BARANOF ISLAND HOUSING AUTHORITY APPLICATION FOR ASSISTANCE WEATHERIZATION PROGRAM & NAHASDA TRIBAL CITIZEN HOME REPAIR PROGRAM
Application for Assistance Applicant Information Name: : Mailing Address: Phone (h): City: State: ZIP: Phone (w): Street Address: Phone (m): Legal Description : Lot: Block: Subdivision: Property Information Type of Dwelling: Single Family Duplex / Zero Lot Modular / Mobile* Owner Occupied Rental Unit Multi-family (Apartment) Number of Rooms: (Include rooms other than bedrooms such as living and dining room, etc.) Approx. Square Footage: Year Built: Number of Occupants: Renters complete the following: Landlord/Owner Name: Phone: Address: Complete the Landlord-Tenant Agreement included with this application. Eligibility Requirements TRIBAL ENROLLMENT: To qualify for the Tribal Citizen Home Repair program, the head of household or a member of the immediate family, (spouse or children) must be an enrolled citizen of the Sitka Tribe of Alaska and live in the home at least 9 months of the year. This requirement does not apply for those applying for Weatherization program funds. However, income guidelines do apply for eligibility for both programs. General Information Do you own any other homes or properties? Y N If yes, provide information such as the location of the property, current appraised value, and state any income received for rents, lease agreements, or other income generated by the property. Also state the reason you do not live in the residence. Are you the Owner of Record for the property to be worked on? Y N If no, *please provide documentation from the tribe of your status as the recognized caretaker and resident of the subject property. Have you received assistance from any other agency for work on your home within the last five years? Y N If yes, state the name of the agency and type of assistance you received. Page 1
Family Composition List all other household members. If you need more space, feel free to add a separate sheet of paper. Name: Age: SSN: Enrolled in STA: 1. Y / N 2. Y / N 3. Y / N 4. Y / N 5. Y / N 6. Y / N 7. Y / N 8. Y / N INCOME: Annual household income must be at or below 80% of the Area Median Income limits for Sitka. Annual income is the anticipated total income from all sources received by the family head and spouse, (even if temporarily absent) and by each additional member of the family, including all net income derived from assets, for the twelve (12) month period following the effective date of determination of income, exclusive of certain types of income. Income Information Beginning with the primary applicant, list all sources of earned and unearned income for all household members over the age of 18 years For a complete list of earned and unearned countable income and the required documentation, see page 3 of this application. Name: Annual Income Amount: Source: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. TOTAL COMBINED HOUSEHOLD INCOME: Page 2
Annual Income Limits Per HUD FY 2009 80% 60% 50% 30% 1 person 2 persons 3 persons 4 persons 5 persons 6 persons 7 persons 8 persons 44,800 51,200 57,600 64,000 69,100 74,250 79,350 84,500 33,600 38,400 43,200 48,000 51,825 55,690 59,500 63,375 28,200 32,250 36,250 40,300 43,500 46,750 49,950 53,200 16,950 19,350 21,800 24,200 26,150 28,050 30,000 31,950 Sitka Borough Effective March 19, 2009 For a definition of what is considered income for the purpose of this program, see the Tribal Citizen Home Repair Program policy. Liquid Assets The applicant may not have more than 5,000.00 in liquid assests available to them at the time of application. Elderly applicants are exempt from this requirement. Liquid assets include but are not limited to; cash on hand, liquidable stocks/bonds, etc., gift sources, and any other source of funds that are available to the applicant. Name Asset Type Amount/Current Value Checking and Savings Accounts List all accounts owned by all household members over the age of 18 years: Total: Name of Account Holder Name of Bank Type of Account and Account Number Amount Page 3
Required Income Documentation In order to be considered for participation in this program, you must submit the following documentation with this application. The application will not be considered complete until all required documentation is provided by the applicant. If anyone receives the following income: Submit copies of the following: (REQUIRED) Employment Earnings (wages, tips, overtime, etc.) * Public Assistance (GA, APA, ATAP, TANF, etc.)* Unemployment Compensation VA Benefits* Workers Compensation Cost of Living Allowance (COLA) Longevity Bonus* Alimony Child Support Native Dividends (in excess of 2,000 per person) Social Security (retirement or disability)* Self-Employment Income Dividend Income (investments) Annuity Payments Government Employee Pension* Private Pension* Railroad Retirement* Insurance Payments (recurring) Alaska Permanent Fund Dividend* Rental Income Insurance Payments (other than lump sum) Estate Income Most recent check stubs and W2s Statement of benefits for last 12 months Statement of benefits for last 12 months & 1099s Statement of benefits for last 12 months & 1099s Statement of benefits for last 12 months & 1099s Most recent check stub showing YTD allowance and W2 None, just state amount received for last 12 months Copy of divorce decree with any amendments, if applicable Support order or divorce decree Most recent notification of benefits or check, 1099s Tax return and Schedule C for last 3 years (signed by taxpayer) Most recent check stub or copy of direct deposit, 1099s Most recent check stub or copy of direct deposit, 1099s Most recent check stub or copy of direct deposit, 1099s None, just state the amount received (even if garnished) Tax returns (signed and dated by taxpayer) with schedule E and year to date and signed and dated year-to-date Profit/Loss Statements *If income is received as a direct deposit to your bank account, a complete copy of the most recent statement may be submitted as proof of that income. All required documentation must be provided in order for this application to be complete. The application must be fully complete, dated and signed prior to processing of application. Complete copies of tax returns for the last three years that are signed and dated by the applicant must be submitted with the application. If you have not filed taxes for any reason during those years, a written statement of the reasons for not filing must be attached to the application. Originals may be brought to the BIHA office and copies will be made for the application file. There is no charge for the making of such copies or the acceptance or processing of this application. Page 4
Dwelling Information Plumbing: Operable Toilet Y N Operable Kitchen Sink Y N Operable Tub/Shower Y N Electricity: City Power Grid ( ) Generator ( ) Other* ( ) Sewer System: City ( ) Septic tank ( ) Chemical ( ) Other *( ) Water Source: City ( ) Private Well ( ) Collection Tank ( ) Other ( ) Primary Heating System: Oil ( ) Wood ( ) Natural Gas ( ) Electric ( ) Other * ( ) *Describe Other: Alternative Heating System: Oil ( ) Wood ( ) Natural Gas ( ) Electric ( ) Other* ( ) *Describe Other: Approximate Annual Energy Usage for primary and alternative heat systems: Gallons of Fuel Oil: Kilowatt Hours (electricity): Pounds (natural gas) Cords of Firewood: Other: Fuel / Utility Supplier Information and Release Fuel Supplier Mailing Address: City Zip Code Account Number Fuel Supplier Mailing Address: City Zip Code Account Number Electric Utility Mailing Address: City Zip Code Account Number I hereby authorize you to release information on my fuel bills, both past and future, to Baranof Island Housing Authority. I agree that a photocopy of this release may be used for the purpose stated. I understand that this information will be used only to provide data for the above-mentioned agency, and no information obtained through this release shall be made public in such a manner that the dwelling occupants can be identified. Customer Name Mailing Address: City State Zip Code Signature: :
Eligible Work In order to provide as much assistance as possible, BIHA will help each applicant to apply for additional funds from other agencies to supplement the funding available from BIHA. The funding available under this program is to be used to address threats to the occupants health and safety, and accessibility issues. Eligible repairs/replacements include, but are not limited to, the following: Health and Safety Furnace/heating system Electrical system Plumbing Foundation Roof Floors (structural) Exterior wall Framing Mold/mildew Unsafe entry stairs/decking Repair/replacement of broken windows Energy Efficiency Insulation Windows/ doors Necessary Appliances Range/stove Refrigerator Hot water heater The funding for this program is not intended to be used for cosmetic improvements. Any repairs or replacements requested by the applicant that would otherwise be considered cosmetic must be supported by written correspondence from a health care professional (doctor, physical therapist, etc.) or be recommended by the contractor/maintenance crew, in order to be addressed under this program. Emergency Repairs For the purpose of this program, emergency repairs will be defined as: Repairs requiting immediate corrective action due to a sudden occurrence or hazardous condition that threatens the health and safety of the occupant. Describe the emergency conditions including the cause and date of occurrence: For more detail regarding what constitutes and emergency, see the Tribal Citizen Home Repair Program policy. Page 5
PERMISSION TO ENTER PREMISES I, owner/authorized agent of the building located at have read and understand and grant permission for representatives of Baranof Island Housing Authority to enter the premises for the purpose of collecting eligibility documentation from residents and the development of a work plan which may include a blower door test, infared scan, testing of the air, and combustion testing. Furthermore, I have been informed of my responsibility to provide safe, sanitary conditions and clear access to the property and areas of work. Printed Name Signature BIHA Representative/title Personal Declaration: (All household members 18 years of age and older must sign the application and release of information forms): I/we understand that this is not a contract and does not bind either party. I have no objections to inquires made for the purpose of verifying the statements made herein. Applicant Affirmation: I subscribe and affirm, under the penalties of law, that the statements made in this application for Weatherization and/or Tribal Citizen Home Repair program(s) (including statements mad in any accompanying papers) have been examined by me and to the best of my knowledge and belief are true and correct. Prior to any work performed, I agree to notify BIHA of any changes in the information in this application. I understand that by signing this application, I consent to any other inquiry to verify or confirm the information I have given. I certify that no household member has received an AHFC Home Energy Rebate after May 1, 2008. I certify that no household member holds a Temporary Resident Status granted under the Immigration and Nationality Act as amended under the Immigration and Control Act of 1986 (Public Law 99-603). Weatherization Program assistance has no affect upon my social security, public assistance or any other income I have. The Weatherization work done will not obligate me financially and no lien or mortgage will be held on the property, unless false or inaccurate information has been provided to make me eligible for this assistance. Tribal Citizen Home Repair Program funds are an obligation and a lien shall be held against the property, with BIHA as beneficiary until expiration of five years from the date repairs are completed. Funds shall be recaptured in full should the property be sold or ownership transferred in any way prior to the end of the fifth year. I will not be held liable for any injury or damage occurring on my property which is not the result of my negligence or malfeasance. I certify that I have given my permission to allow work and monitoring of work on the property listed in this application. I understand that it is the dwelling occupant and or owner s responsibility to discover and correct unsafe or out of compliance conditions which exist apart from the weatherization or repair work. Page 6
I understand it will be my responsibility to remove personal property and belongings from all work areas, and to ensure that those areas are safe and sanitary for workers. I also understand any mistreatment of workers by myself or any member of the household/guests, or failure to ensure work areas are clear of belongings and safe and sanitary shall result in work cancellation. I understand that this application for assistance does not guarantee that assistance will be granted but will be used in determining eligibility for the program. Whether or not an eligible applicant will be provided assistance will depend in part upon the number of applications received, the funds available and the priorities to be met by the program. I have read and understand the provisions of the Federal Privacy Information Act. _ Applicant Signature _ Spouse/Co-Applicant Signature Homeowner Certification I/We, certify that I/we am/are the owner(s) of the property located at Applicant/Owner s Signature _ Co-applicant/Co-Owner s Signature Page 7
LANDLORD TENANT AGREEMENT PERMISSION TO ENTER PREMISES / RENTAL AGREEMENT Landlord, complete this page and the Landlord Certification on the back. Also, provide proof of ownership. Tenant, complete the Renter Certification on the back. I,, certify that I am the owner/authorized agent, herein referred to as Owner for the property located at:: Street Address or Legal Description City State The property is currently rented to the following: Primary Tenant: for rent per month year Number of rental dwelling units in this structure: Owner/Agent authorizes Baranof Island Housing Authority (BIHA) as provider of Weatherization services to conduct energy related building inspections and assessments, repairs, and improvements. Any materials installed under this agreement shall remain as part of the premises. The amount of materials and labor provided by BIHA will not exceed 4,000 per unit for buildings with four or fewer units (3,000 per unit for buildings with five or more units) unless the Owner is willing to contribute. Owner will be asked to contribute 50% of the cost of Weatherization services above the no-to-exceed limit. BIHA will match dollar-for-dollar an Owner contribution up to an amount estimated by BIHA s assessor, not to exceed 4,000 of Weatherization funds per unit for buildings with four or fewer units (3,000 per unit for buildings with five or more units). The cost of building permits shall be borne by the Owner of the building. An addendum defining the scope of work to be accomplished on this building will be attached to this agreement following the Weatherization assessment, should the Owner choose to participate financially or with in-kind services. Owner will be asked to contribute toward Weatherization improvements. Please indicate the option you think best suits your needs. [Note: Option c is available only to individual landlords (not businesses or consortiums) who own four or fewer rental units either in single or multi-family structures combined.] a. Cash contribution toward Weatherization services. (In addition to (d.) below, BIHA will match Owner contributions dollar-for-dollar, to an amount to be determined by the Weatherization assessor. At the discretion of BIHA, this contribution may be paid directly to a contractor or vendor designated by BIHA. b. In-kind contribution (to be completed prior to Weatherization improvements wherever possible). Legitimate expenses can qualify for the match defined in (a.) above. c. Waiver of Owner contribution based on verification by BIHA that the Owner s Gross household income does not exceed Weatherization income guidelines. d. No Owner contribution toward Weatherization improvements. Weatherization provider will provide up to 4,000 per unit for buildings with four or few units (3,000 per unit for buildings with five or more units). Only eligible Weatherization measures as defined by the Alaska Weatherization Assistance Program shall be applied to any building, if the funds used to perform those measures are funds provided by Alaska Housing Finance Corporation (AHFC), and/or the U.S. Department of Energy (DOE). No undue enhancement shall occur to the value of the dwelling units as a result of the Weatherization work performed. Undue enhancement is defined as any enhancement to a building that increases the value of the property and does not provide energy conservation or health and safety benefits to the tenant.
Commencing on the date the Owner and/or tenant signs that work is complete and continuing for a period of eighteen (18) months, Owner agrees not to increase rents on units weatherized. If a lease in effect expires prior to the end of the eighteen-month period, a new lease may be signed, but rents will remain at the previous level until the expiration of the eighteen-month period, unless demonstrably related to matters other than Weatherization work. (10CFR 440.22 (b)(3) (ii)) Demonstrably related to matters other than Weatherization work performed is defined as an increase in excess of 25% per year in (1) Fair Market Value of rental units, (2) an increase in property taxes, or )3) an increase in the rate of utilities paid by Owner. Any increases should be split equally between all units in the building. Owner also agrees not to terminate or evict any covered tenants or any subsequent tenants, commencing on the date the Owner and/or tenant signs that work is complete and continuing for a period of eighteen (18) months. This provision is in effect provided the tenant complies with all obligations owed to the Owner in accordance with any leases or rental agreements between the Owner and tenants. This agreement applies to the present tenants and any subsequent tenants for the eighteen-month period. If a tenant believes rents have increased contrary to the provisions of this agreement or has received an eviction notice without cause, the tenant may contact Alaska Legal Services. This agreement shall run with the land an/or weatherized unit in the case of sale or transfer to other Owner(s)/Agents. The Owner is responsible to give official notice of this agreement to any subsequent Owner(s). Either party to this agreement may bring an action for specific performance of its terms. Tenants residing in dwelling units covered by this agreement are intended third-party beneficiaries of any of the provisions of the agreement related to rental increases, evictions, and terminations of tenancies. TENANT Certification I,, certify that I am currently renting a dwelling unit located at: Street Address or Legal Description City State I have read and understand the terms of this agreement. Signature I have read and agree to the terms of this agreement. LANDLORD (Owner or Authorized Agent) Certification Signature of Owner or Authorized Agent* Mailing Address City State Zip Phone: FAX: Msg: *AGENT: INCLUDE A COPY OF YOUR AGENT AGREEMENT WITH THE OWNER. I have read and agree to the terms of this agreement. WEATHERIZATION SERVICE PROVIDER Certification Signature of Weatherization Service Provider Authorized Agent Baranof Island Housing Authority PO Box 517 Sitka, AK 99835 phone: (907) 747-5088 FAX: (907) 747-5701