APPLICATION DEPOSITORY:
City of ChicagoDepartment of Housing and Economic Development
121 N. LaSalle Room 1006 Chicago, IL 60602
Attn: Annie Coakley
PH 312-744-8280 Fax 312-742-8549
E-mail:
INSTRUCTIONS: Complete the following application and attach photos of current façade conditions. Applications must be received by 4pm CSTFriday June 3, 2011.
PROJECT LOCATION
Street Address,City, StateZip
To check if this property is in a CDBG-eligible area, contact Annie Coakley, City of Chicago at 312-744-8280 or
Is this location in a CDBG-eligible low to moderate income community? Answer YES or NO here:
NOTE: If “NO” this project does not qualify for the 2011 Façade Rebate Program.
APPLICANT INFORMATION
Name of Applicant Applicant is a (select one): Business Organization Property Owner
Applicant Street Address, City, State,Zip
Applicant FEIN or Social Security Number (used for vetting applicant for City indebtedness)
Contact Person, Daytime Phone, E-Mail
Complete/attach the following documents:Economic Disclosure Statement and Personal Financial Statement (PDF files); business applicants must also submit their tax returns for the previous 3 years.
Provide the current number of full-time and part-time employees:
Provide the projected number of retained full-time and part-time employees after the Façade Rebate Program project completion:
Provide the projected number of created full-time and part-time employees after the Façade Rebate Program project completion:
Property Owner information (if Applicant is not the Property Owner)
Name
Street Address,City, StateZip
Contact Person,Daytime Phone,E-Mail
Tenant information (use additional sheet, if necessary)
Business Name Owner’s Name Type of business Activity
Project Description: THIS SECTION MUST BE FILLED OUT BY ALL APPLICANTS
Describe proposed improvements to the building façade (use additional sheet, if necessary). If the façade improvements are part of a larger building project, specify what portion is façade work compared to the non-façade work.
Has the Applicant or Property Owner or anyone with an ownership interest in either the Applicant or the Property Owner, received a rebate through the program before? (circle one) YES NO
If yes, list the property location(s), rebate amount(s), and date(s).
Property Location(s) Rebate Amount(s) Date(s)
Has the Applicant or Property Owner or anyone with an ownership interest in either the Applicant or the Property Owner received assistance or are they now under consideration for assistance from other Department of Housing and Economic Development (HED) or City programs? (circle one) YES NO
If yes, list the program(s), amount(s), and date(s).
Program(s) Amount(s) Date(s)
Is any individual with an ownership interest in the Applicant or Property Owner, or any spouse of any such individual, currently employed by the City of Chicago?Answer YES or NO here:
If yes, list the individual(s).
Does the Applicant or Property Owner, or any individual with an ownership interest in the Applicant or Property Owner, have any contracts or business with the City of Chicago? Answer YES or NO here:
If yes, provide an explanation:
State of Illinois )
)SS
County of Cook )
AFFIDAVIT AND CERTIFICATION OF PROPERTY OWNER
- LESSEES ONLY-
To induce the City of Chicago to make, and in consideration of the making of a grant to
("Grantee"), (the “Affiant”) the undersigned owner of the Property to be improved by Grantee does hereby state and certify to the City of Chicago ("Grantor") the following:
- Affiant is the owner of the building and property located at in Chicago, Illinois (the "Property") with the PIN (insert PIN # here): .
- Affiant currently leases to Grantee the Property or that portion of the Property to be improved by Grantee, the term of Grantee's current lease to the Property is scheduled to end on 20, and a copy of said lease is attached to the Façade Rebate Application.
- Affiant has reviewed the improvements to the Property proposed by Grantee.
- Affiant approves and gives the Grantee authority to implement the improvements described below on the Property under the City of Chicago Façade Rebate Program.
Description of the Owner-Approved Improvements (or attach hereto)
- Affiant certifies that it has not contributed and will not contribute funds to pay for or reimburse the Grantee’s proposed improvement to the Property.
The Affiant does hereby acknowledge that this Affidavit is made for the purpose of inducing the Grantor to advance the proceeds of a grant to the Grantee in conjunction with the Façade Rebate Program.
Dated this day of , 2011.
AFFIANT
______
Signature
Printed Name and Capacity, if applicable
bank/trust number
The undersigned, a notary public in and for said County, in the State aforesaid, does hereby certify that ______, personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person and severally acknowledged that he signed and delivered the said instrument as his free and voluntary act for the uses and purposes therein set forth.
(NOTARIAL SEAL)
Notary Public: ______
My commission expires: ______
CITY OF CHICAGO DEPARTMENT OF REVENUE
STATE OF ILLINOIS
COUNTY OF COOK
AFFIDAVIT
The undersigned Applicant, having been duly sworn on oath or affirmation hereby states that to the best of my knowledge:
The Applicant or any individual with an ownership interest in the Applicant, owes no debt to the City of Chicago, and has no outstanding parking violation complaints issued to any vehicle owned by the applicant.
The Applicant or any individual with an ownership interest in the Applicant has listed herein all debts owed by the applicant to the City of Chicago, and all outstanding parking violation complaints issued to any vehicle owned by the applicant.
Description of Debt Date of Occurrence Amount
Total $
The undersigned Applicant understands that failure to disclose any debt owed to the City, or any outstanding parking violation complaint may be grounds for the imposition of applicable penalties, or the termination of the privileges sought in connection with this affidavit, in accordance with the procedures set forth in the Municipal Code of Chicago.
Applicant Name (please print)Applicant Signature
MailingAddressCity, State Zip
Business Name
BusinessMailingAddressCity, State Zip
Subscribed and sworn to before me this _____ day of ______, 20_____
Notary ______My commission expires ______
City of Chicago 2011 CDBG Façade Rebate Program Application Page 1 of 5