Applicant Affidavit and Certification for ADU Grant
Last revised: 05-24-2022
Applicant Affidavit and Certification for CalHFA Accessory Dwelling Unit Grant
I, _________________________________________________, and I, ____________________________________________________,
and I, ________________________________________________, and I, __________________________________________________
(each, an “Applicant”), having applied for a grant to construct an accessory dwelling unit (“ADU”) on the below property (“Property”) with funds
made available by the California Housing Finance Agency (“CalHFA”) pursuant to its ADU Grant Program (“Program”)under the terms and
conditions of the Program, do hereby represent and warrant as follows:
Property Address
Street:
City: County: Zip:
Statement of Citizenship, Alienage and Immigration Status for State Public Benefits
Applicant certifies that I am either: (1) A citizen or other National of the United States, or (2) A “Qualified Alien” as defined at 8 U.S.C §
1641.
Owner Occupancy
Applicant certifies that I occupy the above Property as my primary residence.
ADU Zoning and Building Codes
Applicant certifies that the ADU will meet all local zoning ordinances and building codes for use of the Property.
Acknowledgement of Tax Form 1099-G
Applicant acknowledges that I may be receiving an IRS income tax form 1099-G which reflects the receipt of benefits from the CalHFA
ADU Grant Program. Applicant also acknowledges that this may have income tax consequences and are advised to consult with a tax
professional.
Applicant Certification
I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
FOREGOING IS TRUE AND CORRECT. I AGREE THAT THE AGENCY (I.E., CALHFA)
TO WHICH I AM APPLYING MAY,
DIRECTLY OR THROUGH ITS CONTRACTORS, AGENTS, GRANTEES OR DESIGNEES, TAKE SUCH ACTIONS AS IT DEEMS
NECESSARY TO VERIFY THE ACCURACY OF THIS CERTIFICATION. I FU
RTHER UNDERSTAND AND AGREE THAT ANY
PERSON OR ENTITY CONTACTED BY THE AGENCY AND/OR ITS CONTRACTORS, AGENTS, GRANTEES OR DESIGNEES, IN
THE COURSE OF SUCH VERIFICATION, MAY RELEASE SUCH PERTINENT INFORMATION TO THE AGENCY AND/OR ITS
CONTRACTORS, AGENTS, GRANTEES OR DESIGNEES.
________________
______________________ ___________ ______________________________________ ___________
Signature Date Signature Date
________________
______________________ ___________ ______________________________________ ___________
Signature Date Signature Date
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