NORTH LAUDERDALE COMMUNITY DEVELOPMENT DEPARTMENT

CITY OF NORTH LAUDERDALE

701 SW 71^st Avenue

North Lauderdale, Florida 33068

Home Rehabilitation Program

APPLICATION FOR ASSISTANCE DATE: ____________________

*Information contained herein shall be kept confidential and shall be used only for the purpose of determining eligibility in the Home Rehabilitation Program. All information supplied will be verified at a later date through supporting documentation, including income tax returns and bank statements. PLEASE PRINT CLEARLY.

IMPORTANT: IF YOU DO NOT OWN AND LIVE ON THIS PROPERTY AS YOUR PRIMARY ADDRESS, YOU ARE NOT ELIGIBLE FOR THIS PROGRAM.

THE APPLICANT IS THE PERSON WHO OWNS THE HOUSE AND IS RESPONSIBLE FOR THE MORTGAGE PAYMENT. IF YOU OWN THE HOUSE WITH SOMEONE ELSE, CO-APPLICANT INFORMATION MUST BE PROVIDED.

-------------------------------------

PERSONAL INFORMATION

APPLICANT	CO-APPLICANT
NAME: ________________________________	NAME: ________________________________
DATE OF BIRTH:________________________	DATE OF BIRTH: ________________________
SOCIAL SECURITY NUMBER: _______________________________________	SOCIAL SECURITY NUMBER: _______________________________________
ADDRESS:______________________________ _______________________________________ _______________________________________	ADDRESS:______________________________ _______________________________________ _______________________________________
PHONE (HOME):_________________________	PHONE (HOME):_________________________
PHONE (WORK):_________________________	PHONE (WORK):_________________________

My house is a (Please check one:

Single Family Home: ( ) Townhome: ( ) Condominium: ( ) Villa: ( )

Are there other parties on Deed? Yes ( ) No ( )

Name_________________________________________________

Relationship____________________________________________

Are real estate taxes current? Yes ( ) No ( ) Most recent year paid ?_____________________

Is the first mortgage current? Yes ( ) No ( ) Most recent month paid?___________________

Is there a second mortgage? Yes ( ) No ( ) If yes, most recent month paid?_____________

Are all utilities current? Yes ( ) No ( ) If no, what utilities are not current?

__________________________________________________________________________________

APPLICANT	CO-APPLICANT
MARITAL STATUS:	MARITAL STATUS:
Married ( ) Single ( ) Divorced ( )	Married ( ) Single ( ) Divorced ( )
Widower ( ) Separated ( )	Widower ( ) Separated ( )
Relationship to Co Applicant_______________	Relationship to Co Applicant_______________
Race___________________________________	Race___________________________________
US Citizen? Yes ____ No____	US Citizen? Yes ____ No____
If no, Alien Registration # _________________	If no, Alien Registration # _________________

LIST DEPENDENTS OR MEMBERS OF HOUSEHOLD WHO WILL RESIDE IN PROPERTY WITH YOU AND CO-APPLICANT:

Full Name Relationship Age S.S.# Occupation

1.________________________________________________________________________________

2.________________________________________________________________________________

3.________________________________________________________________________________

4.________________________________________________________________________________

5.________________________________________________________________________________

6.________________________________________________________________________________

FINANCIAL INFORMATION

Note: Be sure to include ALL SOURCES OF INCOME RECEIVED within the last 24 months.

APPLICANT	CO-APPLICANT
EMPLOYER NAME: _______________________ _______________________________________	EMPLOYER NAME: _______________________ _______________________________________
EMPLOYER ADDRESS:_____________________ _______________________________________ _______________________________________	EMPLOYER ADDRESS:_____________________ _______________________________________ _______________________________________

POSITION HELD:_________________________	POSITION HELD:_________________________
LENGTH OF EMPLOYMENT:_________________	LENGTH OF EMPLOYMENT:_________________
GROSS MONTHLY SALARY:_________________	GROSS MONTHLY SALARY:_________________

PREVIOUS EMPLOYER’S NAME & ADDRESS: ________________________________________ ________________________________________ ________________________________________	PREVIOUS EMPLOYER’S NAME & ADDRESS: ________________________________________ ________________________________________ ________________________________________

POSITION HELD:_________________________	POSITION HELD:_________________________
LENGTH OF EMPLOYMENT:_________________	LENGTH OF EMPLOYMENT:_________________
GROSS MONTHLY SALARY:_________________	GROSS MONTHLY SALARY:_________________

LIST ANY OTHER HOUSEHOLD INCOME (If any, include Child Support, Alimony, Interest, Dividends)

NAME EMPLOYER/SOURCE GROSS MONTHLY INCOME

1.________________________________________________________________________________

2.________________________________________________________________________________

3.________________________________________________________________________________

4.________________________________________________________________________________

OTHER INCOME NOT SHOWN ABOVE __________________________________________

(social security, child support, alimony, etc.) __________________________________________

__________________________________________

WHAT IS YOUR HOUSEHOLD’S TOTAL GROSS MONTHLY INCOME: $_____________

(Attach copy of latest Income Tax Returns.)

TOTAL ANNUAL INCOME $_________________

ASSETS

Checking or Savings Accounts

Bank Name Account No. Type Balance

____________________________ ________________ __________ _________

OUTSTANDING LOANS OR OTHER DEBTS (Including all charge cards):

Lender/Creditor Account No. Monthly Pmt Balance

____________________________ ________________ __________ _________

LIST ANY ADDITIONAL NAMES UNDER WHICH CREDIT HAS PREVIOUSLY BEEN RECEIVED:

APPLICANT:______________________

CO-APPLICANT:___________________

THESE QUESTIONS APPLY TO BOTH APPLICANT AND CO-APPLICANT. IF YOU ANSWER YES TO ANY OF THESE QUESTIONS, PLEASE EXPLAIN IN SPACE PROVIDED.

APPLICANT	YES	NO	CO-APPLICANT	YES	NO

Are there any outstanding judgments against you?	( )	( )	Are there any outstanding judgments against you?	( )	( )
Have you declared bankruptcy within the past seven years?	( )	( )	Have you declared bankruptcy within the past seven years?	( )	( )
Been party to a lawsuit?	( )	( )	Been party to a lawsuit?	( )	( )
Are you obligated to pay alimony, child support, or separate maintenance?	( )	( )	Are you obligated to pay alimony, child support, or separate maintenance?	( )	( )
Are you a co-maker or endorser on a note?	( )	( )	Are you a co-maker or endorser on a note?	( )	( )

EXPLAINATION:____________________________________________________________________________

_________________________________________________________________________________________

AGREEMENT

AFFIDAVIT AND RELEASE

The undersigned applies to participate in the Home Rehabilitation Program indicated in this application, which requires a loan to be secured as a second mortgage on the property received through this program. The undersigned further understands that he/she must own and live in the unit for a least a period of 5 years and the City of North Lauderdale is not responsible for any damage, and I the undersigned release and hold harmless the City from any and all liabilities to myself and personal property. The undersigned further understands that all statements made in this application are true and made for the purposes of participating in this Home Rehabilitation Program. The undersigned warrants that all income from every person in the household is accurately listed on this application. Verifications may be obtained from any source named in the application. The undersigned fully understands that it is a federal crime punishable by fine or imprisonment or both, to knowingly make any false statements concerning any of the above facts, as applicable under the provisions of Title 18, U.S. Code, Sections 1001 and 1014.

_________________________________________ ____________________

Applicant’ Signature Date

_________________________________________ ____________________

Co-Applicant’ Signature Date

-----------------------------------------------------------

AUTHORIZATION FORM REQUIRED BY FEDERAL PRIVACY ACT

IMPORTANT – APPLICANT(S) READ BEFORE SIGNING: Under the Privacy Act of 1974, it will be necessary for the Program/Lender to supply the appropriate agencies you listed on your Application with written approval from you to allow them to release information from your files to verify the information you provided on your application. Please sign the appropriate space below to authorize these verifications if required.

This authorizes the Program/Lender to have free access to my information and records relative to my employment, sources of other income, creditors and mortgage verifications as may be required to process my Home Rehabilitation Application.

____________________________________ ________________________ _______________

SIGNATURE OF APPLICANT SOCIAL SECURITY # DATE

____________________________________ ________________________ _______________

SIGNATURE OF CO-APPLICANT SOCIAL SECURITY # DATE

CITY OF NORTH LAUDERDALE

COMMUNITY DEVELOPMENT DEPARTMENT

_____________________________________________________________________

NOTE: This form must be filled out, witnessed and notarized in its entirety to be valid.

***WARNING**** Section 817.03, Florida Statutes, provides that willful false statements or misrepresentations concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and are punishable by fines and imprisonment as provided pursuant to Sections 775.082 and 775.083, Florida Statutes.

AFFIDAVIT OF ALTERNATIVE INCOME SOURCES

I_____________________________ do solemnly swear that I_____ do or____ do not receive ANY form of alternative income at the present time nor in the past 12 months other than which is reported on my application and this form. I understand that the term “alternative income applies to ANY form of funds that I may have received whether taxable or non-taxable.

______ My alternative income sources are as follows:

1. Source___________________________________ Amount__________

2. Source___________________________________ Amount__________

3. Source___________________________________ Amount__________

4. Source___________________________________ Amount__________

5. Source___________________________________ Amount__________

______ I do not receive, nor have received, in the past 12 months, ANY source of alternative income.

Applicant Name Printed_____________________________________________

Applicant Address Printed__________________________________________

Applicant Telephone Number: Home_______________ Work____________

Applicant Signature________________________________________________

Signed and sworn to before me this_____ day of __________, _______.

Notary

Date

APPLICANT AUTHORIZATION TO RELEASE INFORMATION

***IMPORTANT, READ BEFORE SIGNING***

FINANCIAL RECORDS RELEASE

_____________________________________________________________________

NOTE: This form must be filled out, witnessed and notarized in its entirety to be valid.

***WARNING*** Florida Statute 817 provides that willful false statements or misrepresentations concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first degree and are punishable by fines and imprisonment as provided pursuant to Sections 775.082 and 775.83, Florida Statutes.

I/We hereby grant permission and authorize any: bank, employer, insurance agency, lender, creditor and Governmental Agency to release information that is requested by the City of North Lauderdale or its authorized representative. I/We understand this information shall only be used to determine my financial status to qualify for a City of North Lauderdale sponsored program.

I/We understand this information is required to process the Home Rehabilitation Program application. Refusal to provide this form in a properly completed manner will be grounds for disqualification. I/We understand that incorrect or misleading statements of material fact shall be grounds for disqualification. I/We understand this form is only to be used for determining my status and in no way assures qualification. I/We agree to provide all requested information.

I/We certify that I/We have read the terms and conditions of this release. I/We fully understand and grant permission as requested. I/We understand this form will only be valid for 6 (six) months after the date of signing.

Applicant Name Printed_____________________________________________

Applicant Address Printed__________________________________________

Applicant Telephone Number: Home_______________ Work____________

Applicant Signature________________________________________________

Signed and acknowledged before me this_____ day of __________, _______.

Notary

Date

CITY OF NORTH LAUDERDALE

COMMUNITY DEVELOPMENT DEPARTMENT

________________________________________________________________________

NOTE: This form must be completed in its entirety to be valid.

Date__________________________

Address______________________

______________________________

Dear Employer,

We are currently verifying information regarding the below named individual. Please advise us as to this individual’s employment status and pay rate as requested below. Thank you for your assistance regarding this matter.

Applicant Name:__________________________	Person completing form:____________________
Applicant Position:_________________________	Title of person completing form:______________
Social Security Number:____________________	Company name:__________________________
Rate of Pay:______________________________	Telephone number:________________________
Frequency of Pay:_________________________	Fax number:_____________________________
Hours worked per week:____________________	Company Address:________________________ _______________________________________ _______________________________________ _______________________________________
Dates of employment:______________________
Income for last year:_______________________
Year to date income:_______________________
Overtime income:_________________________	Signature of representative:_________________

Thank you in advance for your cooperation in this matter. Should you have any questions, please call my office at (954) 724-7065. This form can be faxed to (954) 720-2064, Attention Community Development or mailed to the address below or returned with the employee.

City of North Lauderdale

Community Development Department

701 SW 71^st Avenue

North Lauderdale, FL 33068-2395

1	2	3	4	5	6	7	8
$42,850	$48,950	$55,100	$61,200	$66,100	$71,000	$75,900	$80,800

Household-Size Income Eligibility