Application for COVID-19 Mortgage Assistance

Application for COVID-19 Mortgage Assistance

All documents must be uploaded using this form. Please allow one to two weeks for application review. Upon approval, please allow 14-21 business days for payments to be processed. This project was financed by a grant from the federal Department of Housing and Urban Development, under the administration of the Commonwealth of Pennsylvania, Department of Community and Economic Development.
Income Eligibility

To be eligible for this program, total family income must be less than 80% of the area median: 1 person - $44,200; 2 people - $50,500; 3 people - $56,800; 4 people - $63,100; 5 people - $68,150; 6 people - $73,200; 7 people - $78,250; 8 people - $83,300.
Applicant Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Today's Date*

MonthDayYear
Date
Number of People in Household*

Members of the Household*

	First Name	Last Name	Social Security Number
1
2
3
4
5
6
7
8
9
10

Has anyone in your household experienced financial hardship which may include, but not be limited to, a period of unemployment, a decrease in household income, or had increased household costs?*

YesNo
If yes, Please provide us a short detailed explanation.
If yes, was this financial hardship due, directly or indirectly, to COVID-19?*

YesNo
Is anyone in your household at risk of homelessness or housing instability?*

YesNo
Has anyone in the household received federally-funded mortgage or utility assistance in the past 24 months?*

YesNo

List Other Assistance Received (if applicable)

	Received From	Amount	Date Received
1
2
3
4

Are you a veteran?*

YesNo
Has anyone been a victim of domestic violence?*

YesNo
Citizenship of Head of Household:*

U.S. CitizenNaturalized CitizenLawfully Present AlienOther
Race of Head of Household (check all that apply):*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteOther
Ethnicity of Head of Household:*

HispanicNon-Hispanic
Gender of Head of Household:*

MaleFemaleOther
Does the Head of Household have a disability?*

YesNo
Mortgage Holder Information
Name of Bank or Financial Institution*
Account Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Household Income
Please tell us about the income of any individual in your household who is 18 or over. Does anyone in your household have any income?*

YesNo
If yes, check all that apply.

CommissionsDividendsGambling/LotteryGuardian FeesMoney Earned from BabysittingMoney for TrainingMoney Paid to You for LoansMoney Paid to You for Housing CostsPensionsSelf-EmploymentSick BenefitsSocial SecuritySupplemental Security Income (SSI)SupportUnemploymentUnion PayVeteran BenefitWages from EmploymentWorkers CompensationOther

List all Household Income

	Name of Person with Income	Type/Source of Income/Name of Employer	Income/Pay: How Much?	How Often Paid	Date of Most Recent Payment
1
2
3
4
5

Household Expenses*

	Monthly $	Arrears $
Mortgage
Electric
Gas
Oil
Propane
Coal/Wood/Other
Trash
Water/Sewer
Internet

Notes
Rights and Responsibilities
RIGHT TO NONDISCRIMINATION

Pike County does not discriminate in any of its programs on the basis of race, color, religion, sex, age, national origin, ancestry, familial status, disability, or use of guide or support animals because of the blindness, deafness, or physical handicap of the user or because the user is a handler or trainer of support or guide animals.

If you are a person with a disability or limited English proficiency and require an auxiliary aid, service, or accommodations to participate, please contact Robert Ruiz, Executive Director of Human Development, at (570) 296-3434 or rruiz@pikepa.org, to discuss how to best accommodate your needs.

Robert Ruiz is designated as Fair Housing Officer for Pike County and that any resident that believes they have been discriminated against may file a complaint with the Fair Housing Officer at the following address:

Robert Ruiz
Executive Director, Human Development
506 Broad Street
Milford, PA 18337
rruiz@pikepa.org
(570) 296-3434

Any complaints, grievances, or comments regarding any components of the program should be written and submitted to Robert Ruiz, Executive Director of Human Development, at rruiz@pikepa.org or 506 Broad Street, Milford, PA 18337. Written responses will be addressed within 15 working days when practicable.

RIGHT TO CONFIDENTIALITY

We will keep your information private. It will only be used to decide which programs you may be eligible for. Any person knowingly violating any of the rules and regulations of this department shall be guilty of a misdemeanor and, upon conviction shall be sentenced to pay a fine, not exceeding one hundred ($100) dollars, or to undergo imprisonment, not exceeding six months, or both (62 P.S. section 483).

RESPONSIBILITY TO PROVIDE INFORMATION

You must give true, correct and complete information. You must help in proving the information, you give. Benefits may be denied if you fail to provide certain proof. If you are contacted by a representative from the county, state, or federal government, you must fully cooperate with those persons or investigators.

PRIVACY ACT STATEMENT

The collection of this information, including the Social Security number (SSN) of each household member, is authorized under 42 U.S.C. § 405(c)(2)(C)(i-iv) and 62 P.S. § 432.2(b)(3).

The information will be used to determine whether your household is eligible or continues to be eligible to participate in this program. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management.

This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. Failure to provide an SSN may result in the denial of assistance to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members. If someone wants help getting an SSN:

(1) call: 1-800-772-1213 or 1-800-325-0778 (TTY); or

(2) visit: www.ssa.gov.

GRIEVANCE PROCEDURE

The grievance procedure for any person who believes that they has been discriminated against or denied equal opportunity or access to programs or services may file a complaint, which shall be referred to as a grievance, with the following:

Gary Orben, Chief Clerk, Pike County, 506 Broad Street, Milford, PA 18337, gorben@pikepa.org, (570) 296-7613 OR EQUAL HOUSING OPPORTUNITY, U.S. Department of Housing and Urban Development, FHEO/Regional III Office Mid-Atlantic Office, 100 Penn Square East, 12th Floor, Philadelphia, PA 19107, (215) 861-7643, Fax: (215) 656-3449 TTY: (800) 927-9275

Grievance procedures and complaint forms may be requested from the offices of Pike County in the following manner: Contact Gary Orben at gorben@pikepa.org or (570) 296-7613.
Document Upload
Government-issued or other personal ID for at least one household member on the mortgage*

Cancelof
Copy of most recent mortgage bill*

Cancelof
Evidence of unemployment benefits, if applicable

Cancelof
Notices of late mortgage payment and/or foreclosure notice, if applicable

Cancelof
Copies of past due utility bills if utility assistance is being requested

Cancelof
Income Documentation
If you have completed your household's federal income taxes for 2020, you will need to provide one of the following:
- Filed 2020 IRS Form 1040
- Filed 2020 IRS Form 1040-A
- Filed 2020 IRS Form 1040-EZ
If you have not yet completed your federal income taxes for 2020 OR you are not required to filed a federal income tax return for 2020, you will need to provide all of the applicable income documentation under one of these two categories:

Acceptable annual income documentation
- 2020 IRS Form W-2
- Current Social Security benefits letter or 2020 Form 1099-SA (including benefits paid to minors)
- 2020 Form 1099-R
- 2020 IRS Form 1099-MISC for contractor income
Other acceptable income documentation:
- Check stubs from your employer for the previous 60 days
- Current unemployment benefits letter including gross benefit amount
- Current letter from your employer verifying gross wages (pay rate, hours/week, pay date)
- Current pension/retirement benefit letter (if applicable)
- Current annuity payment letter
- Current interest statement 1099-INT
- Current dividend statement 1099-DIV
- Certification of income form (for self-employed or cash income)
- Zero income form
Income documentation for all household members*

Cancelof
Attestation/Certification
I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is being submitted by someone acting on my behalf. I certify that all information that has been entered is true under penalty of perjury. I understand that the information entered in this application will be kept confidential and used only to administer benefits. I understand that I may be required to work with other agencies as a condition of my approval for assistance. I agree to provide upon request any additional documentation required (i.e. pay stub, lease, recent bills, proof of unemployment etc.) to aid in determining eligibility.

I agree to repay assistance received from this Mortgage Assistance Program if it is determined to be duplicative.
Applicant Signature

Clear
Printed Name

First NameLast Name
Authorization for Release of Information (tenant only)
I hereby authorize and request the disclosure to the county office any information concerning the age, residence, citizenship, employment, income, and any additional information involving eligibility for the mortgage and utility assistance programs for myself. It is understood that the information obtained will only be used for determination of mortgage/utility assistance or other housing assistance programs.
Applicant Signature

Clear
Date

MonthDayYear
Date
Printed Name

First NameLast Name
Should be Empty:

Application for COVID-19 Mortgage Assistance

Income Eligibility

Mortgage Holder Information

Household Income

Rights and Responsibilities

Document Upload

Income Documentation

Attestation/Certification

Authorization for Release of Information (tenant only)