Revised 02/02/2018
CITY OF LITTLE ROCK
RESIDENCY INCENTIVE PROGRAM APPLICATION
Employee Name: Employee Number:
Date of Hire: End of Probation:
Date of Request:
Department/Division: /
Employee Job Title:
Employee Statement: I hereby request that the City of Little Rock provide to me $ for
expenses related to moving into the City of Little Rock for buying or renting a primary residence as detailed
in Procedure Guideline #1012. I understand that if I terminate my employment with the City for any
reason within two (2) years from the date payment is received I will be personally liable to reimburse the
City 100% of the Residency Incentive payment. The City shall accordingly be entitled to recover any such
amount from any payment due me upon termination including but not limited to wages, leave payoff,
pension disbursements, expense reimbursements, etc. I have included original documents, such as utility
statements, lease agreements, closing papers, sellers’ Purchase Contract (with a copy of the Settlement
Statement – HUD-1 document or closing/title paperwork within five (5) business days after closing, etc.,
demonstrating that I have purchased a home or demonstrated that I intent to buy a home in Little Rock
or that I moved into Little Rock and have leased/rented a home for a minimum of one (1) year.
The incentive payment is limited to one (1) household.
_____________________________________________________________________________
Employee Signature and Date
_____________________________________________________________________________
City Manager Approval and Date
Human Resources Use Only:
Date of Request Received: ________________________________________________________
Date of Hire and end of Probationary Period: _________________________________________
Address validated: ________________
Incentive Eligible For: Rental Purchase
Approved to send to City Manager: _________________________________________________
Payment processed by Human Resources after City Manager Approval: ____________________
