APPLICATION FOR HOUSING ASSISTANCE



Kentucky Mountain Housing Development Corporation, Inc.

PO BOX 729(113 Main Street(Manchester, KY 40962((606) 598-5128(Fax: (606) 598-8199

This is an equal opportunity program. Discrimination is prohibited by Federal Law.

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BORROWER’S INFORMATION

Name: Social Security #:

Date of Birth: Marital Status: ( Married ( Unmarried ( Separated

Current Address: ______________________________

Years at this address: Phone #: ( ) __________________

Employer: Employers Phone #: ( )

Employers Address: ________________________

How long at this job Monthly Income Position

List ALL Household Members:

| | |Full Time Student |Monthly Income |

|First, Middle, Last |Date of Birth |Y (YES) or N (NO) |Amount/Source |

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CREDIT INFORMATION

How would you rate your credit?

( Perfect- no late payments ever ( Not Great- lots of missed payments

( Very Good- a few late payments long ago ( Not Good- past due items or collections

( Good- a few late payments in last 2 years ( Bad- recent bankruptcy or unpaid judgment

Date of Discharge:

CO- BORROWER’S INFORMATION

Name: Social Security #:

Date of Birth: Marital Status: ( Married ( Unmarried ( Separated

Current Address: ______________________________

Years at this address: Phone #: ( ) __________________

Employer: Employers Phone #: ( )

Employers Address: ________________________

How long at this job Monthly Income Position

CREDIT INFORMATION

How would you rate your credit?

( Perfect- no late payments ever ( Not Great- lots of missed payments

( Very Good- a few late payments long ago ( Not Good- past due items or collections

( Good- a few late payments in last 2 years ( Bad- recent bankruptcy or unpaid judgment

Date of Discharge:

DEBTS

| | |INTEREST RATE |PRESENT |MONTHLY | |Co-Borrower |

|ITEM(S) OWED FOR |CREDITOR NAME | |BALANCE |PAYMENT |Borrower | |

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What type of service are you interested in?

( New Construction Do you own property? ( Inventory House

( Home Repair (Home must be built after 1978) ( Replace Existing House

If you are interested in a Home Repair please answer the following?

Subject Property Address:

Lienholder:

Balance:

Market Value:

Type of property: ( Single Family ( Mobile (KMHDC does not work on Mobile Homes)

What types of repairs are needed?

Do you work for K.M.H.D.C.? (Yes (No

Are you related to someone that does work for K.M.H.D.C.? (Yes (No

If so who:

Are you a Board Member for K.M.H.D.C. or related to someone that serves as a Board Member for K.M.H.D.C.? (Yes (No

If so who:

PLEASE NOTE!

CREDIT REPORT FEE: APPLICANT ONLY - $16.30 APPLICANT & CO-APPLICANT - $27.00

CHECK OR MONEY ORDER ONLY

KENTUCKY MOUNTAIN HOUSING DEVELOPMENT CORPORATION, INC.

THE FAIR HOUSING ACT/RIGHT OF APPEAL

Fair Housing/Non-Discrimination Policy

Housing is a basic human need. Having a home instills a sense of safety and security. Our mission at Kentucky Mountain Housing Development Corporation, Inc. (KMHDC) is to provide safe, quality, and affordable housing opportunities. KMHDC’s values guides our work, as we believe that everyone deserves to have a safe place to live and that everyone has a right to fair housing, free from discrimination. The Fair Housing Act was introduced as a component of the Civil Rights Act of 1968. The act provides equal opportunity to all who buy, sell, rent, finance or insure housing. In a nutshell, the act protects each individual’s basic right to choose where to live and ensures equal treatment after obtaining housing. The Fair Housing Act prohibits discrimination in housing based on race, color, national origin or ancestry, sex, religion, disability, familial status, age, sexual orientation, gender identity, marital status.

If you think you have been a victim of housing discrimination, please refer to KMHDC’S RIGHT OF APPEAL.

RIGHT OF APPEAL

For any service rendered by Kentucky Mountain Housing Development Corporation, Inc. (KMHDC), you have the right to appeal and/or express your dissatisfaction concerning denial, exclusion of a service, dissatisfaction with the service received, or failure to act upon a request for service with reasonable promptness.

If you are dissatisfied or feel you have been treated unfairly concerning services received, please submit a written request for a grievance hearing to KMHDC Executive Director, Bobby Wolfe. Once the request is received, a meeting will be scheduled with the Loan Officer/Counselor, Katie Smith, in an attempt to resolve the issue through an informal discussion. A summary of this meeting, including the Loan Officer/Counselor’s determination, will be mailed to you within three days of this meeting. If you do not agree with the Loan Officer/Counselor’s determination, you may request (written or verbal) a review with the Executive Director. This request must be received within five business days of receipt of the Loan Officer/Counselor’s notification of the outcome of the first hearing. This meeting will be scheduled within a reasonable time frame, usually between seven and fifteen days from the date of the request. You will then be notified in writing of the Executive Director’s decision, usually within ten business days of the latter hearing.

I certify by my signature below, that I have read and received a copy of this Fair Housing/Non-Discrimination Policy and Right of Appeal.

Borrower Printed Name Date

Borrower Printed Name Date

KENTUCKY MOUNTAIN HOUSING DEVELOPMENT CORPORATION, INC.

CONSENT AND AUTHORIZATION TO RELEASE FORM

I/we ______________________________________________________, the undersigned do hereby authorize all persons or companies in the categories listed below and any persons or companies I have indicated by application to release without liability, information regarding employment, public assistance income, or any requested information regarding assets or other types of income to Kentucky Mountain Housing Development Corporation P.O. Box 729 Manchester, Kentucky. I/We understand that this information is being sought for the purpose of determining our need under housing assistance guidelines.

INFORMATION COVERED

I/We understand that previous or current information regarding me/us may be needed. Verifications and inquiries that may be requested include, but are not limited to: personal identity; employment, income and assets; medical child care allowances and/or information regarding any source of public assistance income. I/we understand that this authorization cannot be used to obtain any information about me/us that is not pertinent to my/our eligibility for housing assistance. I/We further release any information from any individual or organization I/we have indicated by application to Kentucky Mountain Housing Development Corporation

GROUPS OR INDIVIDUALS THAT MAY BE ASKED

The groups or individuals that may be asked to release the above information include, but are not limited to:

Past and Present Employers Veteran’s Administration

State Unemployment Agencies Social Security Administration

Support and Alimony Providers Medical and Child Care Providers

Banks and Other Financial Institutions Welfare Agencies

Retirement Systems Other Public Assistance Agencies

Any Other Declared Source of Income

CONDITIONS

I/We agree that a photocopy of this authorization may be used for the purposes stated above. The original of this authorization is on file and will stay in effect for one year and one month from the date signed. I/We understand that I/we have a right to review this file and correct any information that is not correct; however, I/we understand that any correction must be verified with proper documentation.

SIGNATURES

Borrower Printed Name Date

Borrower Printed Name Date

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 A COPY OF TAX FORM” MUST BE PREPARED AND SIGNED SEPARATELY.

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INITIAL INTAKE FORM

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