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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