| CITY OF ELGIN 2010 HOUSING REHABILITATION PROGRAM APPLICATION FOR HOUSING REHABILITATION ASSISTANCE In submitting this application, I agree to and acknowledge the following: Please complete the rest of the application and return the application to: MSA Professional Services, Inc. Attn: Liz Kemp, Housing Administrator 1605 Associates Dr, Suite 102 Dubuque, IA 52002 1-888-869-1214 ELGIN HOUSING REHABILITATION PROGRAM (The initial open sign-up period is through September 30, 2010.) Applications postmarked on or before September 30, 2010 will be ranked and receive priority status for funding. Applications postmarked and received after September 30, 2010 will be funded on a first-come, first-served basis subject to funds available.) HOUSEHOLD INFORMATION Name Of Head Of Household: Address: City/State/Zip Code: Telephone Number: _________________________Date of Birth: Social Security Number: Sex: __________ Race White Black Asian American Indian/Alaskan Hawaiian/Pacific Islander American Indian/White Asian/White Black/White American Indian/Black Other Multi-Racial OTHERS LIVING AT THIS ADDRESS: NAME BIRTH DATE SEX SOCIAL SECURITY # Does anyone in the household have a diagnosed handicap? YES/NO If yes, who is it and what is the disability? Doctor’s Name: Doctor’s Address: City/State/Zip Code: Do you own any property other than your home? YES/NO If yes, where is it located? ____________________________ FINANCIAL INFORMATION PLEASE INCLUDE A COPY OF YOUR MOST RECENT INCOME TAX RETURN WITH YOUR APPLICATION. Income - List Total Gross Income for All Persons Living in the Household Name: _____________________________ Monthly Income: __________ Income: ____________________________________ Address: ____________________________________________ City/State/Zip Code: ___________________________________ Name: _____________________________ Monthly Income: __________ Source of Income: ____________________________________ Address: ____________________________________________ City/State/Zip Code: ___________________________________ Name: _____________________________ Monthly Income: __________ Source of Income: ____________________________________ Address: ____________________________________________ City/State/Zip Code: ___________________________________ Name: _____________________________ Monthly Income: __________ Source of Income: ____________________________________ Address: ____________________________________________ City/State/Zip Code: ___________________________________ Assets/Investments Amount Savings Account: Name of Bank ____________________________ Address Source _____________________________ City/State/Zip Code _____________________________ Savings Account: Name of Bank Address Source _____________________________ City/State/Zip Code _____________________________ Assets/Investments - cont. Amount Checking Account: Name of Bank ____________________________ Address Source _____________________________ City/State/Zip Code _____________________________ Stocks/Bonds: Name of Bank Address Source _____________________________ City/State/Zip Code _____________________________ CDs: Name of Bank Address Source _____________________________ City/State/Zip Code _____________________________ Mortgage Do You Have A Land Contract On Your Home? Yes/No Do You Have A Mortgage On Your Home? Yes/No If Yes, Who Is The Mortgage Holder? Lender: Address: City/State/Zip Code: Amount Outstanding: Insurance Name of Homeowner’s Insurance Agent: Address: City /State /Zip Code: Utilities Heating Fuel Provider: Address: City/State/Zip Code: Electric Provider: Address: City/State/Zip Code: Water Service Provider: Address: City/State/Zip Code: Sanitary Sewer Service Provider: Address: City/State/Zip Code: Other Expenses Childcare Provider: Address: City/State/Zip Code: Average Monthly Payment: Do you have monthly medical expenses not covered by insurance? YES/NO If yes, please list name and address of the billing company: Name: _______________________________________________ Address: _____________________________________________ City/State/Zip Code: ____________________________________ HOUSING INFORMATION (Estimated) Age Of Home: Year Of Purchase: ________ Number of Bedrooms: Type of Furnace: Natural Gas/Electric/Oil/LP/Wood Type of Stove: Natural Gas/Electric Type of Dryer: Natural Gas/Electric Type of Water Heater: Natural Gas/LP/Electric Additional Information or Comments: Signature of Applicant: Date: _________ Signature of Spouse: Date: ________ |