INSURANCE CLAIM DECLARATION
Request for Check Endorsement
I, do hereby certify to the following:
a.
Previous Assistance: I previously received financial assistance through the Arizona Department
of Housing, Arizona Housing Finance Authority or the Arizona Home Foreclosure Prevention
Funding Corporation (collectively referred to as the “Department”) for the purchase,
rehabilitation, or foreclosure prevention for my primary residence located at:
(List full address of “Primary Residence”)
b.
Primary Residence: I continue to reside at this address as my Primary Residence which was/is a
condition of assistance, or I have obtained a temporary written waiver from the Department
pertaining to residency requirements.
c.
I have received an insurance claim payout in the amount of $ from
(name of insurance company)
dated .
d.
The following describes the situation(s) that resulted in the insurance claim for my Primary
Residence:
e.
Claim funds will be used solely to make repairs to my Primary Residence, including the
following:
I certify, under penalty of perjury, that all of the foregoing is true and correct:
Signed:
Printed Name: Executed on this date:
Email: Phone:
1110 West Washington Street, Suite 280 · Phoenix, AZ 85007 · Phone: 602-771-1000 · Fax: 602-771-1002
