Home Repair Application Packet

QUALIFYING INCOME CHART

This reflects the Maximum Gross Income for the HOUSEHOLD.

PROPERTY VALUE MAY NOT EXCEED

$250,000 BASED ON THE PROPERTY

APPRAISER “JUST” VALUE

EFFECTIVE 05/15/2023

Income limits are subject to revisions by the Florida Housing Finance Corporation.

Household

Size

Very Low Income

(30% to 50% of AMI)

Low Income

(51% to 80% of AMI)

Moderate Income

(81% to 120% AMI)

1

* Up to - $30,050 Up to - $48,550

NOT

APPLICABLE

FOR HOME

REPAIR

2

* Up to - $34,700 Up to - $55,500

3

* Up to - $39,050 Up to - $62,450

4

* Up to - $43,350 Up to - $69,650

5

* Up to - $46,850 Up to - $74,900

6

* Up to - $50,300 Up to - $80,450

7

* Up to - $53,800 Up to - $86,000

8 or more

* Up to - $57,250 Up to - $91,550

YOUR ELIGIBILITY WILL BE BASED ON THE INCOME

LIMITS THAT AR EIN EFFECT AT THE TIME OF APPROVAL

Name Age Relationship to Head of Household

Applicant/Head oh Household

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ALACHUA COUNTY S.H.I.P. PROGRAM

Application # AC HR

APPLICANT’S INFORMATION:

Applicant (Head of Household): ____________________________________ Last 4 of SS number: _____________

Age: ________ Marital Status: Single ______ Married ______ Divorced ______ Widow _______

Spouse or Co-Applicant: _________________________________________________________________________

Other Person(s) in the title (on the deed):

__________________________________________________________________

Property Address: ______________________________________________________________________________

City State Zip

Mailing Address (if different): ____________________________________________________________________

Telephone: Home: _____________________ Cell: _____________________ Work: _____________________

Email Address: ________________________________________________________________________________

Total number of people residing in the household (including you): __________________

Is anyone in the household considered disabled?

Please see the addendum to the application.

Are you a veteran? Yes ____ No ____ Do you receive veteran benefits? Yes ____ No ____

Are you employed? Yes ____ No ____ Are you self-employed? Yes ____ No ____

Do you currently have a mortgage/lien on the property? Yes ____ No ____

If yes, what is your monthly mortgage payment? $___________

Name of Lender: _____________________________________

LIST NAMES OF ALL INDIVIDUALS WHO RESIDE IN THE HOUSEHOLD

Name Age Relationship to Head of * Type of Gross

Household Income Income

Applicant / HOH

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INCOME QUALIFICATION INFORMATION

List the names, ages, relationship to head of household, and income of ALL persons living in the household:

INCLUDE ANNUAL GROSS INCOME for ALL persons 18 years and over.

*Types of Income: SSI, SSD, “R” for retirement, “E” for employment, “SE” self-employed, “UNE” unemployed

COMPLETE INFORMATION FOR EVERYONE 18 AND OVER

WHO IS EMPLOYED OUTSIDE THE HOME?

APPLICANT'S EMPLOYER INFORMATION (If applicable)

COMPANY: ____________________________________________________ PHONE: _____________________

ADDRESS: ___________________________________________________________________________________

HR CONTACT: _________________________________________________ PHONE: _____________________

O

THER HOUSEHOLD MEMBERS EMPLOYER INFORMATION

COMPANY: ____________________________________________________ PHONE: _____________________

ADDRESS: ___________________________________________________________________________________

HR CONTACT: _________________________________________________ PHONE: _____________________

O

THER HOUSEHOLD MEMBERS EMPLOYER INFORMATION

COMPANY: ____________________________________________________ PHONE: _____________________

ADDRESS: ___________________________________________________________________________________

HR CONTACT: _________________________________________________ PHONE: _____________________

IF A HOUSEHOLD MEMBER IS 18 AND OVER AND IS NOT EMPLOYED,

THEY MUST COMPLETE AND UNEMPLOYMENT AFFIDAVIT

HOUSEHOLD MEMBER Type of Asset (Checking, Savings)

With last 4 digits of account number)

Cash Value Income From

Asset

Item In Need of Brief Description

Repair

Yes / No

ROOF

WINDOWS

DOORS

ELECTRICAL

PLUMBING

HOW WATER

HEATER

WELL / SEPTIC

ACCESSIBILITY

OTHER

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ASSET INFORMATION

List all assets with the current value (checking, savings, retirement, cash on hand, etc.) for all persons

living in the household

1

:

O

ther real estate properties owned / List addresses and if you rent / contract for sale / etc.:

Items Needing Repair

(Attach an additional sheet for further explanation of repairs needed)

WE DO NOT REMODEL.

Black/

0- 26- 41-

62+

Non-

ican

ispani

W ite

Asian

Amer

H c

h

(African-

Other

25 40 61

Hispanic

Indian

American)

Developmentally Disabling Receives HOH Foster Care Domestic

Disabled Condition SSI or SSD (>62) Violence

HOH HOH HOH HOH

Other Other Other

_____________________________________________ _____________________________________________

_____________________________________________________________________________________________

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I UNDERSTAND THAT THE INFORMATION PROVIDED BY ME IS SUBJECT TO REVIEW AND

VERIFICATION BY ALACHUA COUNTY THROUGH ITS AGENTS AND/OR EMPLOYEES, IN

ORDER TO DETERMINE ELIGIBILITY FORTHE PROGRAM BENEFITS/SERVICES FOR WHICH

I AM APPLYING. PROVIDING INACCURATE OR INCOMPLETEINFORMATION WILL RESULT

IN A DENIAL OF SERVICES.

I further understand that all information listed above is subject to the Open Records Law, Chapter 119 of

the Florida Statutes (most clearly stated under 119.07), and therefore is considered public record.

ALL HOME OCCUPANTS 18 AND OVER MUST SIGN APPLICATION

THE INFORMATION PROVIDED IS TRUE AND ACCURATE:

Applicant’s Signature Date Spouse Signature Date

Signature Other Adult Member Date Signature Other Adult Member Date

GOVERNMENT REQUIRED INFORMATION FOR REPORTING PURPOSES ONLY

PLEASE COMPLETE INFORMATION FOR HEAD OF HOUSEHOLD

Ethnicity Race Age

SPECIAL NEEDS FOR HEAD OF HOUSEHOLD OR OTHER MEMBER OF THE HOUSEHOLD

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All occupants 18 and over must sign the application, authorization to release information, and Social

Security Disclosure

YOU WILL NEED TO PROVIDE THE FOLLOWING DOCUMENTATION

THAT APPLIES TO THE HOUSEHOLD

☐ PROOF OF INCOME:

(Current SS awards letter, retirement statement, paystub, etc.)

All home occupants 18 and over must supply income and asset information

☐ INCOME AND ASSETS:

(Six months consecutive bank statements (must include all pages for each statement). Must

include the statements of all household members)

** Documents where/what each of your deposits came from, with as much detail as possible

(i.e., a family member is helping with bills, you have an online sales job, you sell Avon, Mary

Kay, etc.)**

☐ TWO YEARS TAX RETURNS (Only if self-employed)

☐ PROOF OF HOME OWNERSHIP:

(Deed, Certificate of Title, Probate Documents, etc.)

(We may need you to provide a copy of the document if it is not accessible via public records.

Example: The document was recorded prior to 1980 or it is a probate document.)

☐ PROOF OF HOME INSURANCE

☐ VERIFICATION THAT PROPERTY TAXES ARE CURRENT

(We may need proof if you recently made a payment and it is not showing in public records

yet.)

☐ VERIFICATION OF HOUSEHOLD MEMBERS

(Copy of ID with the property address, copy of the first page of tax return reflecting all

minors in household, doctor records, school records.)

☐ COPY OF STATE ID

(Divers License, State Issued ID, Passport)

** Social Security Card are not a form of ID **

☐ DOCUMENTATION 1

ST

MORTGAGE IS CURRENT

(Copy of Mortgage Statement or Letter from Lender.)

DOCUMENTS ENCLOSED FOR YOUR SIGNATURE

• COMPLETED APPLICATION Everyone 18 and older must sign

• ADDENDUM TO APPLICATION IF A HOUSEHOLD MEMBER IS DISABLED

• AUTHORIZATION TO RELEASE INFORMATION Everyone 18 and older must sign

• PHOTO & VIDEO RELEASE (OPTIONAL)

• OPEN RECORDS STATEMENT

• UNEMPLOYED AFFIDAVIT

• ACKNOWLEDGEMENT OF LIENT TO E PLACED ON PROPERTY

All home occupants 18 and over must supply income and asset information.

IF ANYONE IN THE HOUSEHOLD IS DISABLED, PLEASE PROVIDE STATEMENT OF DISABILITY FROM A

DOCTOR OR CAREGIVER.

________________________

________________________________

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ADDENDUM TO APPLICATION

I Certify that either myself or a member of my household qualifies for “SPECIAL NEEDS”

Consideration.

Initial one of the three following options:

_______ Self

_______ Other Household Member

Name of household Member

_______ There is not a member of the household that qualifies for Special Needs based on the

items listed below.

If Self or Other Household Member is Selected, Initial the following applicable options:

_______ Development Disabilities

(Cerebral Palsy, Autism, Spina Bifida, Prader-Willi Syndrome, Developmentally

Challenged, etc.)

_______ Receives SSD / SSI or other Disability Benefits

_______ Youth Aging Out of Foster Care

_______ Survivor of Domestic Violence

_______ Person with a Disabling Condition requiring independent living services (Chronic

Physical illness or disability, developmental disability, serious mental illness, diagnosable

substance abuse disorder, etc.)

I

have enclosed documentation from either a service provider or a doctor if any of the above disabling

conditions are applicable.

Signature of Applicant

You may have the service provider copy the following statement on their letterhead and sign and

date as documentation.

We have determined that ________________________________________ is eligible for and is

receiving services for their “Special Needs” or has been determined eligible and is on a waiting list.

OR

I am the doctor providing care for ____________________________ We are treating them for a

disabling medical condition. (Mental or Physical)

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Authorization for the Release of Information

I __________________________________________________, the undersigned, hereby authorize

____________________________________________ to release, without liability, information regarding

my employment, income, and/or assets to _______________________________ for the purposes of

verifying information provided as part of determining eligibility for assistance under the

___________________________ program. I understand that only information necessary for determining

eligibility can be requested.

Types of information to be verified:

I understand that previous or current information regarding me may be required. Verifications that may be

requested are, but not limited to: employment history, hours worked, salary and payment frequency,

commissions, raises, bonuses, and tips; cash held in checking/savings accounts, stocks, bonds, certificates

of deposits, Individual Retirement Accounts, interest, dividends; payments from Social Security,

annuities, insurance policies, retirement funds, pensions, disability or death benefits, unemployment,

disability or worker’s compensation, welfare assistance, net income from the operation of a business, and

alimony or child support payments.

Organizations/Individuals that may be asked to provide written/oral verifications are, but not

limited to:

Past/present employers, alimony/child support providers, banks, financial or retirement institutions,

Social Security Administration, State Unemployment Agency, Veteran’s Administration, welfare agency

and other: ___________________________________________________________________________

Agreement to Conditions

I the undersigned agree that a photocopy of this authorization may be used for the purposes stated above.

I understand that I have the right to review this file and correct any information found to be incorrect.

Signature of Applicate Printed Name Date

Co-Applicant or Other Household Member Printed Name Date

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Optional Photograph & Video Release

I hereby grant to Alachua County, Florida (“Alachua County”) the permission to use reproductions of my

photographs and video and to use my name associated with those photographs and video in any and all of

its publications, including website entries, without payment or any other consideration. I understand and

agree that these reproductions will become the property of Alachua County and will not be returned.

I hereby irrevocably authorize Alachua County to edit, alter, copy, exhibit, publish or distribute these

photographs and videos for purposes of publicizing Alachua County programs or for any other lawful

purpose. In addition, I waive the right to inspect or approve the finished product, including written or

electronic copy, wherein my likeness appears. Additionally, I waive my right to royalties or other

compensation arising or related to the use of the photograph or video.

I hereby hold harmless and release and forever discharge Alachua County from all claims, demands, and

causes of action which I, my heirs, representatives, executors, administrators, or any persons acting on my

behalf or on behalf of my estate have or may have by reason of this authorization.

I am 18 years of age and am competent to contract in my own name. I have read this release before

signing below, and I fully understand the contents, meaning, and impact of this release.

______________________________ ________________________

(Signature) (Date)

______________________________ ________________________

(Printed Name) (Date)

______________________________ ________________________

(Witness Signature) (Date)

Youth Photograph & Video Release

If the person in the photograph or video is under 18 or not competent to contract for any other reason,

there must be consent by a parent or guardian, as follows:

I hereby certify that I am the parent or guardian of ____________________________________________

________________________________________, and ________________________________________,

and do hereby give my consent without reservation to the foregoing on behalf of this person.

_______________________________ __________________________

(Parent or guardian’s Signature) (Date)

_______________________________ __________________________

(Parent or guardian's Printed Name) (Date)

_______________________________ __________________________

Witness Signature) (Date)

Acknowledgement of Lien

__________________________________

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My name is: __________________________________________________________________________

I have applied for the SHIP Home Repair Program to make needed repairs to my home located at:

_______________________________________________________________________________

I

understand that one of the requirements of this program is that I must own and occupy the property for

15 years from the date of the note and mortgage. If at any time during the 15 year term, if any part of the

Property or any interest in it is sold, transferred, gifted or otherwise conveyed, or the BORROWER

ceases to occupy it as his/he primary residence, or if the property is leased or rented during the 15 year

period, then the full amount of this Note becomes due and payable to Alachua County, Florida a political

subdivision of the State of Florida, by its Board of County Commissioners, P.O. Box 5547, Gainesville,

Florida 32627-554.

EXCEPTION, In the event that the sole owner or all owners executing this agreement are

deceased during the fifteen-year term thereof, the agreement shall be considered satisfied and will

no longer constitute a lien against the property.

I acknowledge that I will be signing a note and mortgage for the amount of the total costs of

repairs. The note is a deferred payment note at 0.00% interest. The mortgage will be recorded on the

public records and is a lien on my property for a 15-year term. After the 15years, the amount of the note

and mortgage is fully forgiven, and a satisfaction of mortgage will be recorded on the public records to

remove the lien.

(Applicant Signature)

(Date)

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Social Security Number Disclosure

The Florida Legislature adopted new requirements effective October 1, 2007, relating to the collection of

personal Social Security Numbers by public agencies in Florida. The legislation, which is codified in

Section 119.071(5), Florida Statutes, requires that a public agency may not collect an individual’s Social

Security Number unless the agency has stated in writing the purpose for its collection.

Social Security Number Policy

Policy related to the collection and release of Social Security Numbers:

Alachua County collects Social Security Numbers for the following purposes: background check/or

employment purposes, classification of utility accounts, customer identification and verification, customer

billing and payment, establishment of creditworthiness, and other lawful purposes necessary in the

conduct of the business of Alachua County. Alachua County may also release your Social Security

Number to other commercial entities engaged in the performance of commercial activities as required or

permitted by law. It will be the policy of Alachua County to advise individuals of this policy in writing

upon collection of Social Security Numbers.

At the time of application for housing program assistance, the Alachua County Community Support

Services Housing Division request that each applicant provide a Social Security Number (SSN). The SSN

will not be used as the applicant’s file ID number. Upon submission of an application, an applicant will

be assigned a unique and randomly generated identification case file number. This permanently assigned

identification number (ID) is directly connected with the applicant’s case file records. If required, will

provide to and/or share your SSN with an entity to obtain verification of income, assets, employment,

credit history, debt information, and identifying information, such as your address, telephone number, and

SSN to determine your eligibility to receive housing program assistance.

Providing your SSN is voluntary, if you choose to provide, it means you consent to allow use to use the

number in the manner described above. Applicants who choose not to provide the SSN will be ineligible

to receive housing program assistance. The privacy and confidentiality of applicant records is protected

by applicable Federal and State laws. We will not disclose a SSN without the applicant’s consent for any

purposes other than those disclosed herein, except as allowed or required by law. Under the Florida

“Public Records Law” Chapter 119 of the Florida Statutes, your application for housing assistance is a

public record. This law provides that any records made or received by any public agency in the course of

its official business are available for inspection, unless specifically exempted by the legislature.

I/We acknowledge that I/We have read and received a copy of the Social Security Number Disclosure:

_______________________________ __________________________

(Applicant Signature) (Date)

_______________________________ __________________________

(Co-Application or Other Household Member Signature) (Date)

________________________________ __________________________

(Affiant Signature) (Date)

STATE OF FLORIDA

COUNTY OF ALACHUA

I HEREBY CERTIFY the forgoing instrument was acknowledged before me by means of ☐ Physical

Presence or

☐ Online notarization, this the _____ day of _____________ 20___, A.D.,

☐ Known to me to be the person(s)

OR

☐ Produced Identification

described in and who executed the forgoing instrument

WITNESS my hand and official seal the date aforesaid.

IDENTIFICATION: _____________________________________

NOTARY PUBLIC: ____________________________________

My Commission Expires: _________________________

Type of Identification Produced: ______________________________

Unemployment Affidavit

Before me this _____ day of ____________________ personally appeared ________________________

_______________________________ Who, being duly sworn, deposes and says:

1. ☐ I have made an application for SHIP assistance from Alachua County

2. ☐ I will be occupying the property, and I am 18 or over

3. Check (a) or (b) as applicable:

a. ☐ I am not presently employed but anticipate becoming employed within the next

twelve months

b. ☐ I am not presently employed and do not anticipate becoming employed in the next

twelve months

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☐ Online notarization, this the _____ day of _____________ 20___, A.D.,

☐ Known to me to be the person(s)

OR

☐ Produced Identification Type of Identification Produced: ______________________________

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Conflict of Interest Disclosure Form

For Housing Programs - Alachua County

I/We, the undersigned, have read and understand this Conflict-of-Interest Disclosure Form, and I/We have

fully disclosed the information requested, if any, as provided. I/We have been provided a list or I/We have

knowledge of the commissioners, members, and individuals referenced below. I/We agree that conditions,

restrictions, or terminations may be imposed to reduce or eliminate a real or potential conflict of interest.

By signing below, I/We agree:

I am not an employee of Alachua County, Florida, or the Alachua County Board of County

Commissioners.

I am not a relative (spouse, fiancé, sibling, parent, child, stepchild, or in-law) of any current

member of the Alachua County Affordable Housing Advisory Committee.

I will update this document promptly if circumstances change the statements above.

____________________________ ____________________________ ___________________

Buyer/Applicant Signature Print Name Date

____________________________ ____________________________ ___________________

Buyer/Co-Applicant Signature Print Name Date

STATE OF FLORIDA

COUNTY OF ALACHUA

I HEREBY CERTIFY the forgoing instrument was acknowledged before me by means of ☐ Physical

P

resence or

described in and who executed the forgoing instrument.

WITNESS my hand and official seal the date aforesaid.

IDENTIFICATION: _____________________________________

NOTARY PUBLIC: ____________________________________

My Commission Expires: _________________________