County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

Hurricane Matthew Housing Program 1 of 8

Funding is available to assist eligible homeowners with damage to their homes from Hurricane Matthew.

This application will be used to identify potentially eligible homeowners in need of pre-1994 manufactured/mobile home replacement or single-family housing rehabilitation.

This program does not pay for repairs that have already been completed.

Following an application review, the applicant will be notified of eligibility status or additional documentation needed. Submitting an application does not guarantee funding.

For assistance with this application, contact Community Assistance at (386) 736-5955.

Contacta el Volusia County (386-736-5955) para obtener más información, impreso en español.

Type or use blue or black ink to complete all sections of the application as described below.

Submit the completed application and all required documents in person or by mail to:

County of Volusia Community Assistance

110 W. Rich Avenue DeLand, FL 32720

(386) 736-5955

Applicant Name:

A. Preliminary eligibility criteria – use this tool to determine if you may be eligible for the program.

1. Was your home damaged or destroyed by Hurricane Matthew? Yes No Stop here; you do not qualify

2. Is your home a single family residence? (including mobile/manufactured housing units) Yes No Stop here; you do not qualify

3. Is the home located in Volusia County? Yes No Stop here; you do not qualify

4. Do you own the home you are applying for? Yes No Stop here; you do not qualify

5. At the time of the disaster, was the unit your primary residence? Yes No Stop here; you do not qualify

6. Have all disaster related repairs on the home been completed? Yes Stop here; you do not qualify No

7. Is your annual gross household income at or below the maximum income limits for your household size? Yes No Stop here; you do not qualify

Household Size 1 2 3 4 5 6

80% $34,300 $39,200 $44,100 $48,950 $52,900 $56,800

8. Is the damaged property currently in foreclosure? Yes Stop here; you do not qualify No

9. Are you currently in bankruptcy that has not been discharged? Yes Stop here; you do not qualify No

10. Are you requesting assistance for one of the following listed below? Yes Please check ONE below

No Stop here; you do not qualify

My pre-1994 mobile or manufactured home on a rented lot is damaged

My pre-1994 mobile or manufactured home on land I own is damaged

My “stick-built” single-family home is damaged and in need of repair

If you meet the questionnaire qualifications shown above, please proceed with the application package.

County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

This checklist is designed to assist your household in gathering the required documents necessary to

complete the application package. This checklist must be submitted with the application.

Applicant Name:

B. Application checklist – Ensure all applicable items are included when submitting your application

Application and release form – completed and signed by all household members 18 or older Original

Picture ID for all household members 18 or older Copy

Social Security Card for all household members Copy

Birth Certificate for household members under the age of 18 Copy

Last 3 months of consecutive paystubs for all employed household members Copy

Note: Self-employed persons must submit the last 2 years tax returns along with a year-to-date profit and loss statement.

Current copy of any Social Security statement/award letter (1099 is not acceptable) Copy

Current copy of any retirement/pension statements (1099 is not acceptable) Copy

Current copy of unemployment statement (if applicable) Copy

Current copy of Temporary Assistance for Needy Families (TANF – cash assistance) (if applicable) Copy

Current copy of any other income in the household; e.g, rental income, child support, alimony (if applicable)

Copy

Last 6 months bank statements/history print out for all accounts for each household member Copy

Proof of ownership For single-family home this is a Warranty or Quit Claim Deed

For a manufactured home this is a Certificate of Title Copy

FEMA Award/Denial Letter Copy

Small Business Administration (SBA) Award/Denial Letter Copy

Property Insurance Statement of Loss (If you did not have private insurance, an original, signed and dated statement indicating that you had no private insurance will be acceptable.)

Copy

Failure to provide any of the above-mentioned documentation may result in denial of assistance.

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County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

Hurricane Matthew Housing Program 3 of 8

C. Applicant(s) information:

TO BE COMPLETED BY APPLICANT (Head of Household):

Last Name:

Middle Name:

First Name:

Current Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Daytime phone:

Mobile Phone:

E-mail Address:

D. Household composition, characteristics, and familial status: As of today, list the Head of Household and all

ndicate if there are any additional members in the near future to the household.sibling, etc.). I, members of the household. Indicate the relationship of each family member to the Head of Household (spouse

Household Member NameRelationship to Head of Household

Date of BirthMarital Status

Is householdmember listed disabled? Y/N

Employed Y/N

Additional Members in the next (12) Months? If yes,

explain, e.g. birth of a child, adoption,

legal custody.

Head of Household

County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

Hurricane Matthew Housing Program 4 of 8

E. Race and ethnicity for head of household: -This information is being collected to ensure compliance with federal Fair Housing and Equal Opportunity regulations.

1. Race (Check all that apply):

☐ American Indian or Alaska Native ☐ Asian

☐ Native Hawaiian or Other Pacific Islander ☐ White

☐ Black or African American ☐ Other Multi-Racial

2. Ethnicity (Check one):

☐ Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race. The term, “Spanish origin,” can be used in addition to “Hispanic or Latino.”

☐ Non-Hispanic or Latino - A person not of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

F. Damaged Property Information: Provide basic information concerning the damaged property

1. Damaged Property Street Address:

City: State: Zip:

2. What type of structure is the property? (Select One)

☐ Single Family ☐ Manufactured Housing Unit ☐ Modular ☐ Other (Describe):

3. Year Built:

4. Are you currently living in the property? ☐ Yes ☐ No

If no, explain your current living situation:

5. Is the damaged property in a Flood Plain? ☐ Yes ☐ No ☐ Don't Know

6. Are you seeking assistance for a manufactured/modular housing unit? ☐ Yes ☐ No

If yes, do you own the land? ☐ Yes ☐ No ☐ Don't Know

7. Are there any other names on the deed or Certificate of Title for the damaged property? ☐ Yes ☐ No

If yes, please list any other names:

County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

Hurricane Matthew Housing Program 5 of 8

G. Other assistance received - Assistance provided under this program may not exceed a household's unmet

need for the disaster. List all disaster related FEMA and SBA assistance. List all insurance companies that were

providing coverage to your real property on the date of the disaster, companies currently covering the

property, and disaster related claims filed. List all sources of disaster related assistance received (local, state,

federal, private sources, non-profit and volunteer services).

Have you applied for any event related assistance for damage to your home from any source (local, state, federal, private)? If yes, proceed with this section. If no, proceed with Income Information (Section H).

☐Yes

☐ No

1. FEMA

a. Have you received any disaster related assistance from FEMA for structural damage to your home? (If no, continue to 2 in this section.)

☐ Yes

☐No Amount Approved? Amount Received to date:

b. What is your FEMA Registration No.(s)? 1

2 2. Small Business Administration

a. Have you received any event-related assistance from the SBA for damage to your home? (If no, continue to 3 in this section.) ☐ Yes ☐ No

Amount Approved: Amount Received to date:

b. What is your SBA Application No.(s)? 1

2

c. What is your SBA Loan No.(s)? 1

2 d. What is the status of your SBA Loan, e.g. paying as agreed, did not use, etc.

3. Insurance

a. Were you carrying Homeowner's Insurance at the time of the event? (If no, continue to 4 in this section.) ☐ Yes ☐ No If “Yes”, what type? ☐ Hazard ☐ Wind ☐ Flood ☐ Contents Other : (Explain)

b. Did you file a claim? ☐ Yes ☐ No

Claim Amount Received: Deductible: Purpose of claim:

c. Provide the name of the Insurance Company(s):

d. Is the insurance coverage currently in effect? ☐ Yes ☐ No

e. Are you involved in an appeal or a lawsuit against your insurance company? ☐ Yes ☐ No

f. What is the status of your insurance appeal/lawsuit? (If Applicable)

4. Other

a. Did you receive any other assistance for the repair of your home? ☐ Yes ☐ No If yes, explain the amount and type of assistance you received e.g. Red Cross, United Way, Volusia County Owner Occupied Rehabilitation Program, Volusia County SHIP Disaster Recovery, VIND, Salvation Army, volunteer services, faith-based organizations, etc.

County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

H. Income information: List ALL household members and their incomes. Attach a separate sheet if you need more space. Income includes: wages, salaries and tips, alimony, child support, military income, part-time income, temporary income, unemployment benefits, TANF, Social Security, other benefits, or other income for all household members over age 18. Food Stamps (SNAP) are not considered income - do not list food stamps.

Household Member NameFull Time

Student? Y/NSource of Income

*See examples of items to list above.Monthly Income

I. Asset information: Provide the requested information on any property you may own or assets you may have.

1. Do you own any other real estate? ☐ Yes ☐ No

If yes, provide address, city and state of property(s):

2. Do you have a mortgage on the damaged property you are seeking assistance on? ☐ Yes ☐ No

If yes, what is the current balance owed on the mortgage?

3. Typical Assets List ALL household members below. Check yes or no for each family member and asset type. Attach a separate sheet if you need more space

Household Member Name Checking Savings/CDs401(k), Pension,

IRA

Stocks, Bonds,

Non-retirement

Investments

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No

4. Additional Assets: Describe below any other household assets other than what is explained above in section 3, if applicable. Examples of additional assets are: treasury bills, collections held as an investment, cash value of a life insurance policy available prior to death, etc.

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County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

J. Applicant Certification: Certify that all the information in the application is true, to the best of your knowledge. By signing this application to verify the information contained, the applicant authorizes the state or any of its duly authorized representatives herein.

PENALTIES FOR FALSE OR FRAUDULENT STATEMENT: Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment provided under Statutes 775.082 or 775.83.

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. WRITTEN STATEMENT REGARDING TO COLLECTION AND USE OF SOCIAL SECURITY NUMBERS: This statement is being provided to you pursuant to Section 119.071(5), Florida Statues. The Community Assistance Division is required by 24 CFR 5.210, to collect the social security number(s) of applicant(s) and their household members, if any. Social security numbers are unique numeric identities that are used by this office to identify, verify, track and search information in conjunction with an applicant’s application for assistance. Community Assistance Division may disclose social security numbers to another agency or governmental entity if it is necessary for the receiving agency or governmental agency to perform its duties and responsibilities.

FLORIDA’S PUBLIC RECORDS LAW: Information provided by applicant(s) may be subject to Chapter 119 Florida Statutes, regarding Open Records. DUPLICATION OF BENEFITS: In the event the homeowner received, receives or is scheduled to receive additional funds related to Hurricane Matthew not previously disclosed to Community Assistance, the homeowner shall immediately notify Community Assistance who will determine if the funds or a portion of the funds are a duplication of benefits. I/We understand the information provided above is collected to determine if I/we are eligible to receive assistance under the Hurricane Matthew Housing Program for the disaster.I/We hereby certify that all the information provided herein is true and correct.I/We understand that providing false statements or information is grounds for termination of housing assistance and is punishable under federal law.I/We authorize the above-referenced County of Volusia and any of its duly authorized representatives to verify all information provided in this application.I/We understand that additional information will likely be required to move forward with this program.I/We understand an agreement, including a certification on Duplication of Benefits (DOB), must be executed I/We acknowledge in the event of DOB, repayment of funds will be determined by the County of Volusia.

ALL HOUSEHOLD MEMBERS 18 YEARS OF AGE OR OLDER MUST SIGN THIS APPLICATION:

Signature: Date:

Signature: Date:

Signature: Date:

Signature: Date:

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County of Volusia

Community Development Block Grant – Disaster Recovery

HURRICANE MATTHEW HOUSING PROGRAM

K. Eligibility Release: It is required that you sign this form, which allows the County of Volusia, State or Vendor to request information from Third Parties concerning your eligibility and participation in this program.

Applicant Name:

Applicant Address: Information Covered: Inquiries may be made about items initialed below by the applicant. Instructions to Applicant: Your signature on this Eligibility Release, and the signatures of each member of your household who is 18 years of age or older, authorizes the state or any of its duly authorized representatives to obtain information from a third party regarding your eligibility and continued participation in the Hurricane Matthew Housing Program for disaster. Each adult member of the household must sign this Eligibility Release. Privacy Act Notice Statement: County of Volusia requires the collection of the information listed in this form to determine an applicant's eligibility for the Program. This information will be used to establish the level of benefits for which the applicant is eligible and to verify the accuracy of the information furnished. Information received from an applicant or as a result of verifying an applicant's eligibility may be released to appropriate Federal, State, and local agencies or, when relevant, to civil, criminal, or regulatory investigators, and to prosecutors. Failure to provide any information may result in delay or rejection of your eligibility approval. County of Volusia is authorized to ask for this information under the National Affordable Housing Act of 1990.

Information Covered: Inquiries may be made about items listed below.

Past and Present Employers Agencies Providing Welfare or Assistance

Unemployment Agencies Social Security Administration

Support and Alimony Providers Retirement Systems

Property Taxes Dependent Income: Full-time Student

Veterans Administration Insurance Agent and/or Agency

Banks and Financial Institutions Assets (all sources)

Florida State Department of Economic Opportunity FEMA

Applicant’s Authorization: I authorize the above-named County of Volusia, to obtain information about me and my household that is pertinent to determining my eligibility for participation in the Program. I acknowledge that:

(1) A photocopy of this form is as valid as the original; AND (2) I have the right to review information received using this form; AND (3) I have the right to a copy of information provided to the County of Volusia and to request correction of any

information I believe to be inaccurate; AND (4) All adult household members will sign this form and cooperate with the County of Volusia in the eligibility

verification process.

ALL HOUSEHOLD MEMBERS 18 YEARS OF AGE OR OLDER MUST SIGN THIS APPLICATION:

Signature: Date:

Signature: Date:

Signature: Date:

Signature: Date:

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