CITY OF PORTAGE
RENTER-OCCUPIED REHABILITATION PROGRAM
For office use only:
APPLICATION NUMBER:
_________
DATE:
________________
ADDRESS (of property to be rehabilitated):
___________________________________
OWNER’S ADDRESS:
________________________________________________
TELEPHONE NUMBER:
________________________________________________
NUMBER OF APARTMENTS IN THE HOUSE:
Current:
____
Proposed:
_____
CURRENT OCCUPANCY:
Apartment 1
Apartment 2
Apartment 3
Apartment 4
Apartment #1
Apartment #2
Apartment #3
Apartment #4
Interior Common Areas
Exterior
**Only work that is considered essential and necessary will be permitted. All Lead
Based Paint Hazards will need to be corrected. Hazards will be determined upon an
initial project assessment of your home. The assessment will include your entire
home.
IMPROVEMENTS NEEDED (Check all that apply)
Roof
Insulation
Interior Walls
Exterior/Siding/Painting
Furnace
Water Heater
Plumbing
Foundation
Doors
Wiring/Electrical
Windows
Porch
Chimney Repair
Other (explain)
Apt #1
Apt #2
Apt #3
Apt #4
Monthly Rent
Utilities Included Yes/No
Number of People
Number of Bedrooms
Complete the information below for all rented units.
Apartment #1
Apartment #2
Name:
Name:
Mailing address:
Mailing address:
Home Phone #:
Home Phone #:
Cell Phone #:
Cell Phone #:
Email address:
Email address:
Apartment #3
Apartment #4
Name:
Name:
Mailing address:
Mailing address:
Home Phone #:
Home Phone #:
Cell Phone #:
Cell Phone #:
Email address:
Email address:
I have received a copy of the pamphlet “Protect Your Family From
Lead In Your Home” with this application.
YES_______ NO________ (please check one)
ARE YOU A U.S. CITIZEN OR A QUALIFIED ALIEN?
____YES _____NO (YOU MUST CHECK ONE)
LIST ALL DEBT AGAINST PROPERTY (For Example: Mortgages, Land Contract, Lines of
Credit, Judgments)
Name of Lender
Loan
Number
Original
Amount
Balance
Due
Term
(# of
years)
Interest
Rate
Type of Loan
(WHEDA, VA,
Land Contract,
Bank, etc.)
**If your home was purchased within the last 3 years, please attach a copy of your appraisal.
HOMEOWNERS INSURANCE
Name of Insurance Co.:
______________
Name of Agent:
__________________
Policy Number:
_________________
Expiration Date:
_________________
Phone Number of agent:
______________________
READ EACH ITEM BEFORE SIGNING THE APPLICATION. IF YOU DO NOT
UNDERSTAND, ASK FOR ASSISTANCE.
Read and initial statements below:
____ I understand the Housing Rehab funds are offered as a loan payable in monthly installment payments
or transfer of title of the property. The loan will be secured by a mortgage and/or promissory note
and there is no pre-payment penalty.
____ I understand the City of Portage will inspect the property to determine if the house meets Housing
Quality Standards determined by the Department of HUD. Based on the inspection, the City of
Portage reserves the right to deny funding.
____ I understand I must carry homeowner’s insurance on the property and keep the policy in force during
the life of the loan.
____I understand if I intentionally make statements or conceal any information in an attempt to obtain
assistance, it is in violation of federal and state laws that carry severe criminal and civil penalties.
____ Failure to comply with these conditions could result in the withdrawal of the City of Portage
participation or the recall of the full amount of the City of Portage loan plus interest.
____ I understand there is a $50 - $100 fee for a title search, a $30 fee to record your mortgage and $300 in
project review fees. These fees are included in the loan.
COUNTY RENTAL LOCATED UNIT IN? ________________________________
(You MUST complete)
Attach copies of the following:
_______
Full and complete description of the property as shown on your deed,
mortgage or land contract.
_______
Copy of your most recent mortgage statement showing your current principal
balance and showing you are current on your mortgage payments.
_______
A copy of your most recent property tax bill or a recent appraisal.
_______
Copy of your homeowner’s insurance policy.
Ins. Co.:
Name of Agent:
Policy #:
Phone # of agent:
APPEAL PROCESS
An applicant may appeal the decision of the CDBG Program Administrator by submitting, in
writing, a request for reconsideration and the reason for the request. If the Program
Administrator again determines the applicant to be ineligible, the City of Portage will hear the
appeal.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I certify that the above information is true and correct to the best of my knowledge. I authorize
the CDBG Program and its agents to contact any of the sources identified to confirm the above
information. I understand that, except as authorized in this paragraph, the CDBG Program will
keep all information contained in this application strictly confidential and will not release it to any
other party without my written permission.
No provision of marital property agreement (including a Statutory Individual Property
Agreement Pursuant to Sec. 766.587, Wis. Stats.), unilateral statement classifying income
from separate property under Sec. 766.59, or court decree under Sec. 766.70 adversely
affects the creditor unless the creditor is furnished with a copy of the document prior to
the credit transaction or has actual knowledge of its adverse provisions at the time of
obligation is incurred.
_________________________ Date: _________________________
(Signature of applicant)
_________________________ Date: _________________________
(Signature of applicant)
Return application to:
City of Portage
C/O Sue Koehn
CDBG Housing Program
201 Corporate Drive
Beaver Dam, WI 53916
Phone: 800-552-6330 Fax: 920-887-4250
Email: skoehn@msa-ps.com
CONFLICT OF INTEREST
Do you have any family or business ties to any of the following people? Yes____ No____
Rick Dodd, Mayor
Sue Koehn, Housing Program Specialist
Jean Mohr, Finance Director
Shawn Murphy, City Administrator
Kari Justmann, Housing Team Leader
Tammy O’Leary, Deputy Clerk/Treasurer
Dennis Nachreiner,
Finance Committee Chairperson
Mary Hamburg, Finance Committee Member
Martin Havlovic, Finance Committee Member
Doug Klapper, Finance Committee Member
Mark Hahn, Finance Committee Member
Stacy Griswold, Housing Program Assistant
Marie A. Moe, City Clerk
If yes, list name of person and disclose the nature of the relationship:
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