Town of Southampton Housing Authority

Town of Southampton Housing Authority

Community Home Improvement Program Application

Applicant:Co-Applicant:

Name: ______Name: ______

Home Address: ______Home Address: ______

Telephone #: ______Telephone #: ______

Current Employment Current Employment

Name of Employer: ______Name of Employer:______

Employer Address: ______Employer Address: ______

Occupation: ______Occupation: ______

Gross Monthly Income: $ ______Gross Monthly Income: $______

If Applicable, please state monthlyincome for the If Applicable, please state monthly income for the

following: following:

Benefits/Pension:$______Benefits/Pension$______

Public Assistance:$______Public Assistance$______

Social Security:$______Social Security:$______

SSI:$______SSI:$______

Disability:$______Disability:$______

LIST ALL HOUSEHOLD MEMBERS*

Names Relationship to Date of Birth Monthly Income

Applicant/Co-Applicant

______

Total Number of Individuals (Family Members) in the Household: ______

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Town of Southampton Housing Authority

Community Home Improvement Program Application

Additional Household Member:

Name: ______

Home Address: ______

Telephone#: ______

Current Employment

Name of Employer: ______

Employer Address: ______

Occupation: ______

Gross Monthly Income: $ ______

If Applicable, please state monthlyincome for the following:

Benefits/Pension:$______

Public Assistance:$______

Social Security:$______

SSI:$______

Disability:$______

INFORMATION FOR HUD MONITORING PURPOSES

The question is being asked for statistical purposes to comply with equal opportunity requirements and to assure that no discrimination occurs. Your answer will not affect, in any way, your selection for the program. If you do not wish to furnish the below information, please check the box below. We must review the below material to assure that the disclosure satisfies all requirements of HUD.

Borrower______I do not wish to furnish this information Co-Borrower ______I do not wish to furnish this information

Ethnicity Hispanic or Latino Y____ N____ Ethnicity Hispanic or Latino Y____ N____

Race/Nationality ____White Race/Nationality ____White

____ Black/African American ____Black/African American

____ Asian ____Asian

____ American Indian/Alaskan Native ____American Indian/Alaskan Native ____ Native Hawaiian/Other Pacific Islander ____Native Hawaiian/Other Pacific Islander

____ Asian & White ____Asian & White

____ Black/African American & White ____Black/African American & White

____ American Indian/Alaskan Native ____American Indian/Alaskan Native

& Black African American & Black African American

____ Other Multi-Racial ____Other Multi-Racial

____ American Indian/Alaskan Native & White ____American Indian/Alaskan Native & White

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Town of Southampton Housing Authority

Community Home Improvement Program Application

Current Value of Home: ______

Date You Purchased Your Home:______

Age of House: ______

Number of Bedrooms: ______

Number of Bathrooms: ______

Do You Currently Have Another Home Improvement Loan Application Pending?______

Do You Rent Any Part Of This Home?______If Yes, To Whom?______

Do You Have a Town or Village Permit? ______

Is Anyone In Your Household Handicapped? ______

(If Yes, Please Provide Name of Household Member and Describe Disability)

______

Have You Received Assistance From This Program Prior to This Application? ______

I am aware that the benefits available under this program are for Resident Property Owners Only

andI consent to the inspection of my house by authorized personnel of the program for the purpose

of itemizing the Rehabilitation work for which I am applying which includes a lead inspection.

I also certify, under the penalties and provisions of U.S.C. Title XY 1001, and any other applicable laws, that the information submitted has been examined and approved and is true, correct, and complete.

I also understand that apart from the penalties and provisions of U.S.C. Title XVIII, Section 1001,

and any other applicable laws, falsification of any item in this application may result in the following:

FORFEITURE OF ALL REHABILITATION FUNDS FROM THE TOWN OF SOUTHAMPTON

______

APPLICANT’S SIGNATURE DATE

______

CO-APPLICANT’S SIGNATURE DATE

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Town of Southampton Housing Authority

Community Home Improvement Program Application

PLEASE LIST BELOW THE ITEMS REQUIRED TO REPAIR YOUR HOME AND BRING IT UP TO CODE

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Town of Southampton Housing Authority

Community Home Improvement Program Application

DISCLAIMER

CREDIT STATEMENT AGREEMENT

I/We authorize the release of financial information on my/our behalf in relation to an application and the financing made available to me/us. This authorization includes the release to the Town of Southampton

Housing Authority (TSHA) by any lender, to which I/we have applied for a mortgage, of all financial information and documentation relating to my/our application.

I/We understand that providing false information may disqualify me/us for consideration in this program.

If any of this information changes prior to a signed contract, it is my/our responsibility to notify the Town

of Southampton Housing Authority so that an updated determination can be made on my/our status.

I/We understand that after review of my financial status, TSHA may determine that I/we do not qualify for

the home improvement program.

If anything changes with my/our income or status on our application, prior to the time of entering into

contract, I/we must notify TSHA immediately as this may affect applicant’s ability to qualify for assistance

in this program. TSHA has the right to re-verify applicant’s program status up until a formal contract is signed.

Disclaimer: It is understood that this is not an offer and that the Town of Southampton may change the terms and conditions at any time. It is further understood that notices by the Town of Southampton may be made in such manner as the Town of Southampton may determine, including solely by advertisement.

MUST BE SIGNED BY APPLICANT AND CO-APPLICANT

I also understand that I may be required to supply/submit additional documentation to complete and substantiate my eligibility.

______

Applicant’s signature Co-Applicant’s signature

______

Date Date

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Town of Southampton Housing Authority

Applicant’s Certification & Authorization

To Whom It May Concern:

Authorization To Obtain A Credit Report

I/We have applied for housing services from the Town of Southampton Housing Authority.

As part of this process, the Town of Southampton Housing Authority is hereby authorized to obtain a credit report (s) from third party agencies in connection with the services provided, either during the process or as part of an ongoing service.

Authorization to Release Information

I/We have applied for housing services from the Town of Southampton Housing Authority.

As part of the process, the Town of Southampton Housing Authority is hereby authorized and permitted to verify any and all information contained in my/our application and in other documents submitted to the Town of Southampton Housing Authority required in connection with the service, either during the process or as part of an ongoing service.

I/We authorize you to provide the Town of Southampton Housing Authority and to any third party designated by the Town of Southampton Housing Authority any and all information and documentation that they may request, including but not limited to employment history and income; bank, money-market, and similar accounts balances, credit history, and copies of income tax returns.

A copy of this authorization may be accepted as an original.

______

(Signature) (Signature)

Date: ______Date: ______

Print Name: ______Print Name: ______

Address: ______Address: ______

______

Social Security # ______Social Security # ______

Date of Birth: ______Date of Birth: ______

______INFORMATION TO BE COMPLETED BY TSHA STAFF ONLY

Individual Credit Report ______Joint Credit Report ______

Requested and Authorized By: ______

TSHA Staff Name

Development/Program Name: ______Date: ______

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Town of Southampton Housing Authority

Community Home Improvement Program Application

CHECKLIST

REQUIRED DOCUMENTS FOR HOME IMPROVEMENT PROGRAM APPLICATION

Completed, Signed and Dated ApplicationYes Yes

If applicable, copies of SIGNED Federal Tax Returns, with

all required schedules and W-2 statements for the last three (3) years.

2013 Yes Yes

2012 Yes Yes

2011 Yes Yes

Completed and signed 4506 request for copy of tax return Yes Yes

If applicable, four (4) most recent consecutive pay stubs that

Indicate year-to-date gross income. If year-to-date is not

included on pay stub, please provide a letter from employer

on company stationery is required. Yes Yes

If applicable, documentation for current Social Security benefits,

child support, pensions, disability, unemployment, etc. Yes Yes

Credit Statement Agreement Yes Yes

If applicable, separation agreement or divorce decree Yes Yes

Copy of most current paid Tax Bill Yes Yes

Copy of Deed Yes Yes

Copy of Survey Yes Yes

Copy of Certificate of Occupancy/Certificate of Compliance Yes Yes

Copy of current Mortgage Statement of Satisfaction of Mortgage Yes Yes

Copy of current Homeowners Insurance Policy Paid to Date Yes Yes

This application will be used to determine eligibility for the Town of Southampton’s Home Improvement Program.

Questions about the application should be directed to:

Rebecca Downs, Housing Subsidy Coordinator

(631) 488-4220 Ext. 202

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INSTRUCTIONS FOR COMPLETING THE 4506 FORMS

The Town of Southampton Housing Authority (TSHA) has reserved the right

to request signed Federal Income Tax Returns as part of their Program Guidelines

for audit purposes regarding all household members whose earnings will be used

as part of the income qualification process. Any person whose earnings will be

used to qualify for the program guidelines “will” be required to sign a “4506”

tax release form to verify their tax returns with the Internal Revenue Service.

IRS FORM 4506

The 4506 form allows TSHA to obtain a complete copy of the applicants Federal

Income Tax Return directly from the IRS, if necessary, to verify what the applicant

state on the Federal Income Tax Returns submitted to TSHA.

DO NOT SEND IN THE $57.00 FEE. IF THE TSHA ELECTS TO UTILIZE

THE 4506 FORM, THE TSHA WILL PAY THE REQUIRED FEES FOR

EACH TAX RETURN REQUESTED.

PLEASE SIGN AND DATE THE 4506 FORM WHERE APPLICABLE.

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PRINT REQUEST FOR COPY OF TAX RETURN FORM 4506 TO GO WITH THIS APPLICATION