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DOCUMENTS NEEDED TO COMPLETE YOUR HOUSING REHABILITATION APPLICATION
1. Signatory & Acknowledgement Page ___________
2. Credit Authorization form ___________
3. Pictorial Consent Release form ___________
4. Proof of all sources of monthly household income including interest and investment income (four (4) most
recent pay stubs, Social Security award letter, pension/annuity/retirement, child support, etc)
5. Complete copies of all bills/expenses you reported on the monthly expense/bill sheet (mortgages, utili-
ties, insurance, medical, taxes, credit cards, etc…) ____________
6. Current copy of flood insurance declaration statement (if property is in a flood zone) ____________
7. Current home owner’s insurance declaration statement _____________
8. Evidence of a will_____________
9. Agreement for repayment of costs in the event I cancel or terminate my participation in the
program_____
* 60 day account printout or copies of your most recent bank statement(s) ________
Please return the completed application along with the items listed on the check list above to the address
below or submit via email to batesl@charleston-sc.gov:
City of Charleston
Department of Housing and Community Development
Housing Rehabilitation Program
75 Calhoun Street, Suite 3200
Charleston, SC 29401
Phone: 843-724-7348
Fax: 843-965-4180
You may also call to set an appointment to bring your application and supporting documents for review.
OWNER: ______________________________________________________________________
ADDRESS: ______________________________________________________________________
HOME PHONE: ______________________________________________________________________
ALTERNATE PHONE: ______________________________________________________________________
TMS#: ______________________________________________________________________
Attachments
2
City of Charleston
Homeowner Rehabilitation Application
Please complete this application is its entirety.
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
me:

 
   
 
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

  to OWNER
 
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
 

  



WEEKLY
BIWEEKLY
SEMI-MONTHLY
MONTHLY
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Employer Address: __________________________________________________________________________
City: ___
_________________ State: _
_________ Zip: _________________
What is your salary? ____________________
How often are you paid?
WEEKLY
BIWEEKLY
SEMI-MONTHLY
MONTHLY
WEEKLY
BIWEEKLY
SEMI-MONTHLY
MONTHLY
WEEKLY
BIWEEKLY
SEMI-MONTHLY
MONTHLY
4
Does anyone in the household receive any of the following? If yes, please fill in the amount and indicate the person(s) in
your household who receive it.






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
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
. 
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 



5
DEMOGRAPHIC INFORMATION
The following questions are for statistical purposes only and have no bearing on the approval of financial assistance. Please
check the box that applies to your household:






Please check the box that applies to the home owner:






 









 
 
 




click to sign
signature
click to edit
click to sign
signature
click to edit
6
I authorize LaToya Bates, Housing Financing Coordinator for the Department of Housing and Community
Development of the City of Charleston, to obtain a copy of my credit report from Equifax. This report will
be attached to my housing rehabilitation program application and is required by the Department of
Housing and Urban Development (HUD).
_________________________________________ _________________________
Owner’s Signature Date
_________________________________________ _________________________
Social Security Number Date of Birth
_________________________________________ _________________________
Co-Owner’s Signature Date
_________________________________________ _________________________
Social Security Number Date of Birth
________________________________________________________________
Address
City of Charleston
Homeowner Rehabilitation Application
Credit Authorization Form
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signature
click to edit
click to sign
signature
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7
City of Charleston
Homeowner Rehabilitation Application Pictorial Consent
Release Form
_____________________________
Co-Owner Name (PLEASE PRINT)
_____________________________
Owner Name (PLEASE PRINT)
Please select ONE of the following statements.
__________I/We DO hereby consent to and authorize the use of images taken of my/our residential property
during my/our participation in the City of Charleston Roof Replacement; Substantial Rehabilitation program for
any publicity or marketing purpose, without compensation.
__________I/We DO NOT hereby consent to and authorize the use of images taken of my/our residential property
during my/our participation in the City of Charleston Roof Replacement; Substantial Rehabilitation program, for
any publicity or marketing purpose, without compensation.
I/We understand these images, including electronic, negatives and positives, printed photographs, and all others,
are owned by the Housing Rehabilitation Program, and will be used only to promote the Program to the
community, to report to the funding agency [US Housing & Urban Development (HUD)], and to present as
information in community development and informational contexts.
I/We hold the City of Charleston and its partners harmless, and free from any claims in connection with this consent
and the use of the images of my/our residential property described herein. This signed consent is hereby declared
valid indefinitely, unless revoked in writing by me/us.
X _______________________________________________________
Owner Name (PLEASE SIGN)
X _______________________
DATE
X _______________________________________________________
Co-Owner Name (PLEASE SIGN)
X _______________________
DATE
8
Have you ever received assistance through any programs offered by the City of Charleston Department of
Housing and Community Development? __________YES __________NO
If you answered YES to the question above, please answer all the questions listed below.
What year(s) did you receive assistance? _______________________________
What program(s) did you receive assistance from? _______________________________
__________________________________________________________________________
At what address was the work completed? _________________________________________
Describe the nature of the work done to your property.
_____________________________________________________________________________
Date
_________________________
_____________________________________________________________________________
_____________________________________________________________________________
I certify that the answers I have provided to the questions above are true, complete and correct to the best of
knowledge.
_________________________________________
Owner’s Signature
________________________________________
Co-Owner’s Signature
Date
City of Charleston
Homeowner Rehabilitation Application
Prior Assistance Questionnaire
_________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
9
City of Charleston
Homeowner Rehabilitation Application
Judgment and Lien Declaration Statement
I/we, __________________________________________________________, hereby declare
to the best of my/our knowledge that there are no judgments and/or liens registered against
me/us.
_________________________ ________________________
Owner’s Signature Date
_______________________ _________________________
Co-Owner’s Signature Date
====================================================================
I/we, __________________________________________________________, hereby declare
to the best of my/our knowledge that the judgments and/or liens listed below are registered
against me/us.
JUDGMENTS/LIENS:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________________
___________________________________ _________________________
Owner’s Signature Date
___________________________________ _________________________
Co-Owner’s Signature Date
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
10



This sheet is only for applications for Roof Replacement, and Substantial Rehab Programs. In order to
determine your exact debt to income ratio and to qualify for a payback loan and/or deferred loan, a
listing of all your monthly bills and expenses are needed. Please fill out the chart below. Please
provide complete copies/verification of all the bills and expenses you list on this form.
11
VERIFICATION OF THE EXISTENCE WILL DOCUMENT
I, __________________________________________________________________, an attor-
ney or a registered notary public for the state of South Carolina, do hereby acknowledge the
existence of a will for ________________________________________________ of
_________________________________________ (address). In signing this statement, I am
verifying the document existence without release of the physical instrument.
______________________________ ______________________________
Witness Signature
______________________
Date
If applicable complete the following:
Notary Public for South Carolina
My commission expires: _________________________
12
City of Charleston Home Owner Rehabilitation Application Signatory and
Acknowledgement Page
I (we) hereby make application for a City of Charleston Rehabilitation Loan Program:
______________________for the property located at ______________________, Charleston, SC
(Name of Program) I have read and examined this application and know the same to be true and
correct. I (we) further understand that I may, at my option, at any time, terminate the whole or part
of this agreement for any reason or no reason at all. In the event that I terminate this agreement, I
understand and agree that I will be responsible for all soft costs and materials delivered for the
project, prior to my cancellation of the Agreement.
In the event I (we) are unavailable or unable to represent myself if during any phase of the application
or construction process I (we) authorize my personal representative listed below to act on my behalf
in all matters pertaining to this Agreement.
_____________________________________
Name of Representative
_____________________________________
Address of Representative
_____________________________________ ____________________________
Owner’s Signature Date
_____________________________________
Print
_____________________________________
____________________________
Co-Owner’s Signature
Date
_____________________________________
Print
Notary Public for South Carolina: ____________________________________________
My commission expires: ____________________________
ROOF REPLACEMENT FEES
Title Search $225.00
Risk Assessment $900.00 *For properties constructed prior to 1978 only*
Credit Report $10.00
Loan Closing $386.00
Loan Set Up $34.00
Submit via Email
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