HB-1-3550
CHECKLIST OF ITEMS TO ACCOMPANY
Attachment 12-E
Page 1 of 2
APPLICATION FOR HOME REPAIR LOAN OR GRANT FUNDS
Applicant Name: Phone: Cell:
Co-Applicant Name: Phone: Cell:
Applicant Email: Co-Applicant Email:
Preferred contact? Mail: Phone: Cell: Email:
Checktheboxesbelowwhencompleted
REQUIRED FORMS: Please submit the following documentation:
Form 410-4, “Uniform Residential Loan Application” complete, sign and date pages 5 & 8.
Form 3550-1 “Authorization to Release Information” for each adult household member.
Form 3550-4, “Employment & Asset Certification” for each adult household member.
INCOME:
Verification of all household income. To qualify for the program, a household’s adjusted
income must be within the established income limit based on size and location. Below are
some examples of income that may be applicable to all household members and what should
be provided to the Agency.
o
Copies of the last four week’s consecutive pay stubs.
o
Copies of recent benefit statements for regular unearned income (such as social
security, public assistance, retirement income, etc.).
o
Last 12 month payment history of alimony and/or child support received as provided
by the court appointed entity responsible for handling payments. If this is not
available, a copy of the separation agreement or divorce decree.
For each applicant, a complete copy of their last two signed and filed Federal Income Tax
Returns. IRS Form W-2, “Wage and Tax Statement,” and/or IRS Form 1099-MISC,
“Miscellaneous Income”, must be attached. For returns mailed to the IRS, provide a copy of
the signed document. For returns filed electronically, include a copy of the signature page
with the Self-Select PIN, confirmation that the return was accepted, or evidence that it was
filed by an authorized E-File provider.
For each applicant, a signed IRS Form 4506-T, Request for Transcript of Tax Return
https://www.irs.gov/pub/irs-pdf/f4506t.pdf
(01-23-03) SPECIAL PN
Revised (08-29-19) PN 527
HB-1-3550
Attachment 12-E
Page 2 of 2
For each non-retired applicant, a written explanation of employment history of less than two
years or employment gaps in excess of 30 days within the last two years.
ASSETS, CREDIT, OTHER DOCUMENTATION:
For each applicant, a copy of their two most recent asset/bank statements. (Note that if you
are obtaining this information through online banking, you should print your bank statement,
as opposed to printing the online transaction history.)
For each applicant, a written explanation for late payments, collections, judgments, or other
derogatory items in their credit history of which they may be aware. If applicants are unsure
what their credit history looks like, they can obtain a free credit report by calling 1-877-322-
8228 or logging into http://www.annualcreditreport.com. By law, individuals are entitled to
receive one free credit file disclosure every 12 months from each of the nationwide consumer
credit reporting companies – Equifax, Experian and TransUnion. This free report cannot
replace the credit report that the Agency will obtain to determine eligibility.
For each applicant, verification of their identity. A copy of a Government-issued photo
identification, evidence of date of birth (only required if not listed on the photo
identification).
For a household member who is a full-time student and 18 years of age or older, a copy of
their school transcript.
If applicable, provide written evidence of child care expenses for dependents 12 years of age
or younger.
If applicable, evidence of out of pocket annual medical expenses (for applicants 62 years of
age and older, or individuals with a disability) who wish to be considered for a deduction to
household income.
PROPERTY INFORMATION:
Evidence of Ownership: Copy of Deed, or other documentation.
Tax Statement: Most recent property tax assessment and annual statement, if applicable.
Insurance: Evidence of homeowner’s hazard or flood coverage, if applicable.
Repair Bid(s) including an itemized description of repairs, material, labor, and a copy of
Contractor’s license, if applicable.
Mortgage Statement: Most recent copy of mortgage statement, if applicable.
Photos of repair(s) and the front and back of property.
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