Fillable INSTRUCTIONS: Information in this application is strictly confidential (City of Council Bluffs)

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INSTRUCTIONS: Information in this application is strictly confidential (City of Council Bluffs)

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City of Council Bluffs, Iowa
Lead Hazard Reduction Grant Application
APPLICANT INFORMATION
Applicant's First & Last Name: Are you a US citizen: Date of Birth Married Widowed
Yes No Divorced Separated
Address: Do you currently own other properties: Yes No
If yes, address of property:
Email Address: Home Phone: Cell Phone: Best Time to Call: Morning
Afternoon Evening
Employer Name & Address: Position: Number of Years :
Full-Time Part-Time
Are you employed anywhere else: Yes No If yes, please list employer name and address:
Race: White Asian Ethnicity: Hispanic or Latino
Black or African American Native Hawaiian or other Pacific Islander
Non-Hispanic or Latino
American Indian or Alaska Native Other - Multi Racial
CO-APPLICANT INFORMATION
Applicant's First & Last Name: Are you a US citizen: Date of Birth Married Widowed
Yes No Divorced Separated
Address: Do you currently own other properties: Yes No
If yes, address of property:
Email Address: Home Phone: Cell Phone: Best Time to Call: Morning
Afternoon Evening
Employer Name & Address: Position: Number of Years :
Full-Time Part-Time
Are you employed anywhere else: Yes No If yes, please list employer name and address:
Race: White Asian Ethnicity: Hispanic or Latino
Black or African American Native Hawaiian or other Pacific Islander
Non-Hispanic or Latino
American Indian or Alaska Native Other - Multi Racial
PROPERTY INFORMATION
Do You Own Your Home: Do you have a mortgage: Name of Mortgage Holder:
Yes No 1st Mortgage: Yes No
Rent Land Contract 2nd Mortgage: Yes No Balance Owed: Escrow Acct: Yes No
# of Yrs Owned Home: Are there any liens/judgements against you or your property:
Payments Current: Yes No Yes No If yes, please explain:
Do you have property insurance: Yes No Ins. Company & Agent:
Do you have flood insurance: Yes No Ins. Company & Agent:
Are your real estate taxes current: Yes No Are your sanitation fees current: Yes No
HOUSEHOLD INFORMATION - PLEASE INCLUDE EVERYONE LIVING IN THE UNIT
Date of Relationship To
Gross Source of Disabled
Name Birth Applicant
Monthly Income Income*
Y or N
APPLICANT
CO-APPLICANT
*Sources of Income (Wages, Social Security, Unemployment, Child Support, Pension, Workman's Comp, Alimony, etc.)
INSTRUCTIONS: Information in this application is strictly confidential and will not be released to persons outside of this program. Information
is requested to establish eligibility and for federal reporting requirements. If you need any help completing this form, please call 712-890-5350
for assistance. There may be a waiting list to receive assistance with the City of Council Bluffs Lead Hazard Reduction Program. There are
preferences on the waiting list for households with children who have an elevated blood level (EBL). This is not a housing rehabilitation
program. All projects focus on the removal of lead paint hazards only.
CHILDREN UNDER AGE SIX
Has your child/children ever been tested for lead poisoning: Yes No
If yes, were the test results: Positive Negative Result Number: Date of testing:
Is your home used as a daycare: Yes No
Are there other children who spend a significant amount of time at your home (3 hours per day on 2 separate days in a week, 6 hours per week total,
60 hours total per calendar year): Yes No If yes, names and ages:
Do your children spend a significant amount of time at another household (3 hours per day on 2 separate days in a week, 6 hours per week total,
60 hours total per calendar year):
Yes No If yes, please provide address:
Is anyone in the household pregnant: Yes No
ASSET INFORMATION
Household Member Name Type of Asset Cash Value of Asset Annual Income from Asset
PROPERTY HAZARDS/CONCERNS
Do you have any of the following hazards in your home: Pest Management (cockroaches, lice, mice, bats, etc.)
Bed Bugs
Electrical Issues
Carbon Monoxide
Radon
Do you have a radon mitigation system: Yes No If yes, date installed:
How did you hear about our program:
ATTACHMENTS
Please attached copies of the following documents if applicable:
Current 6 weeks pay stubs from all income sources
Most recent 6 months statements from all asset accounts (checking, savings, retirement, investments, etc.)
Most recent State and Federal Income Tax Forms (if self-employed, please provide the past 2 years returns)
Proof of Identification
Copy of blood test results
Birth certificate for any child 5 and under or an official form of birth verification
For the following types of income, please provide a statement/award letter:
Social Security, Supplemental Social Security
Pension
Disability
Unemployment
Worker's Compensation
Child Support
Alimony (copy of divorce decree)
Proof of existing homeowner insurance coverage
APPLICANT CERTIFICATION
If I/We do not qualify, withdraw from the program or are denied assistance by the Lead Hazard Reduction Program, correction of any
lead hazards will be the responsibility of the owner(s).
Applicant's Signature Date
Co-Applicant's Signature Date
0
I/We certify that all statements made in this application are true and are made for the purpose of obtaining assistance through the Lead Hazard
Reduction Program. Verification may be obtained by the City, the Lender or by HUD for any source named in this application. I/We also
understand that it may be a federal crime punishable by fine or imprisonment, or both, to knowingly make any false statements concerning any
of the above facts as applicable under the United States Criminal Code. Any misrepresentation or falsification provided by the applicant or co-
applicant shall result in immediate disqualification. I/We also understand that I/We will update all financial information and income calculations
if there is an increase in income, change in employment or change in family size prior to loan closing.
If I/We do not qualify, withdraw from the program or are denied assistance by the Lead Hazard Reduction Program, correction of any lead
hazards will be the responsibility of the owner(s). I/We understand that participation in the program is voluntary, submission of the
application does not guarantee funding.
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INSTRUCTIONS: Information in this application is strictly confidential (City of Council Bluffs)

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Completed 17 July 2020

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