FY 2014-2015 0ctober 1, 2014
Down Payment Assistance (DPA)
PROGRAM APPLICATION PACKAGE
Completed by Lender
Neighborhood Housing and Community Development (NHCD)
Austin Housing Finance Corporation (AHFC)
MAILING ADDRESS: P. O. Box 1088 Austin, Texas 78767
DELIVERY ADDRESS: 1000 E. 11
th
Street, Suite 200
Phone: (512) 974-3100 Fax (512) 974-3161
Email: [email protected]
Website: www.austintexas.gov/empower
Thank you for your interest in the Down Payment Assistance (DPA) Program offered by Neighborhood Housing and Community
Development (NHCD), a department of the City of Austin. Program restrictions apply and assistance is subject to funding availability.
Complete DPA application packages are accepted on a first- come, first-serve basis.
Please submit DPA Prescreening and supporting documentation via:
Mail In-person
NHCD Street-Jones Building
PO Box 1088 1000 E. 11
th
Street, Suite 200
Austin, TX 78767-1088 Austin, TX 78702
Fax Email
(512) 974-3161 [email protected]
For more information call 512-974-3100 or visit www.austintexas.gove/empower.
The City of Austin’s Neighborhood Housing and Community Development (NHCD) is committed to compliance with the Americans with
Disabilities Act (ADA and Section 504 of the Rehabilitation Act of 1973), as amended. Reasonable modifications and equal access to
communications will be provided upon request. Please call 974-3100 (voice) or Relay Texas at 974-3102 or 1-800-735-2989 (TDD) for
assistance. For a sign language interpreter, please call NHCD at 974-3863 at least 7 days in advance.
The City of Austin’s NHCD does not discriminate on the basis of disability in the admission or access to or treatment or employment in
their programs and activities. Dolores Gonzalez has been designated as the City’s section 504/ADA Coordinator. Her office is located
at 505 Barton Springs Road, Suite 600.Austin, TX 78704. If you have any questions or complaints regarding Section 504/ADA rights,
please call the Section 504/ADA Coordinator at 974-3256 (Voice) or 974-2445 (TTY).
FY 2014-2015 0ctober 1, 2014
PROGRAM DESCRIPTION
SEE PROGRAM GUIDELINES FOR MORE IN DEPTH INFORMATION
Purpose:
The Down Payment Assistance (DPA) Program provides eligible first-time homebuyers with
a 0%-interest (0% APR) loan to assist with eligible down payment and closing costs.
Submitting
Applications:
Only DPA Participating Lenders listed on the City of Austin’s website and HousingSmarts
graduates may submit application packages. Packages will be processed when they are
100% complete according to the Lender and Applicant Checklists. Complete application
packages are accepted and processed on a first-come, first-served basis and are subject to
fund availability.
Participants,
Income &
Assets:
Applicants must be first-time homebuyers who are citizens or legal permanent residents.
Households may earn no more than 80% of the Austin Median Family Income (adjusted for
household size), as published annually by the U.S. Department of Housing and Urban
Development (HUD). Asset limits apply. Visit http://www.austintexas.gov/page/income-limits
for current income limits.
**NOTE: “The Household Size, Income and Assets” includes ALL persons (related and
unrelated) residing with the applicant at the time of application and/or those who will reside
with the applicant upon the purchase of the new home.
Properties:
Must be the borrower’s primary residence. Single family homes, town homes or condos are
eligible; duplexes are ineligible. Any new construction must meet Visitability and S.M.A.R.T.
Housing™ standards. Manufactured housing must be new construction on permanent
foundation and meet S.M.A.R.T. Housing™ standards. Properties must be located within the
Full Purpose Jurisdiction of Austin city limits; Extra Territorial Jurisdiction are ineligible.
Financing:
First lien loan must be a fully amortized, fixed-rate loan for 30 years. Interest rate may not
exceed .75% above the prevailing interest rate released in the current Federal Statistical
Release at the time the lender locks the borrower’s interest rate. Annual Percentage Rate
may not exceed 1.5%. Discount point charges may not exceed 1.5%.
Earnest
Money:
All applicants must make a minimum $1,000 Earnest Money contribution.
Sales Price:
Not to exceed 95% of area median purchase price for new or existing single family housing
using data from the Federal Housing Administrations (FHA) for Austin. Please call NHCD
(512) 974-3100 for current applicable limits.
OTHER:
No “principal reduction” or cash back is allowed at closing.
FY 2014-2015 0ctober 1, 2014
PROGRAM DESCRIPTION
SEE PROGRAM GUIDELINES FOR MORE IN DEPTH INFORMATION
DPA Loan
Options:
“Standard DPA”
Up to $14,999, 0% interest (0% APR),
deferred, forgivable loan, second lien
position.
“Shared Equity DPA”
$15,000-$40,000, 0% interest (0% APR),
deferred, forgivable loan, second lien position.
Includes a “Shared Equity Loan Agreement”,
“Subordination Agreement” and “City of Austin
Right of First Refusal” provision.
DPA Loan
Amounts:
A minimum of $1000 up to $14,999 of
assistance for eligible closing costs, pre-
paid expenses, and down payment.
The eligible loan amount is based on the
borrower’s demonstrated financial gap.
A minimum of $15,000 up to $40,000 of
assistance for eligible closing costs, pre-paid
expenses, and down payment. The eligible loan
amount is based on the borrower’s demonstrated
financial gap. Amount may not exceed 30% of
the home sales price.
Debt to
Income
Ratios:
Total combined debt ratio cannot exceed
45.00%
Total combined debt ratio cannot exceed 45.00%
Repayment:
The loan will be due and payable upon
the sale, refinancing, home equity loan,
vacating, lease or transfer of title before
the 5 year maturity date. Otherwise, the
loan is forgiven after 5 years.
The loan will be due and payable upon the sale,
refinancing, home equity loan, vacating, lease or
transfer of title before the 10 year maturity date.
In addition, a percentage of equity gained that
is equal to the percentage of NHCD’s portion
of the original sales price will be added to the
payoff balance. The loan is forgiven after 10
years. However, the shared equity remains and
is forgiven after 30 years.
Property Age
Limit:
None.
Properties constructed before 1978 are
ineligible.
Appraised
Property
Value:
The estimated value of the property must not exceed 95 percent of the median area
purchase price, described in 24 CFR 92.254 (a) (2) (iii).
Updated 10/01/2014. Subject to funding availability. Other restrictions may apply.
For more information, please contact Austin Housing Finance Corporation at (512)974-3100.
FY 2014-2015 0ctober 1, 2014
Section 1 – Applicant Information
Section 2 – Co-Applicant Information
N/A
Name: _________________________________________________________________
Last First Middle Initial
Current Address: ______________________________________________________________________________
City: _________________________ State: _____________________ Zip: ___________________
Mailing Address (if different): _____________________________________________________________________
City: _________________________ State: _____________________ Zip: __________________
Work Phone: ____________________ Home Phone: _____________________ Cell Phone: ___________________
E-mail ____________________________________________________________ Gender:
Male
Female
Marital Status:
Single
Married
Widowed
Divorced
Are you a:
U.S. Citizen
Permanent Resident
Alien: Alien number A: ___________________________
Other: _____________________________________________________________________________________
Alternate Contact Name, Phone Number and Email ____________________________________________________
How did you hear about the Programs? ______________________________________________________________
FY 2014-2015 0ctober 1, 2014
Section 3 – Employment and Income History
Section 4 – Household Members
List all persons (children and adults) living in the home, along with their gross income. By signing in Section 8, you certify,
that you are the owner(s) and/or occupant(s) of the property (identified in Section 1) and that the current gross monthly
and annual income of all persons living in the home (related and unrelated) have been listed below. (Attach additional
page(s) if needed)
Total number of persons living in the household: __________
Name
Relationship
Date of Birth
Age
Gross Income/ Pay
Period
(Applicant)
Self
(Co-Applicant)
Applicant’s Employer _____________________________________Occupation _____________________________
Estimated Gross Monthly Income $___________________ Number of Years with Employer ___________________
Co-Applicant’s Employer __________________________________Occupation _____________________________
Estimated Gross Monthly Income $___________________ Number of Years with Employer ___________________
Ethnic Categories (select one)
Hispanic or Latino
Not-Hispanic or Latino
Racial Categories (select all that apply)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi
FY 2014-2015 0ctober 1, 2014
Section 5 – Property Information (completed by lender)
Section 6 – First Lien Information
Section 7 – Lender and Title Company Information
Applicant Name: _________________________________________________________________
Last First Middle Initial
Co-Applicant’s Name:______________________________________________________
Subject Property Address___________________________________________________________________________
_____________________________________________________________________________________________
City State Zip
Type of property: □ Single Family home □ Condominium □ Town home
□ NEW Manufactured on Permanent Foundation and APPROVED AS part of the S.M.A.R.T. Housing™ Program
□ New Construction □ Existing Construction (pre-owned) Year Built: _______________
Purchase Price of the Property $______________________________________________________________________
Type of loan □ FHA □ Conventional □ Veterans Administration
Interest rate ________ %Lock Expiration Date:______ FIXED RATE for 30 years. Estimated Closing Date ___________
The following people have assisted with this application, and will assist with the closing:
Mortgage Company ______________________________________________________________________________________
Loan Officer ___________________________________Email________________________Phone________________________
Loan Processor: _______________________________Email________________________Phone________________________
Address________________________________________________________________________________________________
Title Company ____________________________________________________________________________________________________
Closing Officer __________________________________________________________________________________________
Address________________________________________________________________________________________________
Work Phone _______________________________________Fax __________________________________________________
Email__________________________________________________________________________________________________
FY 2014-2015 0ctober 1, 2014
Section 8 – Real Estate Company Information
Section 9 – Applicant(s) Signatures
By signing this application you swear under penalty of perjury that the information provided is true and correct to the best
of your knowledge and belief. You understand that any omissions or discrepancies found at any time may disqualify you
from the program(s) and also may require your immediate repayment of any funds spent. You authorize NHCD or AHFC
and/or its designated agents to contact any source to solicit and/or verify what is necessary for an eligibility or
creditworthiness determination.
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making
false or fraudulent statements to any department of the United States Government.
____________________________________________ __________________________________________
Signature of Applicant/Guardian Date
____________________________________________ __________________________________________
Signature of Co-Applicant Date
Real Estate Agent to be contacted to schedule the HQS Inspection:
Real Estate Company ____________________________________________________________________________________
Real Estate Agent ________________________________________________________________________________________
Address________________________________________________________________________________________________
Work Phone _______________________________________Cell Phone____________________________________________
Email__________________________________________________________________________________________________
FY 2014-2015 0ctober 1, 2014
APPLICATION PACKAGE CHECKLIST
Down Payment Assistance (DPA)
Documents Provided by Lender
Neighborhood Housing and Community Development (NHCD)
Austin Housing Finance Corporation (AHFC)
MAILING ADDRESS: P. O. Box 1088 Austin, Texas 78767
DELIVERY ADDRESS: 1000 E. 11
th
Street, Suite 200
Phone: (512) 974-3100 Fax (512) 974-3161
Email: nhcdcs@austintexas.gov
Website: www.austintexas.gov/empower
Complete DPA application packages include all the items listed under both the “Checklist for Lenders” AND the “Checklist
for Applicants.” Only DPA Participating Lenders listed on the City of Austin’s website and approved Borrowers with and
Approved Lender may submit application packages. Only 100% complete DPA application packages will be accepted for
processing.
Original DPA Application, signed by applicant(s)
Original Affidavit, completed and signed by applicant(s)
Original Request for HQS Inspection and Agreement, completed and signed by applicant(s)
DPA Buyer/Seller Certification of Purchase, signed by both parties
Lender’s INITIAL Uniform Loan Application, signed by applicant(s) and lender
Complete Credit Report
Letter of Explanation and complete paper trail (canceled checks, lease agreement, loan repayment
documents, gift documents, etc.) for all non-payroll related deposits into bank accounts
Loan Estimate signed by applicant(s) (if applicable)
“As Is” Property Appraisal (all pages) including a copy of unexpired Appraiser license
Evidence of Underwriter Loan Approval (all calculations should match):
Signed Underwriting Action Sheet/Conditional Approval Checklist
1008 Loan Transmittal
Underwriter signed page 3 & 4 of the Final HUD-92900-A Form (if applicable)
Borrower & lender signed Interest Rate Lock Agreement
Participating Lender Agreeemnt – Loan Officer name and Company Name should match this
application
FY 2014-2015 0ctober 1, 2014
Title Company accepted Survey
Complete copy of Preliminary Title Commitment reflecting Neighborhood Housing and Community
Development (NHCD) as Second Lien Lender
Complete copy of Tax certificates reflecting figures that fall in line with Principal + Interest + Taxes +
Insurance (PITI) calculations on final Underwriting Documents
Evidence of Hazard Insurance Coverage (and flood if applicable) with the following mortgagee clause:
Neighborhood Housing and Community Development or NHCD
Attention: DPA Monitoring Department
PO Box 1088
Austin TX 78767-1088
Copy of Executed/Receipted Sales Contract, signed by both parties
Proof of Earnest Money Contribution
Summary Sheet with MFI, DTI, LTV, PITI, income and asset amounts
Real Estate Contract
Lead-based Paint Disclosure, (completed) and executed by borrower(s) receipt of “Protect Your
Family from Lead in Your Home” pamphlet (only for homes built before 1978); (Standard DPA only)
Homebuyer Education Certificate
FY 2014-2015 0ctober 1, 2014
PROGRAM CHECKLIST- Down Payment Assistance (DPA)
Documents Provided by Applicant
Neighborhood Housing and Community Development (NHCD)
Austin Housing Finance Corporation (AHFC)
MAILING ADDRESS: P. O. Box 1088 Austin, Texas 78767
DELIVERY ADDRESS: 1000 E. 11
th
Street, Suite 200
Phone: (512) 974-3100 Fax (512) 974-3161
Email: nhcdcs@austintexas.gov
Website: www.austintexas.gov/empower
Application (original) completed & signed
Social Security card(s) for applicant(s)
Permanent Residency Card(s) (front & back) (if applicable)
N/A
N/A
Picture Identification for applicant(s)
Texas Driver’s license, Texas Permanent ID Card, or Passport
Last 2 consecutive months paycheck stubs from all household members, 18+ years old
Last quarter’s Profit & Loss Statement & two years Tax Returns (if self-employed)
Most Recent 2 Years W-2 Forms or 1099’s
Most Recent 2 Years Federal Tax Returns, complete with all schedules
N/A
N/A
N/A
N/A
Verification of other income (Check all that apply)
N/A
Social Security Award Letter
Disability Award Letter
Death Benefits
Unemployment
Royalties
Insurance Payments
Child Support or Spousal Support/Alimony
Worker’s Compensation and Severance Pay
Annuity, Retirement, or Pension Payments
Trust Income
Other: _____________________________
Most Recent 6 Months Checking Account Statements and 6 month Savings for all
accounts for all household members
Verification of Assets for all household members (Check all that apply)
N/A
N/A
Certificates of Deposits (CD)
Money Market Account
Mutual Funds or Bonds
Lottery winnings
Capital gains
Inheritances
Retirement Savings (ex. IRA,401K,403B,Keogh)
Pension Annuity
Life Insurance (Whole Life or Universal)
Victim’s restitution Insurance Settlements
Real Estate (Other than Primary Residence)
Other: _____________________________
FY 2014-2015 0ctober 1, 2014
AFFIDAVIT
I (We) hereby submit the attached Application, Uniform Residential Loan Application, tax returns, and other furnished documents to be
considered for the Neighborhood Housing and Community Development’s Down Payment Assistance Program. Under penalty of law, I
certify the home being purchased is located at:
____________________________________________________, Austin, Texas, Zip _______________.
The information contained in the submission of the required program-related documents is true and correct. I further certify that:
1. Neither I or the Co-Applicant have owned a home in the last three years
2. I (we) am a U.S. citizen or I (we) have legal permanent resident status
3. The house I (we) am purchasing will be my (our) primary place of residence
4. The house I (we) am purchasing is located within the Full Purpose Austin city limits
5. The following is a list of all persons (related and unrelated), including myself, who will occupy the home after
closing:
Name
Age
Relationship
Gross Mo. Income
SELF
$
$
$
$
$
TOTAL
$
I (we) understand that:
1. “Standard DPA” is from $1,000 up to $14,999 in a 0% (0% APR) interest, deferred, forgivable loan and is in a second lien
position. See Program Guidelines for more detailed information. “Shared Equity DPA” is from $15,000 up to $40,000 and
is in a 0% interest, deferred, forgivable loan. It includes a “Shared Equity” agreement and “City of Austin Right of First
Refusal” provision. The DPA loan amount is based on the borrower’s demonstrated financial gap.
2. The DPA loan will be due and payable upon early sale, refinancing, home equity loan, lease or transfer of title before the
affordability period of 5 years for Standard DPA, or 10 years for Shared Equity DPA. Shared equity is forgivable after 30
years.
3. Households may earn no more than 80% median family income for Austin.
4. DPA loans require a minimum borrower contribution of $1,000 in Earnest Money.
5. DPA funds will be for: eligible closing costs and pre-paid expenses identified in a signed Good Faith Estimate and
reflected in the final HUD1 Settlement statement; and a down payment amount calculated according to the borrower’s
demonstrated financial gap.
6. The first lien mortgage loan must be a fully amortized, fixed-rate loan of up to 30 years, with an interest rate that does not
exceed the prevailing market rates for conforming loans.
7. The DPA second mortgage when combined with the first may not exceed the estimated value of the property including all
closing costs.
8. A homebuyer education class and Shared Equity pre-closing meeting (if applicable) must be completed before closing.
____________________________________________ _____________________________________________
Applicant (original signature) Date Co-Applicant/ (NPS) (original signature) Date
FY 2014-2015 0ctober 1, 2014
AFFIDAVIT (continued)
I (we) agree to release whatever information the State Attorney General determines to be publicly available. I (we) agree to allow the
City and/or its designee, financial institutions, and other appropriate institutions to share information contained in this file for the purpose
of Down Payment Assistance eligibility and related business. I (we) understand that any discrepancy or omissions later found may
disqualify me (us). If such a discrepancy or omission is discovered after closing, I (we) understand that any financial assistance
provided by the City of Austin may immediately become due and payable.
I (we) read, completed, and executed this Affidavit in connection with the DPA application.
Applicant (original signature) Date Co-Applicant/NPS (original signature) Date
Ethnicity: Ethnicity:
Hispanic or Latino Hispanic or Latino
Not Hispanic or Latino Not Hispanic or Latino
Race/National Origin: Race/National Origin:
Alaskan Native or American Indian Alaskan Native or American Indian
Native Hawaiian or Other Pacific Islander Native Hawaiian or Other Pacific Islander
White White
Asian Asian
Black or African American Black or African American
Multi________________ Multi ___________________
Gender: Gender:
Female Female
Male Male
Has a Disability: Has a Disability:
No No
Yes (complete the Verification of Disability form) Yes (complete the Verification of Disability form)
STATE OF TEXAS
COUNTY OF TRAVIS
This instrument was acknowledged before me on the ____________ day of ___________________, 20_____ , by
__________________________________________________________.
Notary Public, State of Texas
My commission expires: ___________________________.
FY 2014-2015 0ctober 1, 2014
HOUSING QUALITY STANDARDS/VISITABILTY
EXISTING HOME INSPECTION AGREEMENT
We/I, ______________________________________________________________________________________, as an
applicant(s) to Neighborhood Housing and Community Development’s “Down Payment Assistance” (DPA) Program
hereby agree to and understand the following:
A Housing Quality Standards (HQS) Inspection defined by the U.S. Department of Housing and Urban
Development (HUD) is required of each existing home purchased under the DPA Program. This inspection will
be performed by a HQS-certified Inspector.
This inspection is a requirement of HUD and in no way should serve in lieu of a structural inspection of the
property. Neighborhood Housing and Community Development (NHCD) encourages the Buyer/Purchaser to
obtain a separate inspection or report that addresses the structural integrity of the property.
I (we) understand that all utilities must be ON for the inspection to occur.
I (we) understand that all repairs identified as necessary through the HQS Inspection must be completed before
the date of closing, as a condition of participation in the DPA Program. The repairs may be undertaken through
agreements with the Seller, or through other means determined to be acceptable in consultation with NHCD.
Follow up inspections will be required to assure that necessary repairs identified in the initial HQS inspection are
completed satisfactorily.
If lead-based paint hazards are found at the time of the HQS inspection, a certified contractor will have to follow
HUD’s safe work practice methods.
HQS inspections (by NHCD inspectors only) are paid for by NHCD.
Subject Property: _________________________________________________________________________________
_______________________________________________ _______________________________
Applicant Signature Date
_______________________________________________ _______________________________
Co-Applicant/NPS Signature Date
_______________________________________________ _______________________________
Seller Signature Date
_______________________________________________ _______________________________
Seller Signature Date
** ALL DOCUMENTS WITH ORIGINAL SIGNATURES MUST BE SUMBITTED PRIOR TO APPROVAL**
FY 2014-2015 0ctober 1, 2014
BUYERS/SELLERS CERTIFICATION OF PURCHASE
Date:
Property Being Sold: ________________________________________________________________________________
Owner(s)/Seller(s):__________________________________________________________________________________
Buyer(s):_____________________________________________________________________________________
Dear Owner(s)/Seller(s):
The property referenced above is believed to be owned by you is being considered for purchase. Because Federal funds, in the
form of downpayment and closing cost assistance to the Buyer(s), may be used in the purchase of your property, we are
required to disclose the following information by the U. S. Department of Housing and Urban Development (HUD) in accordance
with the Uniform Relocation Assistance and Real Property Acquisition Policies Act as amended (URA), Section 24.101(b) (2):
1. The proposed sale is voluntary. In the event negotiations fail to result in an agreement, the property will not be
acquired by either voluntary purchase or eminent domain.
2. The fair market value of the property is estimated to be $ . However, since this transaction is
voluntary, current or future negotiations may result in a different price that may be the same, higher or lower than this
amount.
An owner-occupant who sells his or her property under these terms does not qualify as a displaced person for relocation
payments. Additionally, any person who occupies the property for the purpose of obtaining assistance under the URA does not
qualify as a displaced person. However, tenant-occupants displaced as a result of a voluntary acquisition may be entitled to
URA relocation assistance and must be informed in writing as soon as feasible.
In accordance with HUD requirements, if the information provided above is disclosed after an option to purchase or contract has
been executed between the Buyer(s) and the Seller(s), the Seller(s) must be provided the opportunity to withdraw from the
agreement.
Any title deficiencies, liens, or encumbrances on the property must be cleared prior to any closing. Generally, this is a cost that
is borne by the Seller(s) of the property; however, payment of these costs may be negotiated between the Buyer(s) and
Seller(s). No federal funds can be used to pay these costs.
Should you have any questions, please feel free to contact (lender’s name)
at telephone number .
** ONLY APPLICATIONS WITH ORIGINAL SIGNATURES WILL BE ACCEPTED**
Buyer(s) Date Buyer(s) Date
Seller(s) Date Seller(s) Date
WARNING: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly
making false or fraudulent statements to any department of the United States Government.
FY 2014-2015 0ctober 1, 2014
We Do Business in Accordance With
Federal Fair Lending Laws
UNDER THE FEDERAL FAIR HOUSING ACT, IT IS ILLEGAL, ON THE BASIS
OF RACE, COLOR, NATIONAL ORIGIN, RELIGION, SEX, HANDICAP,
OR FAMILIAL STATUS (HAVING CHILDREN UNDER THE AGE OF 18), TO:
Deny a loan for the purpose of purchasing,
constructing, improving, repairing or maintaining a
dwelling, or deny any loan secured by a dwelling; or
Discriminate in fixing the amount, interest rate,
duration, application procedures or other terms or
conditions of such a loan, or in appraising property
IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST,
YOU SHOULD SEND A COMPLAINT TO:
Assistant Secretary for Fair Housing and Equal Opportunity
Department of Housing & Urban Development
Washington, DC 20410
For processing under the Federal Fair Housing Act
and to:
Division of Compliance and Consumer Affairs
Federal Deposit Insurance Corporation
Washington, DC 20429-9990
For processing under FDIC regulations
UNDER THE EQUAL CREDIT OPPORTUNITY ACT,
IT IS ILLEGAL TO DISCRIMINATE IN ANY CREDIT TRANSACTION:
On the basis of race, color, national origin, religion,
sex, marital status, or age,
Because income is from public assistance, or
Because a right was exercised under the Consumer
Credit Protection Act
IF YOU BELIEVE YOU HAVE BEEN DISCRIMINATED AGAINST,
YOU SHOULD SEND A COMPLAINT TO:
Division of Compliance and Consumer Affairs
Federal Deposit Insurance Corporation
Washington, DC 20429-9990
________________________ ____________ _______________________ _________
Applicant Signature Date Co-Applicant Signature Date
FY 2014-2015 0ctober 1, 2014
HOME Program
Eligibility Release Form
Organization requesting release of information (PJ
name, address, telephone, and date)
Purpose: Your signature on this HOME Program
Eligibility Release Form, and the signatures of each
member of your household who is 18 years of age or
older, authorizes the above-named organization to
obtain information from a third party relative to your
eligibility and continued participation in the:
HOME TBRA Program HOME
Homebuyer Program
HOME Rental Rehabilitation Program HOME
Homeowner Rehabilitation Program
Privacy Act Notice Statement: The Department of
Housing and Urban Development (HUD) is requiring the
collection of the information derived from this form to
determine an applicant’s eligibility in a HOME Program
and the amount of assistance necessary using HOME
funds. This information will be used to establish level of
benefit on the HOME Program; to protect the
Government’s financial interest; and to verify the
accuracy of the information furnished. It may be
released to appropriate Federal, state, and local
agencies when relevant to civil, criminal, or regulatory
investigators, and to prosecutors. Failure to provide
any information may result in a delay or rejection of
your eligibility approval. The Department is authorized
to ask for this information by the National Affordable
Housing Act of 1990.
Instructions: Each adult member of the household
must sign a HOME Program Eligibility Release Form
prior to the receipt of benefit and on an annual basis to
establish continued eligibility. Additional signatures
must be obtained from new adult members whenever
they join the household or whenever members of the
household become 18 years of age.
NOTE: THIS GENERAL CONSENT MAY NOT BE
USED TO REQUEST A COPY OF A TAX
RETURN. IF A COPY OF A TAX RETURN IS
NEEDED, IRS FORM 4506, “REQUEST FOR
COPY OF TAX FORM” MUST BE PREPARED
AND SIGNED SEPARATELY.
Information Covered: Inquiries may be made about
items initialed by applicant/tenant.
Initials
Initials
Income (all sources)
Assets (all sources)
Child Care Expense
Handicap Assistance
Expense (if applicable)
Medical Expense (if
applicable)
Other (list)
Dependent Deduction
Full-Time Student
Handicap/Disabled
Family Member
Minor Children
Authorization: I authorize the above-named HOME
Participating Jurisdiction and HUD to obtain
information about me and my household that is
pertinent to eligibility for participation in the HOME
Program.
I acknowledge that:
(1) A photocopy of this form is as valid as the
original.
(2) I have the right to review the file and the
information received using this form (with a
person of my choosing to accompany me).
(3) I have the right to copy information from this
file and to request correction of information I
believe inaccurate.
(4) All adult household members will sign this form
and cooperate with the owner in this process.
Head of Household—Signature, Printed Name, and Date: Family Member
HEAD
Other Adult Member of the Household—Signature, Printed Name, and Date:
Family Member #2
Other Adult Member of the Household—Signature, Printed Name, and Date:
Family Member #3
Other Adult Member of the Household—Signature, Printed Name, and Date:
Family Member #4