Homes and Community Renewal



New York State

Housing Trust Fund Corporation

RESTORE Program

(Residential Emergency Services To Offer home Repairs to the Elderly)

RESTORE Project Detail Sheet

|Complete and submit this form within 7 days of project completion to: |

|Access-RESTORE@ |

|SHARS ID:       |LPA:       |

|Project ID:       |Term of Contract:       |

|(assigned by LPA) | |

| |Amount of Contract:       |

|Person completing this form:       |

|Title:       |Phone:    -   -     |

| |

|Recipient Data: |

|Owner’s Name: |Date of Birth: |Age: |Sex: |

|      |      |    | |

|Owner’s Name: |Date of Birth: |Age: |Sex: |

|      |      |    | |

|Home Owners Phone Number:    -   -     |

| |

|Physical Location of Building: |

|Note: this must be the physical location of building, not mailing address since it is used in mapping. |

|Street # |Street Name |City/Town/Village |County |Zip Code |

|      |      |      |      |      |

| | Incorporated Village:       |

| | Unincorporated Village, Hamlet or Place:       |

| |

|Parcel Identification: |

| |Section: |Block: |Lot: |Sub Lot: |

|Standard S/B/L: |      |      |      |      |

|NYC B/L: | |      |      |      |

|Non-Standard: |Other Parcel ID or Tax Parcel ID:       |

|Type: |# of Units: |# Living in the home: |

|Type of referral: |Other Type Specifics:       |

| |

|Referrals (if applicable): |

|Was client referred to other programs for non-RESTORE services, programs, grants, etc.? |

|Agency/Program Referred to: |Services Requested: |

|      |      |

|      |      |

OCR use only:

Received: Site Specific Certification & Appendix A:

Photos: Front Elevation View Before After

Contractor Invoices: PMD Receipt:

|Demographics: Percent of Median Income: |

|Annual Income: $      Is there a person with a disability living in this unit? |

| |

|Repair Detail: |

|Assessment made by:       |      |

|Name |Title |

|Date of Emergency Referral:       |Date of Assessment:      |

| |Must be within 72 hours of referral |

|Date Repairs Began:       |Date of Completion:       |

|Must start within 7 days after assessment |Must be completed within 30 from start date |

| |

|Nature of the Emergency: State the problem(s), how it endangers the life, health or safety of the elderly homeowner, and the type of repairs needed. |

|      |

| |

|Contractor Information: |M/WBE |

|Please type the Name/Address/Zip/Phone all on the same line: | |

|      | |

|      | |

|      | |

|Description of Repairs Completed: |

|      |

| |

|Repair Financing: List the names of all sources of funds and the dollar amounts needed to complete the repair(s). List RESTORE funds first and use only |

|whole dollar amounts. |

|RESTORE Project Costs: |$      |

|* RESTORE Delivery Costs: |$      |

|Total RESTORE Funds Used: |$      |

|Other sources (leveraged funds): |

|      |$      |

|      |$      |

|      |$      |

|Total Project Costs: |$      |

|(Total RESTORE funds + other sources) | |

|*Program Delivery Description:       |

| |

|Previous RESTORE Funding: Has building received previous RESTORE funding? If Yes, previous RESTORE amount: $      (The maximum lifetime |

|RESTORE funding per building is $5,000) |

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