PROGRAM APPLICATION- Home Repair

Neighborhood Housing and Community Development (NHCD) Austin Housing Finance Corporation (AHFC)
MAILING ADDRESS: P. O. Box 1088 l Austin, Texas	78767 DELIVERY ADDRESS: 1000 E. 11th Street, Suite 200
Phone: (512) 974-3100 l Fax (512) 974-3161
Email: nhcdcs@austintexas.gov Website: www.austintexas.gov/empower

To apply for any City of Austin AHFC/ NHCD Home Repair Program(s), please fill out all attached forms and gather all applicable documentation listed in the attached document checklist. Information in this application is confidential. It is used to establish eligibility for local and federal programs and is only released to persons outside of the program and funding agencies with your written permission. Feel free to contact us with any questions while completing the application. We look forward to working with you!

Section 1 – Applicant Information

Name: __________________________________________________________________
Last	First	Middle Initial

Property Address:   	

City:  	

State:   	

Zip:  	

Are you the:	Homeowner

Renter

Year House Was Built:  	

Mailing Address (if different):   	

City:  	

State:   	

Zip:  	

Work Phone:	Home Phone:	Cell Phone:  	

E-mail	Gender:	Male

Female

Marital Status:

Single

Married

Widowed

Divorced

Are you a:	U.S. Citizen

Permanent Resident

Other:  	

Is the applicant female head of household?

Yes

No

Is any household member disabled?

Yes

No

Alternate Contact Name, Phone Number and Email                                                                                                          
 					:_

Have you ever received City of Austin home repair assistance in the past?	Yes

No

How did you hear about the Programs?  	

Section 2 – Co-Applicant Information	N/A

Name: _________________________________________________________________
Last	First	Middle Initial

Work Phone:	Cell Phone:  	

E-mail	 Gender:	Male

Female

Marital Status:

Single

Married

Widowed

Divorced

Are you a:	U.S. Citizen

Permanent Resident

Alien: Alien number A:  	

Other:  	

Alternate Contact Name, Phone Number and Email  	

Are you receiving Medicaid?

Yes

No

Section 3 – Requested Services

Check all services required.

Foundation Roofing Plumbing Electric Heating & AC

Address Sewage Problem Windows
Door Widening & Accessible Hardware

Wheel Chair Ramps & Handrails
Restroom Mobility- Showers, Faucets, Toilets, Grab Bars

Please elaborate upon these needs below:

Section 4 – Household Members

List all persons (children and adults) living in the home, along with their gross income. By signing in Section 8, you certify, that you are the owner(s) and/or occupant(s) of the property (identified in Section 1) and that the current gross monthly and annual income of all persons living in the home has been listed below. (Attach additional page(s) if needed)

Total number of persons living in the household:  	

Name	
Relationship	
Date of Birth	
Age	
Gross Income/ Pay Period	

(Applicant)	
Self				

(Co-Applicant)					

					

					

Section 5 – Mortgage Information: Complete this section for HRLP and Holly ONLY

If a homeowner:
Do you have a Mortgage on this property?

Yes

No

Do you have property insurance?	Yes

No

Mortgage Company  	

Do you have a Second Mortgage on this property?

Yes

No

Mortgage Company  	

Section 6 – Landlord or Property Manager

If a renter:

Amount of monthly rent you pay $              Landlord or manager’s name: _______

Landlord or manager’s phone number:   _____ 

Fax Number:	_

Landlord Contact Address:  	

City:  	

State:   	

Zip:  	

Section 7 – Demographics

Ethnic Categories (select one)

Hispanic or Latino	Not-Hispanic or Latino

Racial Categories (select all that apply)

American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Asian
White

Black or African American
Other

Section 8 – Applicant(s) Signatures
By signing this application you swear under penalty of perjury that the information provided is true and correct to the best of your knowledge. You understand that any omissions or discrepancies found at any time may disqualify you from the program(s) and also may require your immediate repayment of any funds spent. You authorize NHCD or AHFC to contact any source to solicit and/or verify what is necessary for eligibility.

You authorize NHCD or AHFC to share and/ or refer you and your information to other organizations or other city departments for additional assistance and/ or to avoid duplication of services.

Signature of Applicant/Guardian

Date

Signature of Co-Applicant

Date

The City of Austin is committed to complying with the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973, as amended. Reasonable modifications and equal access to communications will be provided upon request. Please call (512) 974-3100 (voice) or route through Relay Texas at 711 for assistance. The City of Austin does not discriminate on the basis of disability in providing admission, access to, treatment, or employment in its programs and activities. For complaints regarding your ADA/ Section 504 rights, please contact Dolores Gonzalez, City of Austin ADA/504 Coordinator at (512) 974-3256 or route through Relay Texas at 711.

Program funding is provided by the U.S. Department of Housing and Urban Development (HUD) and City of Austin.

Suggested Programs (for office use only):

	Grant							Loan
	Architectural Barrier Removal Program (ABR)	        Homeowner Rehabilitation Loan Program (HRLP)
	Private Lateral Program (PLP)

Neighborhood Housing and Community Development (NHCD) Austin Housing Finance Corporation (AHFC)
MAILING ADDRESS: P. O. Box 1088 l Austin, Texas78767 DELIVERY ADDRESS: 1000 E. 11th Street, Suite 200
Phone: (512) 974-3100 l Fax (512) 974-3161
Email: nhcdcs@austintexas.gov Website: www.austintexas.gov/empower

State of Texas, County of Travis

I,	residing  at	_, in consideration of the service and/or equipment provided in my home by the City of Austin/ Austin Housing Finance Corporation under the Architectural Barrier Removal Program, Lead-Based Paint Removal Program, Private Lateral Program, Homeowner Rehabilitation Loan Program, and/ or Holly Good Neighbor Program; knowingly and voluntarily execute this release for the purpose of and intending to release and hold harmless the Austin Housing Finance Corporation and the City of Austin from any claims arising out of the service or equipment provided.

It is my intention and I understand that I am binding myself, my heirs, executors, administrators, assigns, and successors in interest, and understanding this, so hereby expressly release and discharge the City of Austin Housing Finance Corporation, its successors, administrators, assigns and agents from any claims against the Austin Housing Finance Corporation, as well as the City of Austin, a Texas home rule city, created by or arising out of, or in any way whatsoever related to the service or equipment provided at my residence on this date. I understand that my claims, which may in the future arise out of personal injuries, injuries to the residence or damage to my property of any kind, are hereby waived.

I have read this release and understand its terms. I am entering into it voluntarily and with full knowledge and understanding of its significance and in consideration of the service or equipment provided.

 	 	 	

 	 	

We Do Business in Accordance With Federal Fair Lending Laws

UNDER THE FEDERAL FAIR HOUSING ACT, IT IS ILLEGAL, ON THE BASIS OF RACE, COLOR, NATIONAL ORIGIN, RELIGION, SEX, HANDICAP,
OR FAMILIAL STATUS (HAVING CHILDREN UNDER THE AGE OF 18), TO:
•	Deny a loan for the purpose of purchasing, constructing, improving, repairing or maintaining a dwelling, or deny any loan secured by a dwelling; or
•	Discriminate in fixing the amount, interest rate, duration, application procedures or other terms or conditions of such a loan, or in appraising property

IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU SHOULD SEND A COMPLAINT TO:
Assistant Secretary for Fair Housing and Equal Opportunity Department of Housing & Urban Development
Washington, DC 20410
For processing under the Federal Fair Housing Act

and to:
Division of Compliance and Consumer Affairs Federal Deposit Insurance Corporation Washington, DC 20429-9990
For processing under FDIC regulations

UNDER THE EQUAL CREDIT OPPORTUNITY ACT,
IT IS ILLEGAL TO DISCRIMINATE IN ANY CREDIT TRANSACTION:
•	On the basis of race, color, national origin, religion, sex, marital status, or age,
•	Because income is from public assistance, or
•	Because a right was exercised under the Consumer Credit Protection Act

IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST, YOU SHOULD SEND A COMPLAINT TO:
Division of Compliance and Consumer Affairs Federal Deposit Insurance Corporation Washington, DC 20429-9990

VERIFICATION OF INCOME AND ASSETS
For All Household Members 18+ Years Old

Household members over the age of 18 must report all income and assets. By signing below, applicant(s) certify the accuracy of provided information as of the date completed. Applicant(s) acknowledge any inaccuracy and/or misrepresentation provided herein may constitute fraud, which is punishable by law.

WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government.

Sources of Income
Employment Income

HOUSEHOLD MEMBER 1

Assets
Checking Account

Self-Employment (Includes sales like Avon) Social Security
Disability Death Benefits
Child Support or Spousal Support/Alimony Unemployment, Workers Comp or Severance Annuity, Retirement, or Pension Payments Rental Income (Real or Personal Property) Recurring Payments from Outside Household Insurance Payments
Periodic Payments from Inheritance or Trust Interest or Dividends from Assets
Royalties
Other:  	
I currently have no sources of income

Savings Account 
Certificates of Deposits (CD) Money Market Account Mutual Funds or Bonds Lottery Winnings
Capital Gains
Retirement (ex. IRA, 401K, 403B, Keogh) Pensions
Annuities
Life Insurance (with payout value if canceled) Victim’s Restitution Insurance Settlements Real Estate (Other than Primary Residence) Inheritances
Other:  	
I currently have no assets

 	
Name	Signature	Date

Sources of Income
Employment Income

HOUSEHOLD MEMBER 2	N/A

Assets
Checking Account

Self-Employment (Includes sales like Avon) Social Security
Disability Death Benefits
Child Support or Spousal Support/Alimony Unemployment, Workers Comp or Severance Annuity, Retirement, or Pension Payments Rental Income (Real or Personal Property) Recurring Payments from Outside Household Insurance Payments
Periodic Payments from Inheritance or Trust Interest or Dividends from Assets
Royalties
Other:  	
I currently have no sources of income

Savings Account 
Certificates of Deposits (CD) Money Market Account Mutual Funds or Bonds Lottery Winnings
Capital Gains
Retirement (ex. IRA, 401K, 403B, Keogh) Pensions
Annuities
Life Insurance (with payout value if canceled) Victim’s Restitution Insurance Settlements Real Estate (Other than Primary Residence) Inheritances
Other:  	
I currently have no assets

 	
Name	Signature	Date

Neighborhood Housing and Community Development (NHCD) Austin Housing Finance Corporation (AHFC)
MAILING ADDRESS: P. O. Box 1088 l Austin, Texas	78767 DELIVERY ADDRESS: 1000 E. 11th Street, Suite 200
Phone: (512) 974-3100 l Fax (512) 974-3161
Email: nhcdcs@austintexas.gov Website: www.austintexas.gov/empower

Please gather all applicable documents listed below and submit this documentation in person, by email, fax, or mail. Feel free to contact us with any questions while gathering this documentation.  

Application (original) completed & signed	N/A	
Social Security card(s) for applicant(s)
Permanent Residency Card(s) (front & back) (if applicable)	N/A
N/A	
Picture Identification for applicant(s)
Texas Driver’s license, Texas Identification Card, or Passport	N/A	
Last 2 months’ paycheck stub (for all received by all household members 18+ years old)	N/A
Most Recent Profit & Loss Statement (quarterly) & Tax Return (if self-employed)	N/A	
Verification of all other income (for all 18+ years old)
	N/A	
Social Security	Child Support or Spousal Support/Alimony Disability	Worker’s Compensation and Severance Pay Death Benefits	Annuity, Retirement, or Pension Payments
Unemployment	Trust Income
Royalties	Other:  	 Insurance Payments	
Most Recent Bank Statements (all pages) for all accounts for all household members 18+	N/A
	
Verification of Assets (for all household members 18+ years old)	N/A	
Certificates of Deposits (CD)	Retirement (ex. IRA,401K, 403B, Keogh) Money Market Account	Pension	 Annuity
Mutual Funds or Bonds	Life Insurance (with payout value if canceled) Lottery winnings	Victim’s restitution Insurance Settlements
Capital gains	Real Estate (Other than Primary Residence)
Inheritances	Other:  		
Utility Bill
Austin Water Utility Letter (if received)	N/A N/A	

If applying for a repair related to a disability and not 62+ years old, please also provide one of the following:
 Medicare card      SSDI letter       Verification of Disability signed by medical practitioner (provided by org)

If applying for Home Repair Loan Programs for more extensive repairs, please also provide all of the following:
	Most recent 6 months’ checking & 1 month savings account statement(s) (all pages for all accounts held by all 18+)
	Past 2 years’ tax returns for all 18+ (or statement from IRS they were not filed by anyone not included on tax return)    
	Home Insurance Declarations Page           Most Recent Mortgage Stmt(s)