Quick Guide to Utility Connection Grant Program · Proof that you are current on your mortgage...

CITY OF CAPE CORAL

QUICK GUIDE TO THE UTILITY CONNECTION GRANT PROGRAM

Purpose of Program The purpose of this program is assist income qualified homeowners with the cost of connecting to City utilities when they become available. The funding is provided by the US Department of HUD Community Development Block Grant and the State of Florida State Housing Initiative Partnership (SHIP) Program and is subject to availablity.

Homeowner Benefit Homeowners will receive a one-time grant for the connection to the City’s water, sewer, and irrigation systems.

Eligible Applicants • Must meet income guidelines. These limits are based on

the income and assets of all residents in the household and adjusted on an annual basis. (See Income Guidelines Chart Below)

Lee County, Florida

Income Guidelines Chart (2014)* Your annual income must fall within the

categories below Household

Size Low

Up to 50% MI Moderate

50.01-80% MI

1 $20,300 $32,500

2 $23,200 $37,150

3 $26,100 $41,800

4 $29,000 $46,400

5 $31,350 $50,150

6 $33,650 $53,850

7 $36,000 $57,550

8 $38,300 $61,250

*Will change annually

• The home must be the primary residence of the client. • Must have legal right to reside permanently in the United

States. • The homeowner must be current on monthly mortgage

payments and maintain homeowners and flood insurance (if applicable).

• Calculated homeowner assets (as defined by US Department of HUD) cannot exceed $20,000.

Eligible Properties Free standing single family homes, condominium units, and duplexes that have a separate strap and fee simple ownership.

Funding Qualified buyers will receive assistance in the form of a grant from the City of Cape Coral.

Qualifying items

• Payment to plumber for connection of home to utility • Abandonment of septic tank • Septic Abandonment Fee • Meter Fee

Homeowner Maximum Assistance A maximum grant award of $2,000 is available per property.

Application and Program Information This program is being run by City of Cape Coral Housing Development Corporation, a non-profit corporation. The Agency is located at 609 SE 9th TER, Cape Coral. The Agency can be reach at (239) 471-0922. An application can be requested by phone, email, or by visiting the Agency.

The application must be submitted in person at Cape Coral Housing Development Corporation. The Agency will accept applications every Wednesday, beginning October 1, 2014 from 1pm – 4pm.

Once a completed application is submitted, Agency staff will set up an in-person intake interview to discuss the program, the process, and the requirements in detail.

Submission of an application does not ensure you will be awarded funding. Funding is limited and is awarded on a first come, first approved basis.

Applications may be submitted to our offices at 609 SE 9th

Ter, Cape Coral, FL 33990.

PLEASE BE ADVISED THAT THIS DOCUMENT DOES NOT INCLUDE ALL REQUIREMENTS FOR THIS PROGRAM AND IT IS SUBJECT TO CHANGE AT ANYTIME AT THE DIRECTION OF PROGRAM ADMINISTRATORS AND THE US DEPARTMENT OF HUD.

UTILITY CONNECTION GRANT PROGRAM APPLICATION REQUIREMENTS

In order to properly process your application, please be sure to include copies of the following:

□ Social Security card for all occupants as well as driver's licenses if applicable.

□ If not a US citizen, you must bring proof of Permanent Resident Alien Status.

□ Proof of income other than employment (i.e. SSI, Child Support, Disability)

□ If self-employed: last three (3) years tax return (including Profit & Loss statement)

□ Birth Certificates for all children

□ Last two months of pay stubs

□ Proof that you are current on your mortgage payments. (Please provide mortgage statements for the most recent 3 months).

□ You must be current in your property taxes to the City

□ Proof of hazard insurance (which may include a copy of your homeowner's insurance or fire insurance policy)

□ Proof of flood insurance if required by Law. Use of Federal funds require flood insurance even if your mortgage is paid off

NOTE: Additional information may be needed to determine eligibility once the information provided above is reviewed.

1

CAPE CORAL HOUSING DEVELOPMENT CORPORATION 609 SE 9th TER, Cape Coral, FL 33990

Phone: (239) 471-0922; Fax: (239) 471-0915

APPLICATION FOR UTILITY CONNECTION GRANT PROGRAM

APPLICANT INFORMATION FILE#

APPLICANT NAME:

CO-APPLICANT NAME:

Home Phone: Work Phone: Cell Phone:

APPLICANT'S E-MAIL ADDRESS:

ADDRESS:

CITY: STATE: ZIP:

STRAP# OF PROPERTY:

I am applying for assistance with the utility connection cost at above referenced property.

DECLARATIONS (circle one) A CO-AP

Are you a US citizen or Permanent Resident Alien? Yes No Yes No Do you have any outstanding unpaid collections or judgments? Yes No Yes No Have you been declared bankrupt within the past 7 years? Yes No Yes No Do you or the co-applicant's combined value of assets exceed $20,000? Yes No Yes No Have you ever been awarded child support for any of your children, regardless of whether Yes No Yes No

or not it is received? If yes, in what State or County was it awarded? Is applicant, co-applicant or any other household member over the age of 18 a full-time student? Yes No Yes No

lf so, who? Is anyo,ne in your household expecting a child? Yes No Yes No Is anyone in your household handicapped or developmentally disabled? Yes No Yes No

PROPERTY INFORMATION - please provide the following items (if applicable):

1. Proof of Property Ownership (this may include the copy or original of one of the following items: warranty deed, quitclaim deed, homestead exemption, tax records, life estate). 2. Proof that you are current in your property taxes to the city (this may include a copy or original of one of the following items: property tax payment receipt from the city, cancelled check to the city for property taxes, affidavit certifying payment of property taxes, mortgage statement from lenders indicating taxes were paid). 3. Proof of hazard insurance (which may include a copy of your homeowner's insurance or fire insurance policy). 4. Proof of flood insurance if required by Law. 5. Is the above referenced property the subject of a pending foreclosure? (circle one) Yes No

HOUSEHOLD INFORMATION (Include all household members) Relationship to Applicant

Name Social Security Number

Date of Birth

Age Sex Marital Status M,S, W, D

Race* Hispanic (check if applicable)

Aoolicant

2

SOURCE APPLICANT CO-APPLICANT OTHER MEMBERS 18OROVER

TOTAL

Gross Salary

Overti JJ1e, Tips, Bonuses, etc. Alimo9y/Child Support

Social Security/SSI Retirement/Pension

AFDC, Welfare

Interest/Dividends

Unemployment, Workers Comp Rental'Netlncome

Business Net Income

Other

* i.e. White (W) Black or African American (B) Asian (A) American Indian or Alaskan Native (I) Native Hawaiian or Other Pacific Islander (H) American Indian/Alaska Native and White (I and W) Asian and White (A and W) Black/African American and White (Band W) American Indian/Alaskan Native and Black/African American (I and B) Other Multi-Racial (0) Total Number of Persons in the Household:

_ _ Elderly __ Handicapped __ Fann Worker __ Developmentally Disabled Other

House;hold Type (circle one): Single Two Parent Single Parent APPLICANT'S EMPLOYMENT (minimum last 2 years J EMPLOYER: PHONE: FAX: ADDRESS: YEARS EMPLOYED: POSITION SUPERVISOR: PREVIOUS EMPLOYER: PHONE: FAX: ADDRESS: YEARS EMPLOYED: POSITION SUPERVISOR:

EMPLOYER: PHONE: FAX: ADDRESS: YEARS EMPLOYED: POSITION SUPERVISOR: PREVIOUS EMPLOYER: PHONE: FAX: ADDRESS: YEARS EMPLOYED: POSITION SUPERVISOR:

CO-APPLICANT'S EMPLOYMENT (minimum last 2 years J

ANNUAL HOUSEHOLD INCOME

ASSETS TYPE INSITITUTION OWNER ACCOUNT# CASH VALUE

Checking Account $ Savings Account $ Stocks, Bonds, CD's $ IRA' s, 401(k) $ Equity in Properties $ Life Insurance $ Other $ LIABILITIES (This is not consideration for assistance)

TYPE CREDITOR'S NAME MONTHLY PAYMENT BALANCE Mortgage Credit card balances

Outstanding loans

Personal loans Medical bills

Car loan

Other

3

I ---------------------~ hereby certify that I am a permanent resident of Lee County, Florida, and my property is NOT the subject ofa pending or threatened foreclosure, and no mortgage (or other encumbrance creating a lien against the property) is in default.

I understand that Florida Statue 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 Statues 775.082 or 775.83. I further understand that any willful misstatement of information will be grounds for disqualification. I certify that the application information provided is true and complete to the best ofmy knowledge. I consent to the disclosure of information for the purpose of income verification related to making determination of my eligibility for UTITLITY CONNECTION GRANT PROGRAM assistance. I agree to provide any documentation needed to assist in determining eligibility and am aware that all information and documents provided are a matter of public record and subject to public review in accordance with Florida's public record law, Chapter 119, Florida Statutes.

Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true and that all additional information submitted by me in connection with my Utility Connection Grant Program is true and correct.

Signature of Applicant Date

I ______________________ ., hereby certify that I am a permanent resident of Lee County, Florida, and my property is NOT the subject of a pending or threatened foreclosure, and no mortgage ( or other encumbrance creating a lien against the property) is in default.

I understand that Florida Statue 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 Statues 775.082 or 775.83. I further understand that any willful misstatement of information will be grounds for disqualification. I certify that the application information provided is true and complete to the best of my knowledge. I consent to the disclosure of information for the purpose of income verification related to making determination of my eligibility for UTITLITY CONNECTION GRANT PROGRAM assistance. I agree to provide any documentation needed to assist in determining eligibility and am aware that all information and documents provided are a matter of public record and subject to public review in accordance with Florida's public record law, Chapter 119, Florida Statutes.

Under penalties of perjury, I declare that I have read the foregoing and that the facts stated in it are true and that all additional information submitted by me in connection with my Utility Connection Grant Program is true and correct.

Signatlure of Co-Applicant Date

4

THIRD-PARTY VERIFICATION OF EMPLOYMENT •

State and/or Federal Regulations require us to verify employment history and income information for the --I = :;;:,::, person that has provided authorization below, in order to determine their eligibility for program C

I assistance. Your cooperation in providing the requested information below is most appreciated. --c 2 3 9 4 7 1 0 91 5 > A self-addressed return envelope is enclosed or you may fax to: __ _ _-_ _ _-__ _ __________ _ :;;:,::,

I --I -< -< Authorization: m :;;:,::, I hereby authorize the release of requested information. A copy of the executed "Authorization for the .....

release of Information" is attached which indicates my agreement with the release of information requested ,...... for the sole purpose of determining eligibility for program assistance. =::j

c::,

= c::, Signature of Applicant Print Name Date .....

m ::3: --c Co-ApplicanVHousehold Member Print Name Date ,--0 -<

Please return information to: ::3: m

Name: Elena Schwartz Title: Client Coordinator --I = Department: Cape Coral Housing Development Corporation Phone: 239-471-0922

609 SE 9th TER, Cape Coral, FL 33990 ress: ____________________________________ _ Add

Employer/Company Name: _____________________________ _

Address: ____________________________________ _

City: ________________ State: __________ Zip: _______ _

Please provide information about anticipated employment income during the next 12 months:

Position:. _____________________ Length of Time Employed: ______ _

Pay Rate: ___________ Pay Frequency (Hr, Wk, Mo): _____________ _

Overtime Pay Rate: Average Overtime Hours/Wk: ______________ _

Total Annual Base Pay Earnings: $ Total Overtime Base Pay Earnings: $. ______ _

Amount and Frequency of Other Compensation (bonus, raise, commission, tips): $ ___________ _

Vacation Pay (Y or N): _____________ If yes, number of days: ___________ _

Retirement Account (Y or N): Amount Accessible to Employee: $ __________ _

Total Gross Annual Income, including other compensation, for next 12 months:$ ____________ _

Signature of authorized representative: __________________________ _

Printed Name: __________________ Title: ______________ _

Date:. _____________________ Phone: _____________ _

WARNING: 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 and 775.083.

NOTE: For ALL applicable Household Members 18 years or over, obtain a signed copy of this form for each verification to be completed. Send form directly to the appropriate employment source; do not send form through applicant. Upon receiving verification, date-stamp, and compare information to that received on application. Make any necessary notations, date and initial. If significant differences exist between amount reported and verified, obtain a written explanation from applicant and attach to file.

FHC/FHFC Revised July 2008 PROGRAM ADMINISTRATION ■ DI

THIRD-PARTY VERIFICATION OF ASSET INCOME (To Be Completed For All Household Members, Including Minors)

• State and/or Federal Regulations require us to verify asset income information for the person that has provided --I authorization below, in order to determine their eligibility for program assistance. Your cooperation in ::c providing the requested information below is most appreciated. A self-addressed return envelope is enclosed or ::,:::,

C, you may fax to: 239-471-0915 I """Cl )>

Authorization: ::,:::,

I hereby authorize the release of requested information. A copy of the executed "Authorization for the Release of --I -<

Information" is attached which indicates my agreement with the release of information requested for the sole -< m

urpose of determining eligibility for program assistance. ::,:::,

r, )>

Signature of Applicant Print Name Date --I

0 :z: Co-Applicant/Household Member Print Name Date 0

Please return information to:

Name: Elena Schwart z Title: Client Coordinator

Department: Cape Coral Housing Development Corporation Phone: _23_9_-_4_7_1_-_0 9_2_2 ________ _

Address: 60 9 SE 9th TER, Cape Coral, FL 33990

To: Name of Institution: _________________________________ _

Address: ______________ City: _________ State: _____ Zip: __ _

Complete the (applicable) Sections below:

""T"'I

Checking account No. Average monthly balance for last 6 months

Current interest rate

Withdrawal penalty

Savings account No. Current Balance Current interest rate

Money Market account No. Average monthly balance for last 6 months

Current interest rate

Certificate of deposit account No. Amount Current interest rate

RA, Keogh, retirement account No. Amount Current interest rate Withdrawal penalty

Signature of authorized representative: __________________________ _

Printed Name: ______________________ Title: ___________ _

Date: ___________________ Phone: ________________ _


FHC/fHFC Revised July 2008 PROGRAM ADMINISTRATION ■ 02

-------------

TH I RD-PARTY VERIFICATION OF REGULAR CASH CONTRIBUTIONS (i.e. Rents Income, Regular Family Assistance, Alimony, etc.) •

State and/or Federal Regulations require us to verify regular cash contributions made to the person that has provided authorization below, in order to determine their eligibility for program assistance. Your cooperation in providing the requested information below is most appreciated. A self-addressed return envelope is enclosed or you may fax to: _2_3_9-_4_7_1_-_09_1_s _____ _

...., Authorization: t'""'I

I hereby authorize the release of requested information. A copy of the executed "Authorization for the l> -C) Release of Information" is attached which indicates my agreement with the release of information = C) equested for the sole purpose of determining eligibility for program assistance. ...., == l"T'I

C: Signature of Applicant Print Name Date ~

rl>

== t'""'I Co-Applicant/Household Member Print Name Date l> ...., :::c t'""'I

-C) Please return information to: = Name: Elena Schwartz Title: Client Coordin -Oepartment:_cc_H_n_c ___ _ == -g:J

C: Address: 609 SE 9th TER, Cape Coral , FL 33990 Phone: 239-471-0922 C)

...., To:------------------------------- = Address: ____________ City: ________ State:. ___ Zip: __

Type of Contribution: _________ _ Amount:

Frequency of contribution (circle one): _daily _weekly _monthly _yearly

Will payment continue over the next 12 months (circle one): Yes _No

Expected termination date of cash contributions: ___________ _

Anticipate total cash contributions over the next 12 months: $ ___________ _

Signature of Authorized Representative: ____________________________ _ Printed Name: ________________________ Title: _______ _ Date: __________________ Phone: _____________ _


NOTE: For ALL applicable household Members 18 years or over, obtain a signed copy of this form for each verification to be completed. Send form directly to the appropriate source; do not send form through applicant. Upon receiving verification, datestamp, and compare information to that received on application. Make any necessary notations, date and initial. If significant differences exist between amount reported and verified, obtain a written explanation from applicant and attach to file.

FHC/FHFC Revised July 2008 PROGRAM ADMINISTRATION ■ D4

THIRD-PARTY VERIFICATION OF SOCIAL SECURITY BENEFITS •

State and/or Federal Regulations require us to verify Social Security Benefit income for the person that has provided authorization below, in order to determine their eligibility for program assistance. Your cooperation in providing the requested information below is most appreciated. A self-addressed return envelope is enclosed or you may fax to: _ 2_3_9_-_47_1_-_0_9_1s _____ _

Authorization: -,., ,..... I hereby authorize the release of requested information. A copy of the executed "Authorization for the ~ Release of Information" is attached which indicates my agreement with the release of information 0

requested for the sole purpose of determining eligibility for program assistance. = \ -,., 0

...... 0 ,.....

Signature of Applicant Print Name Date > r-......

-m ,..... Co-Applicant/Household Member Print Name Date c:::: :::a

Please return Information to: -< l:l0

-m

m = Name: Elena Schwartz Title: Client Coordinator -,.,

Department: Cape Coral Housing Dev. Corp. Phone: 239-411-0922 ......

Address: 609 SE 9th TER, Cape Coral, FL 33990

To: Name of Institution Social Security Administration

Address: ___________ _ City: _________ State: ___ Zip: __

Complete the Sections below:

Date of Birth: ___________ Social Security #: ______________ _

Type of Social Security Benefit: Gross Monthly Amount: $ ___________ _

Type of Supplemental Security Benefit: ____ Gross Monthly Amount: $ _________ _

Deduction for Medicare (Y or N): If yes, Amount Deducted: $ _________ _

Signature of Authorized Representative: ______________________ _

Printed Name:. _______________ Title:. ________________ _

Date: _________________ Phone: ________________ _


NOTE: For ALL applicable Household Members 18 years or over, obtain a signed copy of this form for each verification to be completed. Send form directly to the appropriate administration; do not send form through applicant. Upon receiving verification, date-stamp, and compare information to that received on application. Make any necessary notations, date and initial. If significant differences exist between amount reported and verified, obtain a written explanation from applicant and attach to file.


THIRD-PARTY VERIFICATION OF UNEMPLOYMENT BENEFITS •

State and/or Federal Regulations require us to verify unemployment benefits made to the person that has provided authorization below, in order to determine their eligibility for program assistance. Your cooperation in providing the requested information below is most appreciated. A self-addressed return enve-lope is enclosed or you may fax to _ 2 _39_-_4_7 _1 -_0_9_1_s _____ _

Authorization: "'T'I I hereby authorize the release of requested information. A copy of the executed "Authorization for the ,......

Release of Information" is attached which indicates my agreement with the release of information :=:; requested for the sole purpose of determining eligibility for program assistance. 0

\ = 0 "'T'I

c= Signature of Applicant Print Name Date = m

:::3: ""C r--0 -<

Co-Applicant/Household Member Print Name Date :::3: m =

Please return information to: -cc m = Name: Elena Schwartz Title: Client Coord. Department: Cape Coral Hous .Dev. Corp ~

Address: 609 SE 9th TER, Cape Coral, FL 33990 Phone: 239-411-0922

To: Company Name _____________________________ _

Address: ____________ City:. _________ State:. ___ Zip:. ____ _


Are Benefits being paid now (Y or N): ___ If Yes, Gross Weekly Payments:$ _______ _

Date of Initial Payment: _______ _

Claimant Eligible for Future Benefits (Y or N): ___ If Yes, provide # of weeks: _______ _

If No, Provide Date of Benefits Termination or Maximum Duration of Benefits: ________ _

Signature of authorized representative: _______________________ _

Printed Name: ________________ Title: ______________ _

Date: ___________________ Phone: _____________ _


NOTE: For ALL applicable household members 18 years or over, obtain a signed copy of this form for each verification to be completed. Send form directly to the appropriate source; do not send form through applicant. Upon receiving verification, date-stamp, and compare Information to that received on application. Make any necessary notations, date and Initial. If significant differences exist between amount reported and verlflsd, obtain a written explanation from applicant and attach to flls.

FHC/FHFC Revised July 2008 PROGRAM ADMINISTRATION ■ 06

00 VERIFICATION OF PENSION AND ANNUITIES C

• < m :::,c, .....,

State and/or Federal Regulations require us to verify pension and annuity benefits made to the person r... that has provided authorization below, in order to determine their eligibility for program assistance. Your =!; cooperation in providing the requested information below is most appreciated. A self-addressed return 0

::z: 239 471 9 5 envelope is enclosed or you may fax to: - -o i 0 ....., -:I m Authorization: I hereby authorize the release of requested information. A copy of the executed ::z: ..,.,

"Authorization for the Release of Information" is attached which indicates my agreement with 0 the release of information requested for the sole purpose of determining eligibility for program ::z:

:I> assistance. = C

\ :I> = = Signature of Applicant Print Name Date c::

m -..,., Co-Applicant/Household Member Print Name Date

Please return Information to:

Name: Elena Schwartz

Address: 609 SE 9th TER, Cape Coral,

Titl

FL 33990

e:Client Coard. Department:Cape Coral Housing Dev Corp.

Phone: 239-411-0922

To: Name of Institution. ____________________________ _

Address: ___________ City: ________ State: ___ Zip: ____ _


Current monthly gross amount of pension or annuity: $ _________________ _

Deduction from Gross for Medical insurance premiums $ ________________ _

Date of initial award $ _______ Effective date of current amount _________ _

Expected change in current amount: ________ New amount $ __________ _

Contribution to company retirement/pension fund $ __________________ _

Amount received in lump sum $ __________ Date ____________ _

Signature of authorized representative: ______________________ _

Printed Name: ________________ Title: _____________ _

Date: ____________ Phone: ___________________ _



\

VERIFICATION OF VETERANS BENEFITS •

State and/or Federal Regulations require us to verify veteran benefits made to the person that has ...,., ,...., provided authorization below, in order to determine their eligibility for program assistance. Your :!::;

cooperation in providing the requested information below is most appreciated . A self-addressed return envelope is enclosed or you may fax to: _2_3_9-_4_7_1_-o_s_1_s _______ _

0 = 0 ...,.,

Authorization: m < ---4

I hereby authorize the release of requested information. A copy of the executed "Authorization for the m :;,c, > .......

Release of Information" is attached which indicates my agreement with the release of information :z:: requested for the sole purpose of determining eligibility for program assistance.

C0 m :z:: m ...,., ---4 ....... Signature of Applicant Print Name Date

Co-Applicant/Household Member Print Name Date


Name: Elena Schwartz Title:Client Coord Department: Cape Coral Housing Dev. Corp.

Address: 609 SE 9th TER, Cape Coral, FL 33990 Phone:239-471-0922

To: -----------------------------------

Address: ____________ City: _________ State:. ___ Zip: _____ _

Complete the Sections below: Name of Veteran ______________________________ _ Address: _________________________________ _

Claim No. _________________ Date of Birth ___________ _

Service dates: From _____________ to _______________ _

Benefits paid to _____________ current benefit amount __________ _

Original start date: ________ this amount will _increase _decrease

Date change takes effect: _________ new amount$ ____________ _

Benefit Type: _______________________________ _


Printed Name: ________________ Title: _____________ _

Date: ____________ Phone: ____________________ _


FHC/f HFC Revised July 2008 PROGRAM ADMINISTRATION ■ D9

--I

VERIFICATION OF VETERANS BENEFITS •

State and/or Federal Regulations require us to verify public assistance benefits made to the person ...., that has provided authorization below, in order to determine their eligibility for program assistance. r"\

:'::j Your cooperation in providing the requested information below is most appreciated. A self-addressed C)

return envelope is enclosed or you may fax to: 239-411-091s = C) ...., -< Authorization: rn rn I hereby authorize the release of requested information. A copy of the executed "Authorization for the ;:x,

Release of Information" is attached which indicates my agreement with the release of information > = ...... requested for the sole purpose of determining eligibility for program assistance. 0::,

rn

\ rn = ....,

Signature of Applicant Print Name Date

Co-Applicant/Household Member Print Name Date


Name: Elena Schwartz Title :Client Coord Department:Cape Cor al Housing Dev. Corp.

Address: 609 SE 9th TER, Cape Coral, FL 33990 Phone: 239-471-0922

To: -----------------------------------

Number in family: ___ ___ _______ _ Monthly Amount

$ ______ _ Aid to family with dependant children

$ _________ _ General assistance

$ _________ _ Other Assistance: Type _____________ _

$ _________ _ Total monthly cash assistance

Is this amount anticipated to change _yes _no

Effective date of change

$ _________ _ New amount


Printed Name: ________________ Title: ____________ _

Date: ____________ Phone: ___________________ _


FHC/fHFC Revised July 2008 PROGRAM ADMINISTRATION ■ DI 0

CHILD SUPPORT AFFADIVIT

Applicant Name

Co-Applicant Name

Child support payments are induded as income whether or not there is a court order awarding payment.

Child support amounts awarded by the courts but not received can be excluded only when the applicant certifies that payments are not being made and further documents that all reasonable legal actions to collect amounts due, including filing with the appropriate courts or agencies responsible for enforcing payment have been taken.

As part of the qualification process required by federal and/or state housing programs the following information is required. Please use a different form for different sources (i.e. payments from different people).

A. Do you receive child support?

B. I receive: 1. Payment amount

2. Frequency

3. Children(s) Full Name(s)

4. Name of Source Use multiple forms for multiple sources

5. Go to C.1

C.

Yes □ No □ GotoB Goto C.1

$ _______ _

1. Have you been awarded child support by court order?

2. Provide a copy of entire document; go to C.3.

3. Is payment being received as awarded? Yes □ Goto3.a

Yes □ No □ GotoC.2 Sign Form

No □ Go to 3.b

a. Indicated the manner by which payment is received and sign form. i. ___ Enforcement Agency

ii. Court of Law

iii. Direct from responsible party

iv. Other (explain)

Name Agency Provide agency print out

Name Court

Name Source Provide affidavit or statement from source

b. If payment is not received or if amount received is less than amount awarded provide details and documentation of collection efforts.

Under penalty of perjury, I certify that the information presented in this affidavit is true and accurate to the best of my knowledge. The undersigned further understands that providing false representations herein constitutes an act of fraud. False, misleading or incomplete information will result in the denial of your application for assistance.

Applicant Signature Date

CHILD SUPPORT AFF ADIVIT REV 1-08

RELEASE OF LIABILITY UTILITY CONNECTION GRANT PROGRAM

I, the undersigned homeowner/applicant, have applied to Cape Coral Housing Development Corporation (further herein referred to as CCHDC), a Florida Not-For-Profit Organization, for assistance with the cost of connecting to City utilities. I understand that this assistance Is provided utilizing funding CCHDC receives from a variety of grants through Grantor Agencies including, but not limited to: local, state, federal government and private foundations. If CCHDC accepts my application and provides assistance to connect my home to ,::ity utilities, I release CCHDC and its Grantor Agencies from liability as follows:

In consideration of the funding provided to me by CCHDC for Utility Connection Grant Program, I, the undersigned homeowner/applicant, for me and my heirs, legal representatives and assigns, hereby Release, Waive, Relinquish, and Forever Discharge CCHDC and its Grantor Agencies from any and all claims, causes of action, liabilities, demands, rights, damages, costs, expenses, and promises of every kind and description, whether at law or in equity, known or unknown, attributable to or arising out of the connecting my home to City Utilities and the work or materials furnished by the contractor including, without limitation, any claims for defective workmanship, defective materials, and damages to my home. I understand that neither CCHDC nor'the Grantor Agencies guarantee any work or materials furnished as part of this project.

Furthermore, I understand that any and all claims, causes of action, liabilities, demands, rights, damages, costs, expenses, and promises of every kind and description, whether at law or In equity, known or unknown, attributable to or arising out of the connectinl! my home to City Utilities and the work or materials furnished by the contractor including, without limitation, any claims for defective workmanship, defective materials, and damages' must be settled between myself and the Contractor.

Furthermore, I understand that any such unsettled claims or disputes between myself and the Contractor arising out of or related to the work shall be submitted to arbitration under the laws governed by the State of Florida. Notice of the demand for arbitration shall be filed in writing with the other party to this agreement, and shall be made within a reasonable time after a dispute has arisen. The award rendered by the Arbitrator shall be final and judgment may be entered upon it in accordance with applicable law in any court having jurisdiction thereof. The prevailing party may be entitled to recover all costs, including reasonable attorney's fees.

Furthermore, I understand that CCHDC and Grantor Agencies reserve the right to limit the scope of work and/or withdraw from any project due to any unforeseen conditions or circumstances.

Homeowner/Applicant Signature Date Homeowner/Applicant Signature Date

Homeowner/Applicant Printed Name Date Homeowner/Applicant Printed Name Date

STATE OF FLORIDA ,I COUNTY q>F LEE I The foreg~ing instrument was acknowledged before me this ., ,:,. · · day of___, 20__:_, by ______________ ,i

I

Signature 'of Notary Public-State of Florida ' (NOTARY SEAL} I

Name of Notary Typed, Printed, or Stamped

PersonallylKnown ___ OR Produced identification __ _ Type of ld~nt ification Produced - - --- -----~-- --- - _ _ _ _ -· ·- --- ·· l-- - ...... - . - . . . ... ,._ _ ___ .., ·- - ·-- ~. ---- - -~-- ·~ · -

STATE OF ~LORIDA COUNTY Of LEE

The forego(ng instrument was acknowledged before me this _ ·_day of~ 20__, by ________ ~--~--

Signature of Notary Public-State of Florida (NOTARY SEAL)

Name of Notary Typed, Printed, or Stamped

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RELEASE OF LIABllllY Utility Connection Grant Program.docx 5/ 15/201410:48:00 AM

Quick Guide to Utility Connection Grant Program · Proof that you are current on your mortgage...

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