Application ID #: __________________
Page 6 of 6
HoAP Intake Application and Packet
Version 1.4 March 2020
13. APPLICANT RELEASE AND CERTIFICATION
Damaged Property Address:
(Street, City, State, Zip)
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.
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.
Co‐Applicant – Printed Name (If Applicable)
Co‐Applicant – Signature (If Applicable)