or occupancy of the property that is rehabilitated with funds provided by the City of Lynn, Lynn Housing Authority and Neighborhood Development. Regulations issued by the U.S. Department of Housing and Urban Development (HUD) and the Mass. Commission Against Discrimination (MCAD) pursuant to Title VIII of the Civil Rights Act of 1968, as amended in 1988, and Massachusetts General Law, Chapter 151B, Section 4, shall apply.
E. OWNERS' PERMISSION TO ENTER AND INSPECT:

I/We hereby give my/our permission for the employees of the City of Lynn, Lynn Housing Authority & Neighborhood Development and their agents to inspect my property including conducting heating system analysis as a condition of applying for assistance through LLAP. Further, I/We relieve the City of Lynn, Lynn Housing Authority & Neighborhood Development its employees and/or agents from any and all claims of damage or liability arising from the performance of property inspections by the City of Lynn.
F. CERTIFICATION:

I/We certify that, under penalty of perjury, all information on this application to the best of my/our knowledge is true. I/We understand that false information given is sufficient grounds for rejection of this application. Furthermore, verification may be obtained from any source herein.

Penalty for False or Fraudulent Statement, U.S.C.
"Title 18, Section 1001, provides: "Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies...or makes any false fictitious or fraudulent statements or representations, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements or entry, shall be fined not more than $10,000 or imprisoned not more than five (5 years) or both.

All persons whose names appear on the recorded copy of the deed must sign here:
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
Signature

Clear
Date

MonthDayYear
Date
*Incomplete applications will result in delay in processing

ELIGIBILITY RELEASE FORM
Date

MonthDayYear
Date
Purpose: Your signature on this Eligibility Release Form, and the signatures of each member of your household who is 18 years of age or older, authorizes the Lynn Housing Authority & Neighborhood Development to obtain information from a third party relative to your eligibility in the:

HOME/CDBG Homebuyer Program
HOME/CDBG Rehabilitation Program(s)
DeLead Program

Privacy Act Notice Statement: The Department of Housing and Urban Development (HUD) is requiring the collection of the information derived from this form to determine an applicant’s eligibility in a HOME/CDBG/DeLead Program(s) and the amount of assistance necessary using HOME/CDBG/DeLead funds. This information will be used to establish level of benefit on the HOME/CDBG/DeLead program(s); to protect the Government’s financial interest; and to verify the accuracy of the information furnished. It may be released to appropriate Federal, State, and local agencies when relevant, to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in a delay or rejection of your eligibility approval. The Department is authorized to ask for this information by the National Affordable Housing Act of 1990.

NOTE: THIS GENERAL CONSENT MAY NOT BE USED TO REQUEST A COPY OF A TAX RETURN. IF A COPY OF A TAX RETURN IS NEEDED, IRS FORM 4506, “REQUEST FOR COPY OF TAX FORM” MUST BE PREPARED AND SIGNED SEPARATELY.

Authorization: I authorize the Lynn Housing Authority & Neighborhood Development and HUD to obtain information about me and my household from the following sources, that is pertinent to eligibility for participation in the HOME/CDBG/DeLead Program(s):
- Any credit bureau, retail merchants association, bank, financial institution, or other credit-extending organization
- Providers of alimony, child support, credit, handicapped assistance, pension/annuities, the U.S. Social Security Administration, the U.S. Department of Veteran’s Affairs, and Welfare agencies
- All income information and employments records
- Other:
If "other," please provide response
I understand that a photocopy of this form is as valid as the original.
Head of Household Name

First NameLast Name
Head of Household Date

MonthDayYear
Date
Head of Household Signature

Clear
Other Adult Member (Family Member #2) Name

First NameLast Name
Other Adult Member (Family Member #2) Date

MonthDayYear
Date
Other Adult Member (Family Member #2) Signature

Clear
Head of Household (Family Member #3) Name

First NameLast Name
Head of Household (Family Member #3) Date

MonthDayYear
Date
Head of Household (Family Member #3) Signature

Clear
Other Adult Member (Family Member #4) Name

First NameLast Name
Other Adult Member (Family Member #4) Date

MonthDayYear
Date
Other Adult Member (Family Member #4) Signature

Clear
Should be Empty:

Rows	OWNERS' UNIT apt. #	apt. #	apt. #	apt. #
a. # of persons per unit
b. # of children under six years old
c. # of elderly (over 62)
d. # handicapped (non-elderly)
e. # elderly handicapped
f. Is head of household female?

LYNN LEAD ABATEMENT PROGRAM

(1) Applicant

(2) Household Information

(3) Property

FOR OWNERS’ UNIT:

Statistical Information:

EMPLOYMENT INFORMATION

SOURCES OF FIXED INCOME

INCOME and ASSET DOCUMENTATION CHECKLIST

REPRESENTATIONS AND CERTIFICATIONS OF THE PROPERTY OWNER/S

All persons whose names appear on the recorded copy of the deed must sign here:

ELIGIBILITY RELEASE FORM