JEFFERSON COUNTY HOUSING AUTHORITY
7490 West 45th AvenueCOMPLETE BOTH SIDES OF ALL PAGESWheat Ridge, Colorado 80033Rehab Program Information: (303) 403-5423; Melody Fax: (720) 974-5808APPLICATION for SINGLE-FAMILY, HOMEOWNER HOUSING REHABILITATION PROGRAMDate received by JCHA:_ Application number: HOMEOWNER INFORMATION:NAMEDATA1.Applicant (Head of Household) : . (Last Name) (First) (Middle initial)Date of Birth: / / ; Male or FemaleSocial Security #: - - .PHONE--Home: Work or other phone ( 303 ) - ; ( ) - ; 2.Co-applicant (Spouse/co-owner of home): . (Last Name) (First) (Middle initial)Date of Birth: / / ; Male or FemaleSocial Security #: - - .PHONE--Home: Work or other phone:( 303 ) - ; ( ) - ; YOUR HOME:3.Address: , (Street) , CO , (City) (Zip Code)Email Address: ,4. Legal Description (Lot, Block, Subdivision, etc.) Important - We need the Legal Description to process your application. It may be found on your Title/Deed papers or your Property Tax statements (if lengthy, attach copy). If this is for a mobile home, please include description; including year built, size, and manufacturerOTHER MEMBERS OF YOUR HOUSEHOLD (Children, dependents, etc., who list your home as primary residence, other than applicant or co-applicant):5.NAMEDate of BirthRelationship to Head of Household & SS# , ________ (Last Name) (First) (Middle initial) / /____Relationship: ___________________Social Security #:______-_____-______ , ________ (Last Name) (First) (Middle initial) / /____Relationship: ___________________Social Security #:______-_____-______ , ________ (Last Name) (First) (Middle initial) / /____Relationship: ___________________Social Security #:______-_____-______(Use back of form or attach another page if needed)Household Information (Note: This information shall be kept confidential and shall be used for statistical reporting and not for the purpose of determining assistance.) 6. Which type of household best describes your situation?7. Race/Ethnicity -- The applicant is: Non-elderly: are under 62 years of age, no dependents Elderly: household with a person 62 years of age or older Related/Single Parent: 1 parent household with dependents under 18 Related/Two Parent: 2 parent household with dependents under 18 Disabled describe: Other than above, describe: White (non-Hispanic) origins of Europe, North Africa, or Middle East Black/African American (non- Hispanic) Native American Asian/Pacific, Islander Hispanic (all races)8.Is any member of your household disabled or has special needs that could require special construction? [ ]Yes or [ ] NoIf yes, please describe need:9.Please give the name of a relative, friend, neighbor, or case worker with whom you have regular contact: Name: Phone: .Property Information10.Type of dwelling:XSingle family house, detached PLEASE ENTER HOA FEES part of duplex, a townhouse, or condo, please indicate amount of HOA fees. $_______ manufactured (mobile) home, please indicate amount of space rent. $ .11.The house has: [ ] attached garage; [ ] detached garage; [ ] car port; or [ ] no garage[ ] full basement; [ ] partial basement; or [ ] no basement Number of bedrooms: ; Number of baths: ; Number of stories: . 12.Ownership data:I have lived in my home for yearsI purchased the home in (month) (year); purchase price: $ .The house was built in (year-approximately) I estimate the property is currently worth: $ .13.Mortgages/Loans on the house:My 1st mortgage is with:(name of lender): _____________________________________Address:________________________________________________________________ loan account #:________________________________ (or attach copy of your monthly statement)) Monthly payments (PITI.) are: $___________/mo.; The current balance owed on the 1st mortgage is approximately: $_______________I have a 2nd mortgage or other loan on the house with:(name of lender): _____________________________________Address:________________________________________________________________ loan account #:________________________________ (or attach copy of your monthly statement) Monthly payments (PITI) are: $___________/mo.; The current balance owed on the 2nd mortgage is approximately: $_______________Other loans or liens against the house:Monthly Utilities: $ . Property Tax:$ Property Insurance: $ (if not included in mortgage payment)14.Is there anyone on the title of the property who does not live there? Yes, or No. If Yes, please give name, explain: 15.Please give a brief description of the critical rehabilitation problems, health and safety repairs, or non-luxury improvements you need assistance with:This rehab work may include: Electrical to code, Plumbing to code New furnace/water heater, if needed Accessible work for the disabled-elderly Mitigation of lead-based paint hazards Well and septic systems Roof and gutters Foundation and site drainage work Insulation and energy saving work New doors and windows Flooring as needed Painting and wall repairs-interior Kitchen/bath/laundry upgrades, if needed Exterior painting or siding if necessary Paving of gravel drives Fencing, tree trimming or removal as neededRepairs needed: Household Income DataSource of IncomeName of HouseholdMember receiving the incomeIncome from:Name of Employer with contact phone #; or name of income source such as: Social Security. SSI, child support, etc.; or type of business if self-employedRate of Income$ per hour, or week, etc.Projected Annual Income(Current rate timesnext 12 months)16. Gross Income fromWages/Salaries(include overtime, bonuses, commissions, tips, etc. as reported to IRS) $ /year $ /year $ /yearAttach copies of recent pay stubs17. Periodic Payments/Benefits(Soc.Sec. SSI, OAP, pension, retirement, unemployment, workers’ comp., etc.) $ /year $ /year $ /yearAttach copies of benefits letter or bank statement if automatic deposits18. Other income(Welfare, alimony, child support, etc.) Or, if self-employed from your business $ /year $ /year $ /year19. Income from Assets(Interest or dividends from savings /bank accounts, CD’s, investments, or rental property owned)Give name of bank or financial institution and account #$ /year$ /year$ /yearPlease attach copies of recent bank statements from checking or savings accounts Total Annual Income:$_____________/year(sum of above income)20. Have you ever been obligated on a home loan that resulted in foreclosure? Yes or No Have you ever filed bankruptcy? Yes or No Has a financial judgment ever been entered against you in a court of law? Yes or No If you answered Yes to any of the above questions, please give specifics on a separate sheet.IMPORTANT - Read before signing: The Applicant/Co-Applicant(s) undersigned does hereby certify ownership and occupancy of the above property and is a legal resident of the State of Colorado and the United States of America and that all information above is true, accurate and complete; and does hereby authorize the Jefferson County Housing Authority to verify and make independent investigations to determine ownership, income and financial standing. The undersigned hereby releases the county, its employees, agents and any firm or person supplying them with information from any liability whatsoever concerning the release or use of the information and will hold them all harmless from any suit or reprisal whatsoever. All holders of any such information are hereby authorized to release any and all such information they may have concerning the undersigned.Applicant Signature:Co-Applicant Signature:__________________________Date____________ ___________________________Date:___________21. Please briefly describe how you heard of the Jefferson County Housing Rehab Program:22. Have you or anyone in your family ever been on any other programs with Jefferson County Housing: 7490 West 45th AvenueWheat Ridge, Colorado 80033 (303) 403-5423; Melody; Fax: (720) 974-5805Rehab Program Information:AFFIDAVIT(An Affidavit is required for each adult residing in the home)I, , swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one):[ ]I am a United States citizen, or[ ]I am a Permanent Resident of the United States, or[ ]I am lawfully present in the United States pursuant to Federal Law.I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statue 18-8-503 and it shall constitute a separate criminal offence each time a public benefit is fraudulently received.SIGNATUREDATEPlease submit copy of one of the following (not expired) valid forms of identification:[ ] Colorado driver’s license or identification card [ ] United State military identification or dependent’s identification card. [ ] United States Coast Guard Merchant Mariner card [ ] Native American Tribal document [ ] United States PassportVerified by Jefferson County Housing Authority Employee:SIGNATURE:Of Jefferson County Housing Authority Employee not clientDATE ................
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