HomeMy WebLinkAboutHELP application-homeowner-final
Homeowner Application
H.E.L.P.
(Housing Exterior Loan Program)
City of Iowa City Housing Rehabilitation 410 E. Washington St., Iowa City, IA 52240-1826
Phone: (319) 356-5246 FAX: (319) 356-5217 TDD: (319) 356-5493
Date: ____________________________________________
Name Applicant #1: ________________________________
Name Applicant #2: _________________________________
E-Mail address _____________________________________
Phone # Personal: ____________Work: ________________
Address: ________________________ _______________
Zip
Owned Since: ____________
Number of household members living at this address: __________ (Include Applicants #1 & #2)
Name: Age: Relationship: Occupation & Employer:
A) Provide a copy of most current federal income tax form.
B) Briefly describe the needed exterior repairs (attach the estimate):______________________________________________
_________________________________________________________________________________________________
.
I, , hereby certify on that the
(Name) (Date)
above-referenced income given for the purpose of establishing my eligibility for a H.E.L.P. loan from the City of Iowa City is true and complete to
the best of my knowledge and belief.
The applicant further certifies that he/she is the owner and principal resident of the property located at the project address .
Applicant #1 Date
Applicant #2 Date
WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE
WILLFUL FALSE STATEMENTS OF MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS
TO ANY MATTER WITHIN ITS JURISDICTION.
NOTE: Please read carefully before signing:
I understand that all information, with the exception of my federal tax return, submitted to the City
relating to this application is subject to the Open Records Law ( Chapter 22 of the Iowa Code). I
hereby certify that all representations, warranties or statements made or furnished to the City in
connection with this application are true and correct in all material respects. I understand that it is
a criminal violation under Iowa law to engage in deception and knowingly make, or cause to be
made, directly or indirectly, a false statement in writing for the purpose of procuring financial
assistance from a state agency or political subdivision.
Applicant #1 Date
Applicant #2 Date
RETURN COMPLETED APPLICATION TO:
Liz Osborne
Housing Rehab, City of Iowa City
410 E. Washington St., Iowa City, IA 52240