CDBG Housing Rehabilitation Application
Pike County
Head of Household Name
*
First Name
Last Name
Social Security Number
*
Email
*
example@example.com
Spouse/ Partner Name
*
First Name
Last Name
Social Security Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you reside in a Private Community/ Home Owners Association?
*
Yes
No
If Yes, What is the name of your Community?
Is your home a mobile home or trailer?
*
Yes
No
Is there mold in the home?
*
Yes
No
Is there a buried oil tank on the property?
*
Yes
No
Have you had a recent soil test (within 6months)?
Yes
No
What year was the home built?
*
How many children under the age of 18?
*
Family Size
*
What is the Household GROSS Annual Income?
*
Is there a female head of household?
*
Yes
No
Does the head of household have a disability?
*
Yes
No
If yes, Please explain.
*
Race, please check that apply.
*
American Indian/ Alaskan Native
Asian
Black/ African American
Native Hawaiian/ Pacific Islander
White
Ethnicity
*
Hispanic
Not Hispanic
Please Provide us with a Brief Reason in Your words for this Application
*
What Resources have you Contacted already?
*
Department of Welfare
LIHEAP
PHFA Mortgage Assistance
Workforce Development Agency
Section 8 Housing Authority
Other
Are you a Veteran?
*
Yes
No
Are you currently receiving Drug and Alcohol Services?
*
Yes
No
Do you currently have a mortgage on the home?
*
Yes
No
Do you have a reverse mortgage?
*
Yes
No
Are you currently receiving Domestic Violence Services?
*
Yes
No
Have you received assistance for more than one housing crisis during a 24-month period?
*
Yes
No
INCOME
*
Rows
Name
Income Type
Monthly Income
Yearly Income
Household Member 1
Household Member 2
Household Member 3
Household Member 4
Household Member 5
Household Member 6
Household Member 7
Household Member 8
INCOME TOTAL FOR ALL HOUSEHOLD MEMBERS
Rows
Amount
SOC. SECURITY
CHILD SUPPORT
ALIMONEY
PENSION
FOOD STAMPS
PENSION
TANF (CASH)
Total
Document Upload
Please Upload the documents needed to complete your application
DRIVERS LICENSE/ ID CARD FOR ALL HOUSHOLD MEMBERS if there are children in the home, please provide either school ID's or birth certificates.
*
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3 Months of Checking/ Savings Accounts Statements for ALL household members
*
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TAX RETURN
*
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WAGES/ PAYSTUBS FOR ALL HOUSEHOLD MEMBERS
*
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UE/ SSI
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DPW- FD STAMP/ CASH
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PROPERTY DEED
*
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COPY of PAID Property & School Taxes
*
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MORTGAGE STATMENT
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Proof of Current Home Owners Insurance
*
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Please upload photos of the home's exterior and interior, including all living areas and rooms in the home
*
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By signing below, I acknowledge and understand that a lien in the amount of the construction contract will be placed on my property for a period of five (5) years. This lien will be fully forgiven upon completion of the five-year term, provided that I retain ownership of the property for the entire period. If the property is sold or transferred before the five-year period expires, I agree that a prorated amount of the lien will be due to the county at the time of sale or transfer. By signing below, I confirm that I have read and understand the terms of this agreement.
*
By submitting this application for assistance from the Pike County Human Services I hereby acknowledge and agree to the following terms and conditions: Accuracy of Information: I certify that all information provided in this application and in any attached documents is true, accurate, and complete to the best of my knowledge. I understand that any false statements or deliberate omissions may result in the denial of my application or termination of any assistance granted. Use of Information: I authorize Pike County Human Services and its agents to use the information provided in this application for the purpose of evaluating my eligibility for assistance. This may include verifying information with third parties, such as employers, landlords, and government agencies, as necessary. Privacy and Confidentiality: I acknowledge that Pike County Human Services is committed to maintaining the privacy and confidentiality of my personal information. Information provided in this application will be used solely for the purpose of assessing my need for assistance and will not be disclosed to any unauthorized parties without my explicit consent, except as required by law. No Guarantee of Assistance: I understand that submission of this application does not guarantee that I will receive assistance. Assistance is provided based on the availability of funds, the eligibility criteria of the program, and the demonstrated need of the applicants. Decisions made by Pike County Human Services regarding the distribution of assistance are final. Changes in Circumstances: Should my circumstances change after the submission of this application; I agree to notify Pike County Human Services promptly. This includes changes in income, family size, address, or any other information that could affect my eligibility for assistance. Terms and Conditions: I agree to comply with all terms and conditions of the assistance program, should I be selected to receive aid. I understand that failure to comply with program requirements may result in the termination of assistance. Release of Liability: I hereby release and hold harmless Pike County Human Services, its directors, officers, employees, and agents from any liability, loss, or damage arising from my participation in the Pike County Human Services or from the denial of my application. By signing below, I acknowledge that I have read, understand, and agree to the above terms and conditions. I also understand that this application is subject to review and approval by Pike County Human Services and that I may be asked to provide additional information or documentation as part of the review process.
*
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