HUD Lead Hazard Control Grant Program APPLICATION FORM (Page 1) Please complete one application per dwelling unit (apartment).

Transcription

1 Project Property Information HUD Lead Hazard Control Grant Program (Page 1) Please complete one application per dwelling unit (apartment). Date: Street: Unit#: City: Zip: Broome County Single-Family Dwelling? Yes Number of Dwelling Units in Building: Owner Occupied? Yes Rental Property? Yes Vacant? Yes Year of Building Construction? Type of Windows (e.g. vinyl, wood): Type of Exterior (e.g. vinyl, wood, brick, stucco): Number of Bedrooms: *Please provide copies of all receipts referenced in the following section, including your deed. Are all City/County taxes paid? Yes Water bills current? Yes Is Mortgage current? Yes N/A Was Mortgage satisfied? Yes When? Is property located in a floodplain? Yes If Yes, is property insured against flooding? Yes Has property been designated historic, or is it located in a historic district? Yes Don t Know Name of Homeowners insurance company: Phone Number: How did you learn about our program? Has the property ever had lead-paint hazard reduction work? Yes Funding provided by: Date of work performed, if known: Is the property currently enrolled in any other type of repair or rehab program? Yes If so, identify: Are you planning any rehabilitation work on this property in the near future? Yes If so, explain:

2 (Page 2) Property Owner Information Last Name: First Name: Street: Unit#: City: Zip: Phone Number: (Home): (Work): (Cell): Fax #: Date of Birth: Address: Social Security Number: Is your ownership: Corporation Partnership LLC Other Property Manager/Representative s Name: Street: Unit#: City: Zip: Phone Number: (Home): (Work): (Cell): Fax #: Address: Household Members/Resident Tenant Information If applicable: Lease expiration date: Monthly Rent: 1. Is there a child under 6 living there full-time? Yes If Yes, please list child ages: *Please attach copies of birth certificates for all children under the age of Is there a child under 6 who is a regular visitor but does not live there (for at least 6 hours per week, 10 weeks per year? Yes *A Visiting Child Certification Form will be required. 3. Is there a pregnant woman living there? Yes How many women aged 16-45? 4. If lead hazards will be removed from the house, will members of the household have a place to go (for up to 7 days)? Yes Where? OPTIONAL INFORMATION This information is used for Federal and statistic compilation only. The Broome County Health Department does not discriminate against any individual or group because of race, sex, religion, age, ethnicity, color, marital status, disability, or political belief. Please check any/all that apply to this household/dwelling unit: American Indian or Alaska Native Asian Hispanic/Latino Black or African-American White/Caucasian Other I choose not to complete this section: Yes

3 (Page 3) Household Members/Resident Tenant Information (Continued) *PROOF OF ALL RESIDENT/TENANT INCOME IS REQUIRED. Household Contact Phone Number: 1. Name: Date of Birth: Age: Relationship: 2. Name: Date of Birth: Age: Relationship: 3. Name: Date of Birth: Age: Relationship: 4. Name: Date of Birth: Age: Relationship: 5. Name: Date of Birth: Age: Relationship: 6. Name: Date of Birth: Age: Relationship: (For additional residents please attach a new sheet of paper) I hereby certify under the penalty of law that, to the best of my knowledge, the information contained herein is true, accurate and complete. Owner/Landlord Name Signature Date Tenant Name Signature Date BCHD Representative Signature Date Questions about the application? Call

4 (Page 4) Point of Construction Asbestos Survey Declaration Due to compliance with New York State Department of Labor (DOL) regulations, all property owners applying for grant assistance through the Broome County s Housing and Urban Development (HUD) Lead Hazard Control (LHC) Grant are required to have a point of construction asbestos survey of the property completed. The scheduling and cost of testing will be the responsibility of the property owner. Asbestos can be found in window glazing, caulk, plaster/drywall, siding and other materials, and can cause serious health problems if not handled properly when disturbed. Point of construction survey samples will only be taken from components directly linked to lead remediation work in order to minimize cost. You will be provided with a list of surfaces that must be tested, and a list of companies that are qualified to do the testing. Cost and timeframes for testing may vary, so you are encouraged to select a testing company that will suit your needs. The cost of the point of construction asbestos survey has ranged between $500 - $600 per building depending on the number of surfaces that must be sampled. If asbestos is identified and your property is eligible for the program, the costs of addressing asbestos will be covered by the grant. However, having this testing done does not guarantee that your property will be assisted through our program. Please keep in mind that work cannot proceed until the required asbestos testing is complete and results have been received by our office. I have read and understand the necessity of the point of construction asbestos survey in accordance with New York State regulations and am fully aware of my responsibility to cover the cost of the survey. Owner/Landlord Name Signature Date Questions about the application? Call

5 (Page 5) ASSISTANCE UP TO $10,000 PER UNIT Each individual housing unit enrolled in the Broome County HUD Lead Hazard Control Program will be eligible for a maximum of $10,000 worth of lead hazard remediation work. Property owners will be required to provide funding for any additional costs of making units lead-safe. The cost of lead hazard control work in a housing unit can vary widely from building to building. Work to be completed will depend on the results of testing, and prices are based on standard rates. The average cost of making a unit lead-safe is currently $10,489, and costs per unit have ranged from $4,782 to $17,032. HUD requires that all lead hazards associated with a unit must be addressed; our program cannot complete partial projects. All property owner contributions must be received prior to contract signing. Property owners will remain responsible for the costs of asbestos testing and occupant relocation. For example, if a single unit requires $10,500 in remediation work to make it lead-safe, the property owner share in the lead remediation cost of the project is $500. If a single unit requires only $4,500 in remediation work, the job can be completed with no remediation cost to the owner. Owners are encouraged to enroll multiple units within a specific property to keep the units costs lower and maximize the lead-safety benefits to the building. Each unit is eligible for up to $10,000 toward lead remediation; therefore two-family dwellings are potentially eligible for $20,000, three-family dwellings for $30,000, and so on. All units are subject to the rules of eligibility determined by HUD. Please note that if the lead remediation for an individual unit costs more than $25,000 it is disqualified from the grant. We encourage property owners to take advantage of the opportunity to participate in the HUD Lead Hazard Control program. This program is completely voluntary, so you may choose to withdraw your application at any time for any reason, prior to the signing of a contract to start the remediation work. However, it is the property owner s responsibility to notify the Health Department of their intent to withdraw from the program. By signing this document, I acknowledge that I have read this policy. Owner/Landlord Name Signature Date Questions about the application? Call

6 Broome County HUD Lead Hazard Control Grant Program Required Documentation Checklist Submitting a complete application will allow us to process your application more quickly. Please contact our office at if you have any questions, or need help making copies. Completely filled-out and signed application form (4 pages). Please be sure that the tenant/resident information page is completely filled out, including names of all residents, names, ages, date of birth, income, Medicaid, and signatures. Information from the property owner: Deed. This provides us with proof of ownership. BCHD can usually obtain a copy of the deed through the Broome County Clerk at Taxes. Proof that taxes are paid and current. Payment history is available through or through the Broome County Department of Real Property Tax Service at or Mortgage. A copy of the current mortgage and proof of mortgage satisfaction or a letter from the mortgage lender demonstrating that the mortgage is paid and current. Insurance. The declaration page of the homeowner s insurance policy. Information from unit residents/tenants: Birth Certificates. Copies of birth certificates for all children under the age of six that reside in or regularly visit the home. Verification of Visiting Child form, if applicable. A doctor s note if the qualifying resident is a pregnant woman. Medicaid Cards. Copies of Medicaid cards (if applicable) for all children under the age of six. Proof of income for all residents. An income eligibility form will be completed by BCHD staff. Proof of income may include the most recent paystubs, SSI or public assistance statements, child support documentation, etc.

7 FY 2013 Income Limit Category Low (80%) Income Limits 1 Broome County HUD Lead Hazard Control Program FY 2013 Income Limits Summary Broome County, New York $32,950 $37,650 $42,350 $47,050 $50,850 $54,600 $58,350 $62,150 *Eligibility for the HUD Lead Hazard Control Program is based on the income of the residents/tenants, not necessarily the owner (if a rental property). *Units must house children under the age of six and/or a pregnant woman to qualify for the program.