H O M E M O D. Application & Instruction Packet. for the. HOMEMOD Program. CITY OF CHICAGO Mayor s Office for People with Disabilities

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1 H O M Application & Instruction Packet for the HOMEMOD Program CITY OF CHICAGO Mayor s Office for People with Disabilities E M O D Rahm Emanuel Mayor Karen Tamley Commissioner

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3 Table of Contence Guide 3 Application Instructions 5-11 Application Appendix A HOMEMOD Program CITY OF CHICAGO Mayor s Office for People with Disabilities 1

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5 PLEASE READ READ DIRECTIONS PRIOR TO COMPLETING THIS APPLICATION. IT IS VERY IMPORTANT THAT ALL QUESTIONS ARE CORRECTLY FILLED OUT AND THAT ALL REQUIRED DOCUMENTS ARE INCLUDED WITH THIS APPLICATION. CHECK TO MAKE SURE THAT ALL ITEMS BELOW HAVE BEEN COMPLETED. ALL ITEMS OF THIS APPLICATION ARE FILLED OUT COMPLETELY AND NEATLY. ALL REQUIRED SUPPORTING DOCUMENTS HAVE BEEN ATTACHED TO THE APPLICATION. VERIFY THAT YOU HAVE NOT MISSED THE DEADLINE. VERIFY THAT YOU HAVE NO UNPAID PARKING TICKETS. IF YOU ARE UNSURE, CALL THE DEPARTMENT OF REVENUE AT 311 VERIFY THAT YOUR WATER BILL IS PAID. IF YOU ARE UNSURE, CALL THE DEPARTMENT OF WATER SERVICES AT 311 VERIFY THAT YOUR PROPERTY TAXES HAVE BEEN PAYED. IF YOU ARE UNSURE, CALL THE COOK COUNTY TREASURER AT (312) (VOICE) VERIFY THAT THE APPLICATION IS SIGNED AND DATED. VERIFY THAT YOU HAVE MADE COPIES OF YOUR APPLICATION FOR YOUR RECORDS. FAILURE TO COMPLY WITH ALL OF THE ABOVE LISTED ITEMS WILL DELAY, AND COULD DISQUALIFY YOU FROM THE APPLICATION PROCESS. 3

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7 Application Instructions HOMEMOD Program CITY OF CHICAGO Mayor s Office for People with Disabilities 5

8 Rahm Emanuel, Mayor City of Chicago Karen Tamley, Commissioner Mayor s Office for People with Disabilities HomeMod INSTRUCTION BOOKLET APPLICATION APPLICATION DEADLINE: DEADLINE: December None 12, 2006 GENERAL INFORMATION: The City of Chicago is committed to increasing the housing options for people with disabilities. Administered by the Mayor s Office for People with Disabilities, the HomeMod program enables people with disabilities of low to moderate income, under the age of 60, to have their homes and apartments modified for accessibility. One of the primary goals of this program is to enhance the independence of people with disabilities. An accessible living environment provides people with disabilities a greater opportunity to fully participate in all aspects of life such as employment,recreation and education. Through the HomeMod program, the homes of people with disabilities may be modified with accessible features such as ramps, lifts, accessible kitchens and bathrooms and with assistive technology devices. If you have any questions about how to complete this application, please call: (312) (voice) (312) (TTY) QUALIFICATIONS: City of Chicago resident Person with a disability Under 60 years of age Renters and home owners Households with incomes below 80% of the area median income may qualify for a full grant; those whose income is over 80% of the area median income may qualify for a partial grant. You must be the head of household, spouse or legal dependent of the head of household. APPLICATION INSTRUCTIONS: 1 2 Use a black or blue ink pen and print or type the answers to all questions. The following information will explain in detail, how to complete the application. Name Indicate the name of the person with a disability who resides in the home and requires modifications. Address Please print the street address, apartment number (if applicable), city, state, ZIP code and ward of the primary residence of the applicant. The addess must be the residence being considered for modification. 6

9 APPLICATION INSTRUCTIONS (CONT.) Phone (Voice/TTY) It may be necessary to contact youin order to complete the processing of your application. Write the areacode and telephone number where the applicant may be reached during the day. Alternate/Work Number Write an alternate telephone number such as a work number or telephone number other than your primary telephone number. Date of Birth Provide the date of birth of the applicant. Social Security Number Provide the Social Security number of the applicant exactly as it appears on his or her Social Security card. Gender Mark an x on the line to the left of the word MALE if the individual with a disability who requires home modifications is male. Mark an x in the box next to the word FEMALE if the individual is a female. Age Please write the age of the applicant. Proof of age must be submitted with the application. COPIES of the following items may be presented as proof of age: -Birth Certificate; or -Drivers Licence; or -State of Illinois ID card; or -Passport; or -Naturalization Papers Ethnic Background Enter an X in the appropriate box. This information is optional and will not be used in a discriminatory manner. Drivers License, or State ID Card Number Provide the Drivers License, or State ID Card Number of the applicant exactly as it appears on his or her Drivers License, or State ID Card Name Please write the full legal name of the individual who is the head of household. The head of houseld is the lease holder or the property oner. If the head of household is the same as the applicant, please write the word, same on line 11. Current Mailing Address If the address on line 2 is not the primary residence being considered for home modifications, write the address being considered for modifications on line 12. Please explain why the address at which you reside is different than the address for which you are requesting modifications. Date of Birth Please write the date of birth of the head of household. If the head of the household is the same as the applicant, please leave this line blank. Social Security Number Please give the Social Security number of the head of household. If the head of household is the same as the applicant, please write same on line 14. What is your (PIN) Property Identification Number? This number may be found on your tax bill. It is a 14 digit number and is unique to your property and identifies your property. If you do not receive a tax bill, you may receive your (PIN) by contacting the Cook County Assessor s office. Do you own the property in which you live? Is the applicant s or head of household s name listed on the deed of the home for which modifications are being requested? Also, does the applicant have possession of or access to the deed? If the answer to both of these questions is yes, mark an X in the box to the left of the yes response. If the answer to either of these questions is no, mark an X in the box to the left of the no response. If there is a special circumstance, explain on a separate sheet of paper. If the answer to question 16 is no, skip to question 19. 7

10 17 18 APPLICATION INSTRUCTIONS (CONT.) List the names of the individuals List the names of the individuals listed as owners on the property s deed. Write the names and Social Security numbers of the other individuals listed as owners on the property s deed and their relationship to the head of household. Other individuals listed on the deed must sign this application as co-applicants to indicate they agree to have the property modified with accessible features. Do you have homeowner s insurance on your property? Does the applicant have a current homeowner s insurance policy in good standing on the property being considered for modifications Does a child live with you, or will one come to visit you at any time? Please identify whether a child live with you of whether one will will visit at any point in time. Have you obtained permission from the landlord to have modifications completed? Have you received permission from the owner of the property to have the property modified with accessibility features? Please mark an X next to the appropriate response. If you are a renter, you must obtain permission from the owner of the building in which modifications are requested. Complete and attach Appendix A to verify that you have perrmission to proceed Proof of insurance must be submitted with the application Do you live in an apartment or a rental unit? Do you pay rent to a landlord or manager for your primary residence? If the answer is yes, mark an X in the box to the left of the yes response. If the answer is no, please mark X in the box to the left of the no response. How long do you plan on remaining there? How long do you plan on remaining at the rental unit for which you are requesting modifications? Provide a copy of your existing legal and binding written agreement (Lease) with the owner of the living unit for which modifications are being requested. Do you live in a government subsidized building? If you live in a building where your rent is determined by your income, and/or if you live in a property funded by the U.S. Department of Housing and Urban Development (HUD), or any other government entity, mark an X in the box to the left of the yes response. If you pay market rate rent and the building does not receive any government funding, mark an X in the box to the left of the no response What type of disability do you have? Plese indicate what type of disability you have. Explain the nature of your disability and how it affects your ability to be independent in your home. Please write information about your disability. Is your disability permanent? If you have been diagnosed with a permanent disability, mark an X in the box for Yes. Otherwise answer No by marking an X in the box for no. If you answered No to question 25, what is the duration of your disability? If your disability is expected to last for one year or less, or if you have been diagnosed with a temporary disability or if the prognosis of your condition reflects that the disability will not continue, indicate how long your disability is expected to continue. 8

11 APPLICATION INSTRUCTIONS (CONT.) At what age did the onset of your disability occur? Please give the age at which you became disabled. Check any that apply to your disability. Please mark an X in the box for the descriptions which apply to you. For instance, if you use a wheelchair, mark an X next to, use a wheelchair. In what way does your disability affect your daily living? Please mark an X in the box for the descriptions which apply to you. For instance, if you cannot enter your home, mark an X next to the correct phrase. Explain further how your disability relates to your need for home modifications. Please elaborate, if needed, on how the modifications will help you become more independent. Explain your ultimate goal. Write what you would like to accomplish if your home is made accessible. What types of modification do you need to increase your accessibility? Mark an X in the box next to the type of modification your home requires in order to be accessible for the applicant. What is your household size? Write the total number of individuals who reside in the home being considered for home modifications. What is your annual income? Indicate the amount of money the applicant receives before taxes are deducted. If taxable income is not received, please indicate the total amount of non-taxable income the applicant receives. Calculate the annual income amount for the year 2012 by multiplying the current monthly income amount received by twelve. This information can be found on your 2010 or 2011 tax return form Please give the full names and relationship and income of the individuals living in the household with the applicant. Please write the names and incomes of the individuals who live in the home being considered for modifications and their relationship to you. On the line next to Total Income please write the total income for all who reside in the household with the applicant including the applicant. That can be done by adding A, B,C, and D. The sum of the amounts is the total income and should be written in the space provided for E. Are you aware of any building code violations on the building for which modifications are being requested? Indicate by marking an X in the box next to the appropriate response whether or not you are aware that the building being considered for home modifications has any building code violations. For instance, improper electrical wiring or below standard heating systems may have warranted a building code violation. Building code violations are issued by the City of Chicago Department of Buildings. If there are building code violations against the building in which you live, please write in the space provided, the actual violations. Building code violations may preclude participation in the HomeMod program. Choose one of the following Please mark an X next to the response that applies to the head of household. Please indicate if you are, a home owner with no mortgage payments, a home owner with mortgage payments, or a renter with monthly rent payments. If you have mortgage payments, write the amount of the mortgage payments and the name of the financial institution to which the payments are made. If you are a renter, please write the amount of rent paid monthly and the name of the person or the management company to which payments are made. 9

12 APPLICATION INSTRUCTIONS (CONT.) I am current in the following bills Please mark an X in the box next to the appropriate response for each bill. If you are a renter, you may not be responsible for paying the water bill or the property taxes. If you are not responsible for paying these bills, mark n/a next to that bill. If you are a home owner and the deed is in your name, it is assumed that you are responsible for paying all bills related to the property. If for some reason a certain bill does not apply to you, please explain, on a separate sheet of paper, why this bill is not applicable to you. A I (have) / (have not) been declared in debt in any child support obligation by the Circuit Court of Cook County or by another Illinois Court of competent jurisdiction. Please mark an X in the appropriate box. If you or your spouse are responsible for paying child support and you or your spouse are current with your payments, mark an X on the first box which indicates, that you/applicant have not been declared in debt for any child support payments. If you or your spouse are late in paying child support, mark an X in the second box which indicates that you have outstanding debt. B I (have) / (have not) entered into and am in compliance with a court approved agreement for the payment of all such child support owed. Mark an X in the appropriate box. If you or your spouse have entered into and are in compliance with a court approved aggrement for payment of all such child support, mark an X on the first box which indicates that you are in compliance. If you are not in compliance mark an X in the second box, which indicates that you are not in compliance I (am) / (am not) in default or in debt on any outstanding loans, water charges, sewer charges, property taxes, sales taxes or other fines, (including but not limited to parking violation complaints), fees, taxes, assessments or charges owed to the City of Chicago, personally or by any partnership, corporation, joint venture or land trust in which I have at least a 5% beneficial interest. Indicate whether or not you or your spouse or any other party who has partial ownership of the home are current in the payments of any loans, water and sewer bills, property taxes, sales taxes or any other fines or bills which are due to the City or that may jeopardize ownership of the home in which you reside. I (have) / (have not) submitted any other application for home modifications to the City of Chicago during the past two years. Please indicate whether or not you have applied to the City of Chicago for home modifications or home repairs. If you have applied to any agency for home repairs or modifications in the past two years, indicate to which agency the applicant applied. Have you recieved home modifications in the past? Please indicate with an X in the appropriate box whether or not you have received home modifications in the past. If so, from what agency and what home modifications were completed? Please indicate which programs you have received modifications from in the past. If you have not received any modifications in the past, mark N/A for this question. Do you receive services from the Illinois Department of Human Services? Please Indicate with an X in the appropriate box, whether or not you have received services from the Illinois Department of Human 10

13 APPLICATION. INSTRUCTIONS (CONT.) Are you currently employed? Please Indicate with an X in the appropriate box, whether or not you are currently employed. If you stated that you are employed please list the name of your employer in the space provided. Are you, your legal guardian or any members of your immediate family employed by the City of Chicago or any of its sister agencies? Please Indicate whether the person for whom the modification is requested, their parents or legal guardian (if a minor), the homeowner or any other member of the immediate family residing in the home. If you recieve an accessibility modification to your home, do you plan on finding employment or returning to a former place of employment? Please Indicate with an X in the appropriate box, whether or not you plan on finding employment or returningto a former place of employment. SIGNATURE / AGREEMENT 47 The signature of the applicant is required on this application. The signature of the applicant attests to the accuracy of the information provided. By signing this application, the applicant is indicating that the information provided is correct. A co-applicant must also sign, if applicable. If the applicant is married, the co-applicant is the applicant s spouse. If the applicant owns the home with someone else, the co-applicant is the individual who shares in the ownership of the home. If the applicant is under the age of eighteen, the legal guardian must sign as the applicant, or if the applicant is an adult, over the age of eighteen, but is not the head of household, the head of household must sign as the co-applicant. If the applicant rents and there is more than one person listed on the lease, the co-applicant is the other person listed on the lease. There may be more than one co-applicant. 11

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15 Application HOMEMOD Program CITY OF CHICAGO Mayor s Office for People with Disabilities 13

16 14 Rahm Emanuel, Mayor City of Chicago Karen Tamley, Commissioner Mayor s Office for People with Disabilities APPLICANT INFORMATION: APPLICATION DEADLINE: None Full Legal Name: First Name Middle Initial Last Name Current Mailing Address: Number and Street Apt. No. (This address must be the residence being considered for modifications.) City State ZIP code Ward Home Phone Number: ( ) - Alternate / Work Number: ( ) - 5 Date of Birth: / / Social Security Number: / / Gender: Male Female Age: (Proof of age must be provided) Ethnic Background: (Enter X in the appropriate box. This information is optional and will not be used in a discriminatory manner.) African-American, Non-Hispanic Hispanic American Indian or Alaskan Native White, Non-Hispanic Asian or Pacific Islander Other, Multiracial Drivers License, or State ID Number: - - HEAD OF HOUSEHOLD INFORMATION: Full Legal Name: Current Mailing Address: (If different from the address Number and Street Apt. No. listed above) Date of Birth: / / First Name Middle Initial Last Name City State Zip code 14 Cut along this line and detach application----> HomeMod PROGRAM APPLICATION Social Security Number: / / Property Identification Number (PIN): (Of the property being modified) (If the answer to question 16 is Do you own the property requiring modification? Yes No NO, go to question 19.) List the Names, Social Security Numbers, and Relationship to applicant of all individuals listed as owner on the property deed. Name Social Security Number Relationship

17 <---cut along this line and detach application HEAD OF HOUSEHOLD INFORMATION: (CONTINUED) Do you have homeowner s insurance on your property? Yes No (If you answer Yes to question 18, please provide a copy of your policy.) Do you live in an apartment/rental? Yes No How long do you plan on remaining there? Do you live in a government subsidized building? Yes No Does a child live with you, or will one come to visit at any time? Yes No Have you obtained permission from the landlord to have modifications done? Yes No DISABILITY INFORMATION: A What type of disability do you have? B Explain the nature of your disability and how it affects your ability to be independent in your home. (Please be specific) Is your disability permanent? Yes No If no, what is the expected duration of your disability? Yrs. Mos. At what age did the onset of your disability occur? (Please provide a copy of your existing lease) Check all that apply to your disability: use a wheelchair use oxygen I am a person who is deaf/hearing impaired use a walker use ventilator I am a person who is blind/visually impaired use crutches I use other assistive devices (specify) In what way does your disability affect your daily living? I cannot leave or enter my home or apartment without assistance I cannot use the kitchen safely and independently I cannot use the bathroom safely and independently I am unable to move from one room to another independently I cannot climb up or down stairs without assistance Other: (Explain) Explain how your disability relates to your need for home modifications. In what area of your home do you believe that a modification will help you increase your independence the most? (Choose only one area to modify) Entrance Bathroom Kitchen Other Areas 15

18 32 34 FINANCIAL INFORMATION: 33 Cut along this line and detach application----> What is your household size? What is your annual income? A $, Please give the full names, relationship to you and income of the individuals living in this household with you. (Add Incomes from A, B, C, and D. Write that amount on line E. (Total Income) B $, C $, D $, Full Name Relationship (Total Income) E $, Are you aware of any building code violations on the building for which modifications are requested? Yes No (If yes, please list the building code violations): Choose one of the following: I reside at the address listed on this application, own the property and have no mortgage payments. I reside at the address listed on this application and I am making monthly mortgage payments in the amount of $, per month. The mortage is held by: I reside at the address listed on this application and I am making monthly rental payments in the amount of $, per month. The building is owned by: I am current in the following bills: Property Taxes Yes No N/A Water Bill Yes No N/A Gas Bill Yes No N/A Electric Bill Yes No N/A Parking Tickets Yes No N/A A I have/ have not been declared in debt in any child support obligation by the Circuit Court of Cook County or by another Illinois Court of competent jurisdiction. B I have/ have not entered into and am in compliance with a court approved agreement for the payment of all such child support owed. I am/ am not in default or in debt on any outstanding loans, water charges, sewer charges, property taxes, sales taxes or other fines (including but not limited to parking violation complaints), fees, taxes, assessments of charges owed to the City of Chicago, personally, or by any partnership, corporation, joint venture or land trust in which I have at least a 5% beneficial interest. I have/ have not submitted any other application for home modifications to the City of Chicago during the past two years. Have you received home modifications in the past? Yes No If so, from what agency and what home modifications were completed? Do you receive services from the Illinois Department of Human Services? Yes No

19 <---cut along this line and detach application FINANCIAL INFORMATION: Are you currently employed? Yes No (If yes, list name of employer) Are you, your legal guardian or any members of your immediate family employed by the City of Chicago or any of its sister agencies? Yes No If you recieve an accessibility modification to your home do you plan on finding employment, or returning to a former place of employment? Yes No SIGNATURE / AGREEMENT I (We) hereby certify that I (We) have read the application and application instruction booklet, and understand and agree to all terms and conditions of the HomeMod Program. I (We) hereby certify that the information given on this application, and all information furnished in support of this application under the HomeMod Program is true and complete to the best of my (our) knowledge. Verification may be obtained from any source named herein. I (We) hereby authorize and permit the City of Chicago, Mayor s Office for People with Disabilities (MOPD) to take photographs and/or make video/or audio recordings of me for use by the City of Chicago, Mayor s Office for People with Disabilities (MOPD) at its discretion either for general publicity or for educational purposes. I (We) hereby acknowledge that I (We) are responsible for any maintenance or fees (including yearly inspections) associated with the services or equipment provided. This authorization is valid with no limitations on time from the date of signature unless revoked in writing by myself or my guardian if I am a minor. Deliberate falsification of any kind may subject me to immediate dismissal from the HomeMod Program, and imprisonment under State and Federal laws. Should any of the information I have given change at any point of the application process, I shall immediately notify the Mayor s Office for People with Disabilities HomeMod Coordinator. Applicant s Signature Co-Applicant s Signature Date Date Send completed applications with all required supporting documentation to: HomeMod Program Mayor s Office for People with Disabilities MOPD Field Office 2102 West Ogden Avenue Chicago, IL

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21 Appendix A HOMEMOD Program CITY OF CHICAGO Mayor s Office for People with Disabilities 19

22 Rahm Emanuel, Mayor City of Chicago Karen Tamley, Commissioner Mayor s Office for People with Disabilities APPLICATION DEADLINE: None LANDLORD INFORMATION: Full Legal Name: Current Mailing Address: Number and Street Apt. No. (This address must be the residence being considered for modifications.) City State ZIP code Ward Home Phone Number: ( ) - First Name Middle Initial Last Name Alternate / Work Number: ( ) - TENANT INFORMATION: HomeMod PROGRAM APPENDIX A Full Legal Name: Current Mailing Address: Number and Street Apt. No. (This address must be the residence being considered for modifications.) City State ZIP code Ward Home Phone Number: ( ) - First Name Middle Initial Last Name Alternate / Work Number: ( ) - Cut along this line and detach application----> Property Identification Number (PIN): (Of the property being modified) The tenant, listed above, is an applicant for the City of Chicago s HomeMod Program, administered by the Mayor s Office for People with Disabilities. If the tenant s application for home modifications is approved, the landlord agrees to allow modifications for accessibility to be completed. I understand these modifications will be paid for by funding provided by the City of Chicago for projects approved for the HomeMod Program. In addition, I will be notified of all work before it is performed, and be able to review plans for modifications as necessary. Tenant Signature: 20

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