Fillable Hurricane Harvey Recovery Homeowner Assistance Program (HoAP) Intake (City of Houston)

Fill Online, Printable, Fillable, Blank Hurricane Harvey Recovery Homeowner Assistance Program (HoAP) Intake (City of Houston) Form

Use Fill to complete blank online CITY OF HOUSTON (TX) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Hurricane Harvey Recovery Homeowner Assistance Program (HoAP) Intake (City of Houston)

On average this form takes 65 minutes to complete

The Hurricane Harvey Recovery Homeowner Assistance Program (HoAP) Intake (City of Houston) form is 6 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 253 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Houston

BROWSE CITY OF HOUSTON (TX) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
Hurricane Harvey Recovery
Homeowner Assistance Program (HoAP)
Intake Application and Packet
This Section is for Office Use Only
Date/Time Application Received:
Applicant ID #:
Application Received By:
NOTES:
Homeowner Assistance Program (HoAP)
Intake Application and Packet
Page 2 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
This section(s) to be completed by Applicant/Co-Applicant.
2. CO-APPLICANT INFORMATION
(If Applicable) ☐
DOES NOT APPLY
List other members of the household who hold as much responsibility for
the property as the Applicant. This person is often referred
to as the co‐owner of the property
First Name:
Middle Name:
Last Name:
Current Address:
(Where Co‐Applicant Resides)
Current City, State, Zip:
(Where Co‐Applicant Resides)
Mailing Address:
(If different from Current Address)
Mailing City, State, Zip:
(If different from Current City, State, Zip)
Home Phone:
Daytime Phone:
Cell Phone:
Email Address:
Date of Birth:
Relationship to Applicant: ☐ Spouse ☐ Parent ☐ Child ☐ Grandchild ☐ Sibling ☐ Friend ☐ Other: _________________________
3. COMMUNICATION DESIGNEE OR ALTERNATIVE CONTACT(S)
(If Applicable) ☐
DOES NOT APPLY
(If you assign a Communication Designee or Alternative Contact(s), complete Attachment B, HoAP Communication Designee Form for
each designee/alternative contact.)
Middle Name:
Last Name:
Current Address:
City, State, Zip:
Home Phone:
Daytime Phone:
Cell Phone:
Email Address:
Relationship to Applicant: ☐ Spouse ☐ Parent ☐ Child ☐ Grandchild ☐ Sibling ☐ Friend ☐ Other: _________________________
Application ID #:
1. APPLICANT INFORMATION
The applicant is the Head of Household, for the purpose of this application
First Name:
Middle Name:
Last Name:
Damaged Property Address:
(Damaged by Hurricane Harvey)
Damaged Property City, State, Zip:
(Damaged by Hurricane Harvey)
Is the Damaged Property Address above where
you receive mail?
☐ Yes ☐ No
Current Mailing Address:
(If different from Damaged Address)
Current Mailing City, State, Zip:
(If different from Damaged City, State, Zip)
Home Phone:
Daytime Phone:
Cell Phone:
Email Address:
Date of Birth:
Marital Status: ☐ Married
☐
Single
☐
Divorced
☐
Widow
Application ID #: __________________
Page 3 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
4. HEAD OF HOUSEHOLD DEMOGRAPHIC INFORMATION FOR HUD REPORTING (check only one)
Race of Head of Household:
☐ American Indian or Alaskan Native
☐ Asian
☐ Black/African American
☐ Native Hawaiian/Other Pacific Islander
☐ White
☐ American Indian/Alaskan Native and White
☐ American Indian/Alaskan Native and Black/African American
☐ Asian and White
☐ Black/African American and White
☐
Other _______________________________________________
Ethnicity of Head of Household:
☐ Hispanic/Latino – A person of Mexican, Cuban, Puerto Rican, South or Central American, or other Spanish culture or Origin, regardless of race.
☐ Non-Hispanic/Latino – A person not of Mexican, Cuban, Puerto Rican, South or Central American, or other Spanish culture or Origin, regardless of
race.
5. HOUSEHOLD COMPOSITION AND CHARACTERISTICS
List all household members and provide the requested information. “Household” is defined as all persons living in the same dwelling unit,
regardless of relationship or age.
Household Member Name
Relationship to Head of
Household
Gender
Date of Birth
mm/dd/yyyy
Dependent
(Y/N)
Disabled?
(Y/N)
Veteran (Y/N)
a. In the next twelve (12) months, are you expecting an increase or decrease in income?
☐
Increase
☐
Decrease
☐
No Change
If Yes, please explain: ________________________________________________________________________________________________
b. In the next twelve (12) months, are you expecting an increase or decrease in household members? ☐ Yes ☐ No ☐ Unknown
If Yes, please explain: ________________________________________________________________________________________________
6. GENERAL INFORMATION
a. Did this property sustain damage from Hurricane Harvey?
☐
Yes
☐
No
b. Did you own the damaged property on August 25, 2017?
☐
Yes
☐
No
c. Was this your primary residence on August 25, 2017?
☐
Yes
☐
No
d. Are any household members over 18 responsible for child support payments?
☐
Yes
☐
No
If YES, is the responsible party current on payments for child support?
☐
Yes
☐
No
Is the responsible party on an approved payment plan for child support?
☐ Yes
☐ No
e. Are property taxes current for the damaged property?
☐ Yes
☐ No
If NO, are the taxes on an approved payment plan?
☐ Yes
☐ No
Is a copy of the payment plan included with this application?
☐
Yes
☐
No
f. Does the damaged property have any Homeowner Association requirements of deed restriction?
☐
Yes
☐
No
Application ID #: __________________
Page 4 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
7. DAMAGED PROPERTY INFORMATION
a. Has the damaged property been demolished?
☐
Yes
☐
No
b. Do you a have a mortgage that you are currently paying for your damaged property?
☐
Yes
☐
No
If YES, are you current on the mortgage payments?
☐
Yes
☐
No
c. Are you also currently living in and paying rent at a different location from the damaged property?
☐
Yes
☐
No
d. Is the damaged property currently in foreclosure?
☐
Yes
☐
No
e. Are there any liens on the damaged property?
☐ Yes
☐ No
☐
Unknown
f. Do you have a deed on the damaged property?
☐ Yes
☐ No
If YES, provide information below for all parties listed on the deed (including any entity, for example, a Trust):
___________________________________________________________________________________________
g. What type of structure is the damaged property?
☐ Single-Detached ☐ Multi-Unit ☐ Manufactured Housing Unit (MHU) ☐ Modular-detached ☐ Townhouse ☐ Condo
☐ Other______________________________________________________________
h. If the damaged property is a MHU, do you have a valid Statement on Location (SOL) filed?
☐
Yes
☐
No
i. If you are seeking assistance for a manufactured housing unit, do you own the land?
☐
Yes
☐
No
8. TEMPORARY RELOCATION & MOVING AND STORAGE ASSISTANCE
a. Are you currently living in the damaged property?
☐
Yes
☐
No
b. If you are living in the damaged property and you are required to move as a result of the repair work,
will you need moving and storage assistance?
☐
Yes
☐ No
c. If you are required to move as a result of the repair work, have you made arrangements for a place to
live temporarily?
☐
Yes
☐ No
If YES, where? _______________________________________
If NO, will you need temporary housing assistance?
☐
Yes
☐ No
d. If you are not living in the damaged property, are you receiving temporary housing assistance?
☐
Yes
☐ No
If YES, who is providing the assistance?
☐ FEMA ☐ Insurance ☐ Non-Profit _________________________
☐
Other _________________________
Did you also receive moving and storage assistance for your temporary housing assistance?
☐
Yes
☐ No
e. Are you willing to relocate during the rehabilitation or reconstruction of the property?*
*Please note that rehabilitation and reconstruction pathways require relocation.
☐
Yes
☐ No
f. Did the damaged property have a tenant in place as of August 25, 2017?
☐
Yes
☐
No
g. Has the damaged property had a tenant at any time since August 25, 2017?
☐
Yes
☐
No
9. ENVIRONMENTAL INFORMATION
a. Was the damaged property built AFTER January 1, 1978?
☐
Yes
☐
No
b. Does the City of Houston provide your drinking water?
☐
Yes
☐
No
☐
Unknown
c. Is there a gas or fuel storage tank connected to the damaged property that is in use for heating or
cooking?
☐
Yes
☐
No
☐
Unknown
d. Are there pungent, foul, or noxious odors typically noticeable at the damaged property?
☐
Yes
☐
No
e. Is the yard area of the damaged property cleared of debris, non-working vehicles, non-working
appliances, storage tanks and/or drums with potentially hazardous materials?
☐
Yes
☐
No
IF NO, are you able to clear the damaged property for an Environmental Inspection to be
conducted?
☐
Yes
☐
No
f. What is the site history of the damaged property?
☐ Residential ☐ Farm / Business ☐ Other: _________________________________
g. Did the site historically include any of the following?
☐ Septic System ☐ Water Well ☐ Underground Storage Tank ☐ Unknown ☐ Other: ______________________
Application ID #: __________________
Page 5 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
10. OTHER ASSISTANCE RECEIVED AND EXPENDITURES
Complete the HoAP Insurance, Benefits and Expenditures Certification (Form C)
11. INCOME CERTIFICATION INFORMATION
Complete the HoAP Household Income Certification (HIC) (Form D1) or HoAP Income Self-Certification (Form D4). Please
submit all requested supporting income documentation and, if applicable, the HoAP Adjusted Gross Income Worksheet and/or the
HoAP Certification of Zero Income.
12. PRIOR FEDERAL ASSISTANCE
Did the damaged property sustain damages due to any federally declared disaster between
January 1, 1994 and December 31, 2016?
☐ Yes ☐ No ☐ U
nknown
Application ID #: __________________
Page 6 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
13. APPLICANT RELEASE AND CERTIFICATION
Applicant Name:
Damaged Property Address:
(Street, City, State, Zip)
Co-Applicant Name:
(If Applicable)
RELEASE
1. I/We authorize the City of Houston/HCDD to use photographs of my/our property in City of Houston and HCDD affiliate promotional
materials. I/We also understand that I/we may opt out or in of this photograph release in writing at any time. Please confirm that you
agree or disagree with these statements:
a. ☐ I Agree
b. ☐ I Disagree
2. I/We authorize the City of Houston and any of its duly authorized representatives to verify all information provided on this application,
including obtaining information about me/us, my/our household, and its members, that is pertinent to determining my/our eligibility
for participation in the City of Houston’s Homeowner Assistance Program (HoAP).
3. I/We understand the following inquiries may be made to obtain third party information to any of the following:
a. Disaster Assistance (FEMA, SBA, Insurance, etc.);
b. Income (all sources);
c. Assets (all sources);
d. Occupancy Preference (Special needs, if applicable);
e. Child Support Payment Verification;
f. Property Tax Payment Verification.
4. I/We acknowledge and understand that:
a. A photocopy of this form is as valid as the original;
b. I/We have the right to review information received using this Release;
c. I/We have the right to a copy of information provided to the entity and to request correction of any information I/We believe
to be inaccurate;
d. Documents submitted may become electronically permanent.
CERTIFICATION
1. I/We certify that I/we are the owner of the home located at the above-referenced address.
2. As the Applicant/Co-Applicant, I/we acknowledge responsibility for completing and returning all required documentation to the
Homeowner Assistance Program (HoAP) within the time period stated on the application materials. If I/we fail to provide these
documents in a timely manner, or if I/we fail to respond to any inquiries made by the Homeowner Assistance Program (HoAP) regarding
my/our application for assistance, I/we may be disqualified from participating in this program and receiving benefits, or I/we may have
to reapply and, consequently, my/our original submission date is no longer effective.
3. I/We understand there is a limitation of funding for the Program, and even if I/we are determined eligible for assistance, this does not
mean an award is guaranteed.
4. I/We understand I/we may be responsible for obtaining and maintaining hazard insurance, flood and/or windstorm insurance, if
applicable, following the completion of assistance as required by law.
5. I/We understand that providing false statements or information is grounds for ineligibility and termination of housing assistance and is
punishable under federal law.
6. I/We certify that, to the best of my/our knowledge, all required documents and materials I/we have completed and submitted for
my/our application for assistance are true and correct.
Warning: Any person who knowingly makes a false claim or statement to HUD may be subject to civil or criminal penalties under 18 U.S.C. 287, 1001
and 31 U.S.C. 3729. Under penalties of perjury, I/we certify that the information presented above is true and accurate to the best of my/our
knowledge and belief. I/We further understand that providing false representations herein constitutes an act of fraud. False, misleading or
incomplete information may result in my ineligibility to participate in this program or any other programs that will accept this document. Title 18,
Section 1001 of the U.S. Code states that a person is guilty of a FELONY if he/she knowingly and willfully makes a false statement to any department
of the United States Government.
Applicant – Printed Name
Applicant – Signature
Date
Co‐Applicant – Printed Name (If Applicable)
Co‐Applicant – Signature (If Applicable)
Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Hurricane Harvey Recovery Homeowner Assistance Program (HoAP) Intake (City of Houston)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 21 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document