Fillable CDBG-CV MORTGAGE ASSISTANCE PROGRAM DOCUMENTS

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CDBG-CV MORTGAGE ASSISTANCE PROGRAM DOCUMENTS

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1
CDBG-CV MORTGAGE ASSISTANCE PROGRAM DOCUMENTS
To properly process your application please be sure to include the following (please do not submit original documents):
Completed application signed by all persons in household over the age of 18
Self-Certification Forms for all persons over the age of 18 in the household
Driver’s licenses or State Issued Identification Cards for all occupants over the age of 18
Social Security Cards for persons under the age of 18
If not a US citizen, proof of Permanent Resident Alien Status
W-9 completed by Mortgage Company/Servicer
Most Recent Mortgage Statement from Mortgage Company/Servicer
One utility bill showing applicant name and address at the location where the applicant is requesting assistance
(cable, water, electric)
Most recent three months bank statements for checking and savings accounts that belong to each household
member
If self-employed, 2019 and 2020 tax returns
2019 and 2020 W-2’s or 1099s
No
te: Additional information may be needed to determine eligibility once the information provided above is reviewed.
Application as processed on a first come, first ready basis meaning that COMPLETE applications with ALL required documents will
be processed prior to those which are missing documentation. Failure to complete a timely and COMPLETE application may result
in you not receiving funding.
2
CDBG-CV MORTGAGE ASSISTANCE APPLICATION INSTRUCTIONS
General Instructions
Read the instructions for this application.
This form is fillable. Please type,
or use BLUE or BLACK ink. Do not use pencil or other colors of ink. Please write legibly. All
blanks must be completed or have N/A written in. Applications that are incomplete or illegible will be returned.
All household members 18 years of age or older must sign and date the application.
Submit application with all the required documentation during the required application period
to:
Online:
www.capecoral.net or
housing@capecoral.net
By Mail:
PO Box 150027
Attn: Planning Division – Mortgage
Assistance
Cape Coral, FL 33915-0027
In Person:
Cape Coral City Hall
Zoning Counter
1015 Cultural Park Blvd.
Cape Coral, FL 33990
DUE TO THE COVID-19 PANDEMIC WE ENCOURAGE APPLICATIONS BE SUBMITTED ONLINE OR VIA MAIL
Applications will not be processed until the application period begins.
Itemized Instructions/Information
1. Applicant Information: Complete all information for the primary applicant including what type of assistance is being
requested.
2. Co-Applicant Information: Complete all information for the co- applicant including what type of assistance is being
requested.
3. Declarations: Complete by indicating Yes or No to each question. Be sure to answer follow-up questions, if applicable.
4. Property Information: Indicate that you provided each of the items listed.
5. Household Information: Provide the requested information for ALL members of the household.
6. Applicant’s Employment: Indicate if self-employed. Provide required employment information for the applicant.
7. Co-Applicant’s Employment: Indicate if self-employed. Provide required employment information for the co-applicant.
8. Household Income: Provide income information for all household members.
9. Household Assets: Provide the requested information on assets for all household members. Examples of what constitutes
an asset are as follows: cash in savings and checking accounts, stocks, bonds, CD’s, mutual funds, money market accounts,
IRA’s, 401k’s, investment properties, retirement, and pension funds, etc.
10. Eligibility: The information collected here is important to determine eligibility as it relates to emergency assistance.
3
11. COVID-19 Information: Provide basic information concerning eligibility related to the public health emergency with
respect to COVID-19. Provide information on whether you or a household member was directly affected by COVID-19.
12. Homeowner Information: This section provides information related to your mortgage. Please be sure to complete i
n
entirety.
13. Self-Certification Form: The Self-Certification form should be signed by all household members over the age of 18.
Additional forms can be found on the City of Cape Coral website.
14. Duplications of Benefit Form: Complete and sign the duplication of benefits form. This form should be signed by the
applicant and co-applicant. In this form you must provide information for any other COVID-19 related assistance
the household has received or anticipates. This includes LEE CARES, Cape Coral CRF Assistance, Lee County CRG
Assistance, etc.
15. Acknowledgments: Read and sign the Acknowledgment Form. This form should be signed by the applicant and co-
applicant
16. Social Security Number Notification: Read and sign the Social Security Number Notification Disclosure.
17. General Release Form: Read, complete, and sign the General Release Form. This should be signed by the applicant and
co-applicant.
18. Conflict of Interest Statement: Read and sign the conflict of interest statement. You must disclose if the applicant,
co-applicant, or any members of the household have relations to or business with an employee, agent, consultant,
officer, or elected or appointed official of the City of Cape Coral. If yes, please indicate the employee and the
relationship.
19. Public Records Disclosure: Read and sign this form informing that your information is subject to public records disclosure
per Florida Statutes.
20. W-9 Form for Mortgage Company: This form will need to be completed by your mortgage company or mortgage servicer.
4
CDBG-CV MORTGAGE ASSISTANCE PROGRAM APPLICATION
1. Applicant Information
APPLICANT NAME:
Home Phone: Cell Phone: Work Phone:
APPLICANT’S E-MAIL ADDRESS:
ADDRESS:
CITY: Cape Coral State: FL Zip Code:
I AM APPLYING FOR ASSISTANCE WITH THE FOLLOWING: Mortgage
2. Co-Applicant Information - Leave blank if N/A
CO-APPLICANT NAME:
Home Phone: Cell Phone: Work Phone:
APPLICANT’S E-MAIL ADDRESS:
ADDRESS:
CITY: Cape Coral State: FL Zip Code:
I AM APPLYING FOR ASSISTANCE WITH THE FOLLOWING: Mortgage
3. Declarations
YES
NO
Are you a US citizen or Permanent Resident Alien?
Have you or the Co-Applicant ever been awarded child support for any of your children,
regardless of whether received?
5
If yes, in what State or County was it awarded? __________________________________
Is applicant, co-applicant or any other household member over the age of 18 a full-time
student?
If so, who? _________________________________________________________
Is anyone in your household expecting a child?
Is anyone in your household handicapped or developmentally disabled?
4. Property Information
Note: Indicate that each of the following is being included with your application by checking each box.
Proof of Property Ownership (this may include the copy of one of the following items: warranty deed,
quitclaim deed, homestead exemption, tax records, life estate).
Proof that you are current in your property taxes to the city (this may include a copy of one of the following
items: property tax payment receipt from the city, cancelled check to the city for property taxes, affidavit
certifying payment of property taxes, mortgage statement from lenders indicating taxes were paid).
Proof of flood insurance if property is located in a Special Flood Hazard Area
5. Household Information – include ALL household members
Relationship to
Applicant
Name
Social Security
Number
Date of
Birth
Sex
Marital Status
M, S, W, D
Race*
Hispanic
Y/N
Applicant
Choose from:White (W) Black or African American (B) Asian (A) American Indian or Alaskan Native (I) Native Hawaiian or Other
Pacific Islander (H) American Indian/Alaska Native and White (I and W) Asian and White (A and W) Black/African American and White (B
and W) American Indian/Alaskan Native and Black/African American (I and B) Other Multi-Racial (O)
Total Number of Persons in Household:
Elderly:_____ Handicapped: _____ Farm Worker:______
Developmentally
Disabled: ________ Other:___________
Single Head of Household
Yes
No
6
6. Applicant’s Employment
ARE YOU SELF EMPLOYED?
Yes
No
EMPLOYER:
Phone:
Fax:
ADDRESS:
YEARS EMPLOYED:
POSITION
SUPERVISOR:
PREVIOUS EMPLOYER:
Phone:
Fax:
ADDRESS:
YEARS EMPLOYED:
POSITION
SUPERVISOR:
7. Co-Applicant’s Employment- leave blank if N/A
ARE YOU SELF EMPLOYED?
Yes No
EMPLOYER:
Phone:
Fax:
ADDRESS:
YEARS EMPLOYED:
POSITION
SUPERVISOR:
PREVIOUS EMPLOYER:
Phone:
Fax:
ADDRESS:
YEARS EMPLOYED:
POSITION
SUPERVISOR:
8. Annual Household Income
SOURCE
APPLICANT
CO-APPLICANT
OTHER
HOUSEHOLD
MEMBERS OVER 18
TOTAL
Gross Salary
Overtime, Tips,
Bonuses, etc.
Alimony/Child
Support
Social Security/SSI
Retirement/Pension
AFDC, Welfare
7
Interest/Dividends
Unemployment,
Workers Comp
Rental Net Income
Business Net
Income
Other
9. Assets
TYPE
INSITITUTION
OWNER
ACCOUNT #
CASH VALUE
Checking Account
$
Savings Account
$
Stocks, Bonds, CD’s
$
IRA’s, 401(k)
$
Equity in Properties
$
Life Insurance
$
Other
$
10. Eligibility Information
YES
NO
Were/Are you or a household member affected financially by COVID-19?
How many household members were/are affected financially by COVID-19?
11. COVID-19 Information – please provide the following for each affected member
First household member affected by COVID-19
Name:
Are they unemployed or underemployed due to COVID-19?
Yes
No
Date household member became unemployed or underemployed
8
Name of Employer when impacted by COVID-19:
Address of Employer when impacted by COVID-19:
What was the annual gross income of this household member prior to being affected by
COVID-19 or March 1, 2020 whichever is later?
What was the projected annual gross income of this household member after being
affected by COVID-19?
Is the person receiving unemployment benefits?
Yes
No
If yes, how much is being received weekly?
Provide additional information about hardship:
Additional household member affected by COVID-19
Name:
Are they employed or underemployed due to COVID-19?
Yes
No
Date household member became unemployed or underemployed
Name of Employer when impacted by COVID-19:
Address of Employer when impacted by COVID-19:
What was the annual gross income of this household member prior to being affected by
COVID-19 or March 1, 2020 whichever is later?
What was the projected annual gross income of this household member after being
affected by COVID-19?
Is the person receiving unemployment benefits?
Yes
No
If yes, how much is being received weekly?
Provide additional information about hardship:
9
12. Mortgage Information
Name of Lender/Mortgage Company:
Name of Contact Person:
Phone Number:
Email Address:
Address:
City:
State:
Zip:
Loan Number:
Monthly Mortgage Payment
Date of Last Full Payment:
How Many Mortgage Payments are past due?
Amount Due:
10
13. Mortgage Program Assistance Self-Certification Form
NAME:
Home Phone: Cell Phone: Work Phone:
APPLICANT’S E-MAIL ADDRESS:
ADDRESS:
CITY: Cape Coral State: FL Zip Code:
I hereby certify that I have been negatively impacted by the COVID-19 pandemic.
I am underemployed or unemployed.
Explain your COVID Related Hardship:
I will receive income from the following sources over the next 12 months: YES NO
Gross wages from employment (including commissions, tips, bonuses, fees, etc.)
$__
______________
Net income from operation of a business $________________
Rental income from real or personal property $________________
Pr
operty Value $ _________________
Cash value of all assets (checking, savings, CD, stocks, bonds) $ _________________
Interest or dividends from all assets $________________
Social Security payments, annuities, retirement funds, pensions, or death benefits
$________________
11
Unemployment Benefits $________________
Disability Payments $________________
Public Assistance Payments/TANF $________________
Periodic allowances such as alimony, child support, or gifts received from persons not living in my
household
$__
______________
Any other source of income not listed above $________________
I currently have no income of any kind and there is no imminent change expected in my financial
status or employment status during the next 12 months.
I certify my anticipated gross annual income for the next 12 months to be (Total of all income in
chart):
I will inform local government staff if my income changes during the period when I am receiving assistance.
Und
er penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my
knowledge. The undersigned further understand(s) that providing false representations herein constitutes an act of fraud.
False, misleading or incomplete information may result in the termination of a lease agreement. The information provided is
subject to verification by the county or eligible municipality.
_______
___________________________________________________________________________________
Signature of Applicant Printed Name of Applicant Date
Wi
tness___________________________________
Witness________________________________________
12
14. Duplication of Benefits – please provide information on any other type of COVID-19
related assistance the household has received
Did you or any other household members receive any other assistance
due to COVID-19 pandemic?
Yes
No
If yes, explain the type of assistance you received e.g. Red Cross, United Way, previous federal or state assistance (CRF, CDBG,
LEECARES, CDBG-DR, HOME), etc.
Amount Approved?
Amount Received to Date:
List agencies providing services:
I/We ___________________________________________ am aware that I can receive no other assistance for the same
purpose. I certify that I have not already received any mortgage assistance for this period of time, and am aware that if I receive
additional assistance in the future for the same purpose, I will be required to notify the City of Cape Coral immediately, and will
be responsible to reimburse the City of Cape Coral CDBG-CV program for any funding deemed to be duplicate.
I/We understand we will need to complete a duplication of benefits agreement prior to receiving assistance.
Applicant Signature: _______________________________________________ Date: ________________________________
Co-Applicant Signature_____________________________________________ Date:_________________________________
13
15. Acknowledgements
I ____
______________________________________________, hereby certify that I am a permanent resident of Lee County,
Florida.
I understand information provided by the myself in this application may be subject to Chapter 119, Florida Statutes, regarding
Open Records.
I understand that Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or
liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment
provided under Statutes 775.082 or 775.83. I further understand that any willful misstatement of information will be grounds for
disqualification. I certify that the application information provided is true and complete to the best of my knowledge. I consent
to the disclosure of information for the purpose of income verification related to making determination of my eligibility for
Mortgage assistance. I agree to provide any documentation needed to assist in determining eligibility and am aware that all
information and documents provided are a matter of public record and subject to public review in accordance with Florida’s public
record law, Chapter 119, Florida Statutes.
I understand that the information provided in this application form is subject to verification by HUD at any time, and Title 18,
Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent
statement to a department of the United States Government, and may be fined not more than $10,000 or imprisoned for not
more than five years, or both. This information will be used to establish a level of benefit for HUD and other Federally funded
program(s); To protect the government’s financial interest; and to verify the accuracy of information furnished. It may be
released to appropriate Federal, State, and Local Agencies when relevant to civil, criminal or regulatory investigators, and
prosecutors. Failure to provide any information may result in a delay or rejection of eligibility or approval.
Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true and that all additional
information submitted by me in connection with my Mortgage Assistance program is true and correct.
_______
______________________________________
Signature of Applicant Date
14
I __________________________________________________, hereby certify that I am a permanent resident of Lee County,
Florida, and my property is NOT the subject of a pending or threatened foreclosure, and no mortgage (or other encumbrance
creating a lien against the property) is in default.
I understand information provided by the myself in this application may be subject to Chapter 119, Florida Statutes, regarding
Open Records.
I understand that Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or
liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment
provided under Statutes 775.082 or 775.83. I further understand that any willful misstatement of information will be grounds for
disqualification. I certify that the application information provided is true and complete to the best of my knowledge. I consent
to the disclosure of information for the purpose of income verification related to making determination of my eligibility for
Mortgage assistance. I agree to provide any documentation needed to assist in determining eligibility and am aware that all
information and documents provided are a matter of public record and subject to public review in accordance with Florida’s public
record law, Chapter 119, Florida Statutes.
I understand that the information provided in this application form is subject to verification by HUD at any time, and Title 18,
Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent
statement to a department of the United States Government, and may be fined not more than $10,000 or imprisoned for not
more than five years, or both. This information will be used to establish a level of benefit for HUD and other Federally funded
program(s); To protect the government’s financial interest; and to verify the accuracy of information furnished. It may be
released to appropriate Federal, State, and Local Agencies when relevant to civil, criminal or regulatory investigators, and
prosecutors. Failure to provide any information may result in a delay or rejection of eligibility or approval.
Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true and that all additional
information submitted by me in connection with my Mortgage Assistance Program is true and correct.
_______
_____________________________________
Signature of Co-Applicant Date
15
16. NOTIFICATION REGARDING RETENTION OF
SOCIAL SECURITY NUMBERS
Th
e following disclosure is being made pursuant to Section 119.071 (5), Florida Statutes:
The City of Cape Coral government retains the social security numbers for all household members on record receiving housing
assistance for one or more of the following purposes:
• To comply with federal laws, specifically 24 Code of Federal Regulations, Part 5.126, requiring the City of Cape Coral and
its contractors to obtain social security numbers for all applicants for housing assistance;
• To verify citizenship or legal immigration status;
• To verify income through computer matching; and
• To ensure there is no duplication of assistance with other housing agencies.
Th
e City of Cape Coral is dedicated to ensuring the proper handling of confidential information relating to its clients and to
ensuring their privacy.
I/
We, the undersigned, acknowledge that I/We received a copy of this disclosure statement for my/our personal records.
_______
____________________________________________________________
Signature of Homeowner/Resident Date
___________________________________________________________________
Signature of Homeowner/Resident Date
___________________________________________________________________
Adult Member Date
___________________________________________________________________
Adult Member Date
16
17. GENERAL RELEASE FORM
I/w
e_________________________________________________________, hereby authorize the City of Cape Coral or its
designated agents to obtain and receive all records and information pertaining to my (our) homeownership, employment, income
(including IRS returns), credit residency, and banking information from all persons, companies, or firms holding or having access
to such information. This authorization hereby gives the City of Cape Coral the right to request all information that we can or could
obtain from any persons, company, or firm on any matter referred to above. I/we agree to have no claim for defamation, violation
of privacy, or otherwise against any person or firm or corporation by reason of any statement or information released by them to
the City of Cape Coral for purposes of the program. In addition, I authorize the City to pass on a copy of my credit report to the
lending institution I use for pre-qualification. The term of this authorization shall commence on the date of signature and be in
force for a period of one (1) year.
_______
____________________________________________________________ _____________________________
Signature of Homeowner/Resident Date Witness
___________________________________________________________________ _____________________________
Signature of Homeowner/Resident Date Witness
___________________________________________________________________ ____________________________
Adult Member Date Witness
___________________________________________________________________ ____________________________
Adult Member Date Witness
17
18. CONFLICT OF INTEREST STATEMENT FOR HUD ASSISTED PROGRAMS
Th
e following conflict of interest statement applies to both HUD assisted and City of Cape Coral SHIP programs.
Per U.S. Department of Housing and Urban Development (HUD) regulations 24 CFR §92.356 and 24 CFR §570.611, no employee,
agent, consultant, officer, or elected or appointed official of the recipient, or of any designated public agencies, or of subrecipients
having any functions or responsibilities related to activities assisted with Community Development Block Grant (CDBG), HOME
Investment Partnership Program (HOME) or Neighborhood Stabilization Program (NSP) funds may benefit from an assisted
activity. For purposes of the City of Cape Coral, this requirement also extends to immediate family members of individuals defined
above. Exceptions may be granted on a case by case basis by HUD upon written request of the recipient and after certain
disclosures are made public. Any conflicts noted will be investigated and resolved in accordance with HUD regulations.
_______I hereby certify that I do not have (nor does anyone in my immediate family have) any relations to or business
with any employee, agent, consultant, officer, or elected or appointed official of the City of Cape Coral or the organization
which is providing the assistance I am receiving.
_______I hereby certify that I do (or someone in my immediate family does) have relations to or business with an
employee, agent, consultant, officer, or elected or appointed official of the City of Cape Coral or the organization which is
providing the assistance I am receiving. Please list the name(s) of the person(s) involved in the potential conflict of interest
and please state the nature of your relationship and/or business interest with the person(s).
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Further information will be required, and a separate meeting will be set up to discuss the disclosure of any potential conflicts of
interest.
Ap
plicant's Name (please print or type): ___________________________________________________________________
Co-A
pplicant's Name (please print or type): _________________________________________________________________
Ap
plicant's Signature ______________________________________________________ Date _____________________
Co-A
pplicant's Signature ___________________________________________________ Date_______________________
18
19. PUBLIC RECORDS DISCLOSURE AND ACKNOWLEDGEMENT
Information provided by the applicant(s) may be subject to Chapter 119, Florida Statutes, regarding Open Records.
Information provided by you/your household that is not protected by Florida Statutes can be requested by any individual for their
review and/or use. This is without regard as to whether or not you qualify for funding under the program(s) for which you are
applying. Having been advised of this fact prior to finalizing the application for assistance or supplying any information, your
signature below indicates that:
I/We agree to hold harmless and indemnify the City/County, any governmental agency, its officers, employees, stockholders,
agents, successors and assigns from any and all liability and costs that may arise due to compliance with the provisions of Chapter
119, Florida Statutes.
I/We agree that the City/County does not have any duty or obligation to assert any defense, exception, or exemption to prevent
any or all information given to the City/County in connection with this application, or obtained by them in connection with this
application, from being disclosed pursuant to a public records law request.
I/We agree that the City/County does not have any obligation or duty to provide me/us with notice that a public records law
request has been made.
I/We agree to hold harmless the City /County or any governmental agency, its officers, employees, stockholders, agents,
successors and assigns from any and all liability that may arise due to my/our applying for assistance.
Applicant's Name (please print or type): ___________________________________________________________________
Co-Applicant's Name (please print or type): _________________________________________________________________
Applicant's Signature ______________________________________________________ Date _____________________
Co-Applicant's Signature ___________________________________________________ Date_______________________
19
20. W-9 – to be completed by Mortgage Company/Servicer
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CDBG-CV MORTGAGE ASSISTANCE PROGRAM DOCUMENTS

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Completed 22 March 2021

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