IMPORTANT PLEASE STOP AND READ CAREFULLYdiscover.pbcgov.org/HES/BHI/Revised Application...

(A)

IMPORTANT – PLEASE STOP AND READ CAREFULLY

HOW TO SUBMIT AN APPLICATION - TIP SHEET

Notice: If you need assistance or an interpreter, find someone you trust to help you

with the application process.

Aviso: Si necesita ayuda o un traductor, usted está obligado a venir con una persona de

confianza para los procesos de solicitud y admisión.

Atensyon: Si ou bezwen yon entêpret ou byen yon asistan, chêche yon moun ke ou fê

kofyans ki pou ede nan pwoses aplikasyon an.

Read and review the entire package before you start completing the APPLICATION and required forms.

Special priority will be given to elderly, persons with disabilities, and veterans above all other eligible income

groups. Proof of eligibility is required at time of intake, (e.g. primary applicant(s) must be age 62 or older evidenced by

birth certificate and valid State identification, proof of disability by Social Security Administration or physician, DD-214.

Keep the forms in order of the Check List. Attach specific documents requested on the CHECK LIST; include all

pages of a document, most current date on top.

Make copies of the following documents for Household Members:

a. DECLARATION FORM (US Citizens complete only, Permanent Residents complete all 4 Pages) b. Release and Consent (for ALL ADULTS in household) c. Asset Addendum (It lists the types of accounts for which you must declare and/or submit a VOD. The Asset

Addendum must be completed for all Household members including minors if they have an Asset) d. Verification of Employment (VOE) (for ALL ADULTS in household) e. Verification of Deposit (VOD) must be stamped by the Financial Institution or Bank (for ALL HOUSEHOLD

MEMBERS including MINORS, if they have an asset) f. 4506, 8821 and SSA3288 (must be completed for all ADULTS in household) g. VOE AND VOD MUST COME DIRECTLY FROM EMPLOYER AND BANK TO PBC/MHI VIA FAX NUMBER

561-656-7653. Call us to verify that your VOE & VOD have been received prior to INTAKE DAY.

Make sure documents that require Notary Signatures and Witnesses have been notarized and signed by the appropriate number of witnesses. Some forms require two witnesses.

Make sure your application is fully completed with all information applicable to your situation. Examples:

a. SECTION 6: TOTAL your household INCOME per person Monthly, Annually and Grand Total for entire household.

b. SECTION 7: TOTAL ALL YOUR ASSETS (Use estimated balances at the time you complete the application).

Failure to fully disclose information will result in automatic denial of your file. Example:

a. Your Spouse (State of Florida does not recognize Separation)

b. Adult children living in your home.

NOTES: TO QUALIFY FOR OUR PROGRAM/S

ASSETS CAN NOT EXCEED $200,000 (See Asset Addendum for list of Assets)

Fair Market value of the property to be purchased through our First and/or Second Mortgage Program, or any other Assistance Program may not exceed the established maximum sales price, which is currently $329,269. The Market Value of the Property is determined using Palm Beach County Property Appraiser’s office “fair market value” for current homeowners.

TO GET:

CLERK & COMPTROLLER (561) 355-6511 (General information); 1-877-769-0251 (State of Florida Child Support

Disbursement Unit automated system for individual case information)

*Wage Earner Statements visit: *IRS Tax Transcripts visit: Social Security Administration Office Internal Revenue Service 801 Clematis Street, Suite 2 1700 Palm Beach Lakes Blvd. West Palm Beach, FL 33401 West Palm Beach, FL 33401 (800) 772-1213 (561) 616-2002 Hours: Monday, Tuesday, Thursday & Friday 9:00 a.m. – 4:00 p.m. Wednesday 9:00 a.m. – 12:00 noon, Closed Saturday & Sunday

*The Wage Earner Statement must be stamped by SSA and the transcript must be stamped by IRS.

DES Mission Statement...

"To advance community sustainability by increasing economic competitiveness and improving the elements that

create a high quality of life for Palm Beach County’s residents.”

IN ACCORDANCE WITH THE PROVISIONS OF THE ADA, THIS AD AND DOCUMENTS LISTED CAN BE REQUESTED IN AN ALTERNATE FORMAT.

AUXILIARY AIDS OR SERVICES WILL BE PROVIDED UPON REQUEST WITH AT LEAST THREE DAYS NOTICE. CONTACT MHI AT (561) 233-3600.

NOTICE: If you require a translator, you are required to provide a trusted person for the application and intake processes. Original documents used to determine IDENTITY and INCOME must be presented to staff (PBC or Sub Recipient), for example Social Security Card or Award Letter, Driver's License, Birth Certificates, Passports, Pay Stubs, Bank Records, etc. Additional Information may be

required b a s e d upon individual circumstances. WHITE OUT or CROSS OUT WILL NOT BE ACCEPTED ON ANY DOCUMENT. USE ONLY BLUE INK.

SECTION I A – STANDARDIZED FORMS – PART I SECTION II – INCOME VERIFICATION (Continued)

______ Signed & Notarized Rights & Responsibilities ______ 1 MONTH’S Pay Stubs for ALL Household

______ Program application ____ Adults ____ Children Members (Date order most current on top)

Must be signed by ALL ADULTS in the Household ______ 6 Months of Bank Statements for ALL household

______ Signed Declaration Format Document Members

US Citizens complete Page 1 only ______ 6 Months Debit Card Statements

Permanent Residents complete all 4 Pages ______ YTD Profit and Loss Statement

______ Signed & Notarized Applicant Release and (For all Self-Employed, Independent Contractors and

Consent

______ Signed & Notarized Applicant Certification Affidavit

And Addendum (Pages 1 and 2)

1099 Employees.)

______ Signed Asset Addendum for ALL household ______ Social Security Benefits Award Letter

members with Assets including Minors ______ Social Security Disability Letter

______ Signed Verification of Assets Disposed ______ Social Security Wage Earner Statement OR

______ Social Security Summary Earnings Query

SECTION I B – IDENTIFICATION/PERSONAL DOCUMENTS (For ALL Non-Working Adults & Students over 18 years)

______ Copy of Driver’s License(s) or State of Florida ______ Child Support Documentation for ALL children

issued Identification ______ Retirement Accounts for ALL Household members

(No expired ID’s will be accepted) (401K, 403B, IRA’s, CD’s, and Pension(s))

______ Original Social Security Cards for Verification PROVIDE COPY OF TAXES AS SUBMITTED TO IRS

______ Birth Certificates (Original or Certified Copies), OR INCLUDING W2’S, 1099’S & ALL ATTACHMENTS

______ Current US Passport or Naturalization Certificate ______ Two Years of Signed Income Tax Returns

______ Current Permanent Resident Card ______ Self-Employed Three Years of Signed Taxes

(Expired Cards will not be accepted) ______ Other____________________________________

______ Social Security Disability Documentation

______ Estranged Spouse – Requires copy of FDL or ID SECTION III – MORTGAGE DOCUMENTS showing a different address for the estranged spouse, ______ 1

st Mortgage Lender Pre-approval

a copy of their utility bill matching address on the ______ 1st Mortgage Lender Copy of Credit Report

FDL/ID & a Notarized letter of explanation

______ Battered Spouse - Restraining Order SECTION III – REHABILITATION & UTILITY CONNECTION

______ Divorce Decree or Settlement ______ Current Property Tax Statement & Proof of

______ Separation Affidavit (spouse must also agree to sign Payment & Homestead Exemptions or Escrow PBC Mortgage and required documents Statement showing taxes and Insurance Escrowed

______ Veterans DD214 ______ Proof of all required Insurance (Home Owner’s

______ Legal Adoption Papers Windstorm and/or Flood)

______ Student Enrollment and Class Schedule (for Adult ______ Mortgage Statement showing mortgage paid Children who are full time students) Current or Evidence of Paid Mortgage

______ Mold Remediation Affidavit (Current Homeowners) ______ Request for Services / Non-Profit Request for

Reimbursement

______ Copy of Lease ______ Verification of Rent ______ Utilities Letter, County Municipal Fees - Impact

(First Time Home Buyers Only) Fees, Sewer & Water Connection Fees

______ Consent to Enter – Release of Liability – Signed

SECTION I C – REQUIRED CERTIFICATIONS & Notarized

______ Home Buyer’s Education Certificate ______ Other ___________________________________

____ Original Certification (No On-Line Class) ______ Other ___________________________________

____ Original One-On-One Certificate

____ Non-Profit Fee Sheet if applicable

SECTION III – FORECLOSURE PREVENTION

______ Foreclosure Demand Notice

SECTION I D – PROPERTY RELATED DOCUMENTS ______ Reinstatement Figures

______ Homeowner’s Insurance (Valid Hazard & Windstorm) ______ Forbearance Agreement (if Applicable)

______ Current Mortgage Statement

SECTION I E – STANDARD FORMS PART II ______ Recorded Warranty Deed

______ Signed Subordination Policy (Borrower /Co-Borrower) ______ Current Year Property Tax Statement THE FOLLOWING FORMS REQUIRED FOR ALL ADULTS ______ Hardship Affidavit/Letter explaining hardship

MAKE AS MANY COPIES OF FORMS YOU NEED ______ Doctor’s Report (If due to medical problem)

______ Signed 4506 Request for Tax Transcript ______ Involuntary Separation (job loss Employer Letter required)

______ Signed 8821 Tax Information Authorization ______ Other ___________________________________

______ Social Security SSA3288 _____________________________________________________

_______________________________________________

SECTION II – INCOME VERIFICATION _______________________________________________

______ Income Limits

FAX the following 2 documents to: [email protected]

______ Verification of Employment (VOE)

______ Verification of Deposit (VOD)

APPLICATIONS ACCEPTED BY APPOINTMENT ONLY INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

mailto:[email protected]


Revised 10-9-13 (C)

YOUR RIGHTS AND RESPONSIBILITIES

Read this page before you sign your name. A copy of this information will be given to you.

Apply for assistance and to have a determination of your eligibility made without regard to race, color, sex, age, disability, religion, national origin, marital status, familial status, sexual orientation, or gender identity or expression.

Have an intake appointment scheduled within 10 business days upon receipt of required verification documents.

Be interviewed and notified of your eligibility to receive assistance within 45 days from the date you turn in a completed request for assistance and be notified of your eligibility within 60 days.

Meet with an assigned planner to accept your completed application with all necessary supporting documentation.

Bring a trusted advisor to aid you in the completion of your request for funding; this includes translation/interpreter assistance.

Expect reasonable accommodations, upon request, in accordance with the Americans with Disabilities Act (ADA).

Receive the assistance for which you are eligible and be notified promptly of any action taken on your application or change in assistance.

Inquire and receive information, upon request, about other funding sources administered by the Department of Economic Sustainability.

Be placed on a waiting list for no more than 120 calendar days should additional funding become available. If no funding becomes available, or a waiting list is prohibited by the funding source, you will automatically be removed from the waiting list without prior notice.

Work with any non-profit, realtor, loan originator or lender of your choice, provided that the company meets the requirements of Palm Beach County

Appeal an adverse funding determination within 90 days and if you believe an error was made during the evaluation process, to submit documentation that support inaccuracies made when determining eligibility and/or creditworthiness.

Pay from your personal assets (out-of-pocket) for any assistance required above the household eligible funding award, these funds must be paid prior to work commencement.

Have the information about you or your household collected by the Department treated confidentially in accordance with federal and state laws.

(NOTE: You have these same responsibilities if you are applying on behalf of someone else.)

Give complete, correct and written proof of information to county staff as requested, within the time limits given, in order to determine your eligibility for assistance.

Notify county staff of any material changes to your household size, income, assets, or credit immediately.

Manage your finances in a prudent manner this includes paying existing debt on time, not incurring additional indebtedness, maintaining savings and the like.

Declare the citizenship or non-citizenship status of your family members who are applying for assistance by signing the request for assistance. You must provide the department documentation from the Bureau of Citizenship and Immigration Services (BCIS), for all persons who are not U.S. citizens for whom assistance is being requested. This information may be subject to verification by BCIS. Information received from BCIS may affect your eligibility and level of assistance.

Pursuant to Section 817.545(2), Florida Statutes, any person making and/or using a material misstatement, misrepresentation, or omission during the mortgage lending process with the intention that the misstatement, misrepresentation, or omission will be relied on by a mortgage lender, borrower, or any other person or entity involved in the mortgage lending process may be subject to criminal prosecution. I HAVE READ AND UNDERSTAND MY RIGHTS AND RESPONSIBILITIES AND PENALITIES.

________________________________________________ _______________________ Signature of Applicant/Recipient/Authorized Representative Date ________________________________________________ _______________________ Signature of Applicant/Recipient/Authorized Representative Date WITNESS MY HAND AND SEAL: State of Florida Palm Beach County

The foregoing instrument was acknowledged before me this ____ day of ________________, 2016 by _____________________________________________who is/are personally known to me or who has/have produced _________________________ as identification. ___________________________________ Notary Seal Signature of Notary Public

___________________________________ Name of Notary Typed, Printed or Stamped Commission No.______________

YOU HAVE THE RIGHT TO:

YOU HAVE THE RESPONSIBILITY TO:

FLORIDA FRAUD LAW INFORMATION

MORTGAGE AND HOUSING INVESTMENTS

$________________________

(1) HOUSEHOLD INFORMATION (Please Include Area Code for all Phone Numbers)

Social Security Number Date of Birth Marital Status _____ Married

___Unmarried ____Separated

Present Address (include city, state, and zip code ) Apartment Number

Cell Phone Number Work Phone Number Home Phone Number Emergency Contact Number

Co-Applicant Name

Social Security Number Date of Birth Marital Status

Present Address (include city, state, and zip code ) Apartment Number

Cell Phone Number Work Phone Number Home Phone Number Emergency Contact Number

AGE

1.

2.

3.

4.

5.

Total Number of Household Members _____

Is the applicant, co-applicant or any household member age 18 or older, and a full-time student? ____ Yes ____ No

If yes, what is that person's name(s)?

(2) PROPERTY TO BE _______ PURCHASED ______ REPAIRED _____ RENTED

Address City

Legal Description

Property Control Number (PCN)

Applicant Name Email Address

TOTAL SUBSIDY REQUEST

LOAN/FINANCIAL INVESTMENTS UNIVERSAL PROGRAM APPLICATION

DEPARTMENT OF ECONOMIC SUSTAINABILITY

□ PURCHASE ASSISTANCE WITH/WITHOUT

□ 1ST MORTGAGE LOAN ASSISTANCE PROGRAM □ HOME MATCH

□ HOME (FEDERAL PROGRAM)

RelationshipEmergency Contact Person

this occur you will be notified and given an opportunity to participate, on a voluntary basis, in an alternative affordable housing and/or

financing program. We may also combine funding strategies to meet your individual and family housing needs.

_______________ _________________

Applicant Initials Co-applicant Initials

initial request for funding.

_______________ _________________


APPLICANT(S) Please complete Sections (1-12A) as applicable

*OTHER HOUSEHOLD MEMBERS

Relationship

REHABILITATION PROGRAMS

REHABILITATION (SHIP)

FIRST-TIME HOMEBUYER PROGRAMS

□ EMERGENCY REPAIRS□ REPLACEMENT HOUSING (RHP)

Name of Organization ______________________________

□ HOUSING REHABILITATION/BARRIER FREE□ ROOF REPAIR/REPLACEMENT

□ DISASTER MITIGATION

□ OTHER

□ Agency or Sub-Recipient □ Home Buyer □ Renter □ Rehabiltation

□ VETERANS HOMEOWNERSHIP & PRESERVATION

□ FORECLOSURE PREVENTION (SHIP)

□ UTILITY CONNECTION/IMPACT FEE PAYMENT

□ VETERANS HOMEOWNERSHIP & PRESERVATION

NOTICE: Palm Beach County reserves the right to verify all information provided, including verifying creditworthiness from the three

major credit bureaus (Experian, Equifax, and Transunion). By submitting a request for funding you hereby authorize consent of

verification.

_______________ _________________


Emergency Contact Person

RELATIONSHIP SSN

Total Number of Bedrooms

*These are persons who are currently or anticipated to be members of the assisted dwelling.

Total Number of Bathrooms

Zip Code

OTHER HOUSING RELATED PROGRAMS PALM BEACH COUNTY PARTNERS

PROGRAM (VHPP)

REVISED 2-17-16 1

Property Type

Sale Price Appraised Value

Is the address above your primary residence?

Is your mortgage current?

_____ Yes _____ No

How much is the loan amount or loan payment?

Is your Interest Rate ____ Fixed or ____ Adjustable? Term [ ] 30 years [ ] 20 years [ ] _____ years

Have you received 20 Day Notice? _____ Yes _____No

Do you have a contract for this property?

_____Yes _____ No

Have you owned a home in the last three years?

_____ Yes _____ No

(3) APPLICANT PRIMARY EMPLOYMENT INFORMATION

* If you are unemployed or disabled, please provide information on your last employer

Name of Employer Type of Business

Job Title Starting Date Ending Date

Employer Address (include city, state and zip code)

Name of Payroll Contact Person (or Supervisor) Phone Number of Payroll Contact Person (include area code )

APPLICANT SECONDARY EMPLOYMENT INFORMATION








Job Title Ending Date



____ Employed _____ Self-Employed _____ Retired _____ Disabled* _____ Unemployed*


Starting Date

Name of Lender/Mortgage contact person Telephone number of Lender/Mortgage contact

If Yes, how long ago? __________________

_____ Yes _____ No

_____ Yes _____ No _____ Yes _____ No

Is a Non-Profit Agency assisting you?

If yes when does the lock expire? ______________

If yes, when does the contract expire?

_____ Single Family _____ Condo _____ Townhouse _____ Duplex

Taxable Value on PAPA

___________ Years __________ Months

Address of your Lender/Mortgage CompanyWhat is the name of your Lender/Mortgage Company?

Have you or spouse had a foreclosure in the last three years?

_____ Yes _____ No

If Yes, please provide the name below

Is your Interest Rate Locked in? _____ Yes _____ No

If No, how many months If delinquent how many years?

(4) CO-APPLICANT PRIMARY EMPLOYMENT INFORMATION

PAPA Assessed Value

Total Number of Units

(2a) CONTINUED from Page 1

delinquent? # of Months______ # of years ________

_____ Yes _____ No

Are your property taxes current?

If so, how long have you lived at that address?

_____Yes _____ No

Do you have a First mortgage? Second mortgage?


REVISED 2-17-16 2






(6) HOUSEHOLD INCOME

Gross Monthly Income

Name

1 Wages / Salary

2 Overtime

3 Bonuses

4 Commissions

5 Dividend / Interest

6 Social Security

7 Pension

8 Disability

9Child Support / Alimony

10 Self-Employment

11 Net Rental Income

12 Unemployment

13 AFDC

14Regular Contributions /

Gifts

15 Other

Total Monthly [Add 1 - 15] (A) (B) __________________ (C) ___________________________

Total Annually [AX12=D] (D) (E)___________________ [Bx12 = E]

Total Annual Household Income [D+E+F=H] (H) ___________________________

(7) HOUSEHOLD ASSETS

Please check the assets held in your name

(individually or jointly)

_____

Checking _____

Checking _____

Savings _____

Savings _____

Treasury Bills _____

IRA Accounts _____

Pension Fund _____

Lump Sum Receipts _____

Stocks / Bonds _____

Other _________________

$

(8) HOMEOWNER HAZARD AND FLOOD INSURANCE (REQUIRED FOR ALL REPAIR PROGRAMS)

Do you have Hazard Insurance? ____ Yes ____No

Insurance Company Phone Number (include area code )

Policy Number Amount of Coverage Date Policy Expires

_____ Yes ____ No

Name of Flood Insurance Company Name of Windstorm Insurance Company

Total Monthly [A+B+C=G]

Household Income (G)

[Column C)

Other Household Member

(Column B)

Co-Applicant

(Column A)

Applicant

Bank or Financial Institution

If yes, please provide belowDo you have Flood and/or Windstorm Insurance?

Retirement Fund (401K, etc) _____

Certificates of Deposits (CD) _____

(F) ___________________________ [CX12= F]

If yes, please provide below

ENTER THE AMOUNT OF YOUR TOTAL COMBINED ASSETS

Debit Card


(5) EMPLOYMENT INFORMATION FOR OTHER HOUSEHOLD MEMBER __________

Name of Hazard Insurance Company

Amount

Amount of Deductible

REVISED 2-17-16 3

(8a) Continued From Page 3

Policy Number Amount of Coverage Date Policy Expires Deductible

(9) SPECIAL NEEDS / BARRIER FREE (Complete this section only if you are applying for the SPECIAL NEEDS/BARRIER FREE Program)

Please check type of assistance needed

___ Grab Bars ___Accessible Ramp ___ Accessible Commode ____ Curbless Shower

___ Accessible Fixtures ___Wider Doors ___ Accessible Kitchen Cabinets and Drawers

Please list other types of assistance needed _______________________________________________________________________________

(10) FORECLOSURE PREVENTION

(Complete this section only if you are applying for the FORECLOSURE PREVENTION Program)

First Mortgage Company Second Mortgage Company

Phone Number Phone Number

Fax Number Fax Number

Loan Number Loan Number

Loan Balance Loan Balance

Monthly P&I Payment Monthly P&I Payment

Monthly Tax Payment Monthly Tax Payment

Monthly Insurance

Payment

Total Amount Delinquent Total Amount Delinquent

Please provide current mortgage statement(s) and a statement of fee needed to bring mortgage current.

APPLICANT & CO-APPLICANT LIABILITIES ( FORECLOSURE PREVENTION ONLY)

1.

2.

3.

4.

5.

TOTAL $ $

(11) UTILITY CONNECTION PROGRAM (Complete this section only if you are applying for the Utility Connection Program)

Fee payment request for Utility Connection Program (Attach a copy of the fee documentation, if available)

Special Assessment Plumbing Costs

County Impact Fee Sewer Connection Fee

Water Connection Fee Meter Installation Fee

Duplex Owners Only

TOTAL $

List other sources of financing both Public and Private

1. Name $

2. Name $

TOTAL $

(12) ADDITIONAL INFORMATION APPLICANT CO-APPLICANT

1.

_____ Yes _____ No _____ Yes _____ No

2. _____ Yes _____ No _____ Yes _____ No

_____ Yes _____ No _____ Yes _____ No

3.

_____ Yes _____ No _____ Yes _____ No

4.

_____ Yes _____ No _____ Yes _____ No

Has your name been on the title of any other property within

the last 3 years excluding your current residence?

If yes, please explain on a separate sheet of paper.

_____ Individual Meter _____ Master Meter

Are you a US Citizen

Monthly Insurance Payment

Are you or a household member disabled?

Windstorm Insurance Company Phone Number (include area code)

Are you an employee of Palm Beach County or related to an

employee of Palm Beach County?

Are you related to an employee of Department of Economic

Sustainability or Mortgage and Housing Investments?

Please list all installment loans, revolving loans, mortgage loans, equity loan accounts, credit cards, student loans, car loans (and car

liens), stock pledges, alimony payments, child support payments and all other debts. (If necessary, use additional sheets.)

Alien Registration Number _________________________

If NO, are you a Lawful Permanent Resident Alien

Flood Insurance Company Phone Number (include area code)

____________________________________________________________________________________________________________________________

Are you or a household member age 62 or older?

If yes, give name, relationship and department / division. ______________________________

If yes, give name, relationship and department / division. ____________________________

Monthly PaymentPresent BalanceAccount NumberDebt Held By

REVISED 2-17-16 4

(12 a) PROGRAM BENEFICIARY INFORMATION

_____ MALE _____ FEMALE

_____ HISPANIC OR LATINO ___ NOT HISPANIC OR LATINO _____ HISPANIC OR LATINO

RACE

Household Special Needs (check all that apply)

"Does any member of your household meet the following definition of special need?" _____ Yes _____ No

An adult person requiring independent living services in order to maintain housing or develop independent living skills and

who has a disabling condition 420.0004(7) FL Statutes

□ A young adult formely in foster care who is eligible for services under s. 409.1451(5);

□ A survivor of domestic violence as defined in s. 741.28; or

□ A person receiving benefits under the Social Security Disability Insurance (SSDI) program or the Supplemental Security

or from veterans' disability benefits.

_____ Farm Workers _____Developmentally Disabled ____ Persons with Disabilities

_____ Homeless _____ At-Risk of Homelessness ____ Veterans

_____ Aging out of Foster Care ____ Female Head of Household

_____ Other

Applicant Signature Date Co-Applicant Signature Date

Adult Household Member Signature Date


Adult Household Member Signature DateAdult Household Member Signature Date


*Please be advised that all programs are based on funding availability. Please confirm the

status of funding with Mortgage and Housing Investments prior to submitting an

application.


ETHNICITY

CO-APPLICANT

_____ FEMALE

___ NOT HISPANIC OR LATINO

This application is for funding from the State Housing Initiative Partnership (SHIP) Program, Home Investment Partnership (HOME)

Program, Neighborhood Stabilization (NSP) Program or other funding sources and the following information is required to monitor

compliance to Equal Credit Opportunity and Fair Housing Laws.

I/We understand that providing false information on this application regarding marital

status, household size and income shall result in automatic denial of the application for

funding. I/We understand the Florida Statute 814 provides that willful false statements or

misrepresentation concerning income, asset, or liability information relating to financial

conditions is a misdemeanor of the first degree, punishable by fines and imprisonment

provided under FL Statutes 775.082 or 775.083. I/We certify that the application

information provided is true and complete to the best of my/our knowledge. I/We consent

to disclose all information for the purposes of income verification related to making a

determination of my/our eligibility for program assistance. I/We agree to provide any

documentation needed to assist in determining eligibility and am/are aware that all

information and documents provided are a matter of public record. I/We understand that

funds provided through all programs are considered a conditional loan and may require

my/our signature on a Mortgage and Promissory Note.

APPLICANT

ETHNICITY

RACE

_____ NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

_____ WHITE

_____ MALE

_____ BLACK OR AFRICAN AMERICAN

_____ NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

_____ WHITE

_____ AMERICAN INDIAN OR ALASKA NATIVE

_____ ASIAN

_____ BLACK OR AFRICAN AMERICAN

_____ AMERICAN INDIAN OR ALASKA NATIVE

_____ ASIAN

Definition of Persons with Special Needs per Florida Statutes s.420.0004

_____ Elderly

_____ Elderly Fraile

REVISED 2-17-16 5

Exhibit 3-5

HUD Occupancy Handbook 1 8/13 Exhibit 3-5

4350.3 REV-1

Exhibit 3-5: Sample Citizenship Declaration

INSTRUCTIONS: Complete this Declaration for each member of the household listed on the Family Summary Sheet

LAST NAME

FIRST NAME

RELATIONSHIP TO DATE OF HEAD OF HOUSEHOLD SEX BIRTH _____________

SOCIAL ALIEN SECURITY NO. REGISTRATION NO.

ADMISSION NUMBER__________________________if applicable (this is an 11-digit number found on DHS Form I-94, Departure Record)

NATIONALITY (Enter the foreign nation or country to which you owe legal allegiance. This is normally but not always the country of birth.) SAVE VERIFICATION NO.

(to be entered by owner if and when received)

INSTRUCTIONS: Complete the Declaration below by printing or by typing the person's first name, middle initial, and last name in the space provided. Then review the blocks shown below and complete either block number 1, 2, or 3:

DECLARATION I, ____________________________________________________ hereby declare, under penalty of perjury, that I am (print or type first name, middle initial, last name):

______ 1. A citizen or national of the United States.

Sign and date below and return to the name and address specified in the attached notification letter. If this block is checked on behalf of a child, the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.

________________________________________________ _________ Signature Date

Check here if adult signed for a child: _______

Exhibit 3-5


4350.3 REV-1

______ 2. A noncitizen with eligible immigration status as evidenced by one of the documents listed below:

NOTE: If you checked this block and you are 62 years of age or older, you need only submit a proof of age document together with this format, and sign below:

If you checked this block and you are less than 62 years of age, you should submit the following documents:

a. Verification Consent Format (see Sample Verification Consent Form in

Exhibit 3-6).

AND

b. One of the following documents:

(1) Form I-551, *Permanent Resident Card*

(2) Form I-94, Arrival-Departure Record, with one of the following annotations:

(a) "Admitted as Refugee Pursuant to section 207";

(b) "Section 208" or "Asylum";

(c) "Section 243(h)" or "Deportation stayed by Attorney General"; or

(d) "Paroled Pursuant to Sec. 212(d)(5) of the INA."

(3) If Form I-94, Arrival-Departure Record, is not annotated, it must be accompanied by one of the following documents:

(a) A final court decision granting asylum (but only if no appeal is taken);

(b) A letter from an DHS asylum officer granting asylum (if application was filed on or after October 1, 1990) or from an DHS district director granting asylum (if application was filed before October 1, 1990);

(c) A court decision granting withholding or deportation; or

(d) A letter from an DHS asylum officer granting withholding of deportation (if application was filed on or after October 1, 1990).

(6) A receipt issued by the DHS indicating that an application for issuance of a replacement document in one of the above-listed categories has been made and that the applicant's entitlement to the document has been verified.

(7) *Other acceptable evidence. If other documents are determined by the DHS to constitute acceptable evidence of eligible immigration status, they will be announced by notice published in the Federal Register.*

Exhibit 3-5


4350.3 REV-1

If this block is checked, sign and date below and submit the documentation required above with this declaration and a verification consent format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult who will reside in the assisted unit and who is responsible for the child should sign and date below.

If for any reason, the documents shown in subparagraph 2.b. above are not currently available, complete the Request for Extension block below.

________________________________________________ _________ Signature Date

Check here if adult signed for a child: ______

REQUEST FOR EXTENSION

I hereby certify that I am a noncitizen with eligible immigration status, as noted in block 2 above, but the evidence needed to support my claim is temporarily unavailable. Therefore, I am requesting additional time to obtain the necessary evidence. I further certify that diligent and prompt efforts will be undertaken to obtain this evidence.

__________________________________________ _____________ Signature Date

Check if adult signed for a child: ______

______ 3. I am not contending eligible immigration status and I understand that I am not eligible for financial assistance.

If you checked this block, no further information is required, and the person named above is not eligible for assistance. Sign and date below and forward this format to the name and address specified in the attached notification. If this block is checked on behalf of a child, the adult who is responsible for the child should sign and date below.

__________________________________________ ___________ Signature Date

Check here if adult signed for a child: ______

10 Revised: 2-17-16

MORTGAGE & HOUSING INVESTMENTS

APPLICANT/TENANT RELEASE AND CONSENT .

Print Name (s) The undersigned hereby authorize the release without liability, information regarding the applicant’s employment, income and/or assets to Palm Beach County Mortgage and Housing Investments, for the purpose of verifying information provided as part of the owner’s assistance under Mortgage and Housing Investments (MHI) through its various programs. It is understood previous and current information regarding the applicant(s) may be needed. Verification and inquires may be requested, but are not limited to the following:

√ Personal Identity √ Assets √ Employment √ Medical Allowances √ Income √ Child Care Allowances √ Credit Bureaus

This authorization will only be used to obtain information about the applicant(s) pertinent to my eligibility for the MHI Program.

Information may be solicited from, but not limited to: Past and Present Employers Retirement Systems Previous Landlord(s) (including Public Housing Agencies) Veterans Administration State Unemployment Agencies Welfare Agencies Social Security Administration Bank and Other Internal Revenue Service Financial Institutions Institutions of Learning (e.g. University public/private/vocational schools & daycare) The applicant(s) understands a photocopy of this authorization may be used for the purposes stated above. The original authorization is on file and will stay in effect for one year and one month from the date signed. The applicant(s) have the right to review this file and correct any information proven to be incorrect. ___________________________ __________________________ Head of Household Print Name ____________________________ __________________________ Spouse / CO-Applicant Print Name ____________________________ __________________________ Adult Member Print Name WITNESS MY HAND AND SEAL: State of Florida Palm Beach County The foregoing instrument was acknowledged before me this ____ day of ________________, 2016 by _____________________________________________who is/are personally known to me or who has/have produced _________________________ as identification.

___________________________________ Notary Seal Signature of Notary Public ___________________________________ Name of Notary Typed, Printed or Stamped Commission No.______________

11

DEPARTMENT OF ECONOMIC SUSTAINABILITY MORTGAGE AND HOUSING INVESTMENTS

APPLICANT CERTIFICATION AFFIDAVIT

The applicant(s) certifies all information in this application and all information furnished in support of this application is given for the purpose of obtaining assistance through the Palm Beach County Mortgage and Housing Investments (MHI) Program. Further, all of the information provided is true and correct to the best of their knowledge and belief.

The applicant(s) further certifies that he and/or she shall:

Occupy the property as their principal place of residence for the period of the conditional mortgage; or

Notify the Palm Beach County Mortgage and Housing Investments or its designee of the owner’s intent to sell and or vacate the property prior to taking such action.

Maintain the property as their principal residence for the period of the conditional mortgage, if not, any portion of the award granted by the original conditional mortgage which is not yet forgiven, may be due and payable to Palm Beach County’s Housing Trust Fund upon sale or upon abandonment of the property unless a separate agreement otherwise has been made between Palm Beach County and the owner(s).

The applicant(s) covenant and agrees that he and/or she will:

Comply with all applicable requirements imposed by or pursuant to the Palm Beach County First and/or Second Mortgage provisions; and

Comply with the requirement prohibiting discrimination on the basis of race, color, religion, sex, sexual orientation, marital status, familial status, disability, age or national origin in the sale of the property constructed or improved with the assistance of Palm Beach County.

Palm Beach County shall be deemed to be the beneficiary of the provisions both for and in its own right and also for the purpose of protecting the interest of the community and other parties, public and private, in whose favor or for whose benefit these provisions have been provided and shall have the right, in the event of any breach of these provisions, to maintain any actions or suits at law or in equity or any other proper proceedings to enforce the curing of such breech. The applicant(s) covenant and agrees he and/or she will notify Palm Beach County Mortgage and Housing Investments from the time of application through thirty-six (36) months after financial assistance is provided if there are any changes in the household’s circumstances, including but not limited to:

The birth of a child; A marriage or divorce; A change in employment or income status; and Any change that might affect the eligibility of the household to receive assistance through this

program.

The applicant(s) hereby authorizes Palm Beach County to obtain verification and information as may be needed in connection with qualifying the applicant(s) for funding.

_____________________________________ _______________________________ Print Applicant Name Applicant Signature _____________________________________ _______________________________ Print Applicant Name Applicant Signature

WITNESSES: _____________________________________ _______________________________ Print Witness Name Witness Signature

_____________________________________ _______________________________ Print Witness Name Witness Signature

WITNESS MY HAND AND SEAL: State of Florida Palm Beach County The foregoing instrument was acknowledged before me this ____ day of ________________, 2016 by _____________________________________________who is/are personally known to me or who has/have produced _________________________ as identification. ___________________________________ Notary Seal Signature of Notary Public ___________________________________ Name of Notary Typed, Printed or Stamped Commission No.______________

12


APPLICANT CERTIFICATION AFFIDAVIT ADDENDUM The applicant(s) covenant and agrees that he and/or she will provide in their own handwriting who will reside in home and/or if someone is using the home as their mailing address:

Persons in Household Residing Mailing Address

EXAMPLE – JANE SMITH EXAMPLE - JANE SMITH EXAMPLE - JANE SMITH

The applicant(s) hereby authorizes Palm Beach County to obtain verification and information as may be needed in connection with qualifying the applicant(s) for funding. _____________________________________ _______________________________ Print Applicant Name Applicant Signature _____________________________________ _______________________________ Print Applicant Name Applicant Signature

WITNESSES: _____________________________________ _______________________________ Print Witness Name Witness Signature

_____________________________________ _______________________________ Print Witness Name Witness Signature

WITNESS MY HAND AND SEAL: State of Florida Palm Beach County The foregoing instrument was acknowledged before me this ____ day of ________________, 2016 by _____________________________________________who is/are personally known to me or who has/have produced _________________________ as identification. ___________________________________ Notary Seal Signature of Notary Public ___________________________________ Name of Notary Typed, Printed or Stamped Commission No.______________

REVISED 2-1-16 13


MORTGAGE AND HOUSING INVESTMENTS UTILITY CONNECTION/WATER SEWER/IMPACT FEE PROGRAM

CONSENT AND AUTHORIZATION TO ENTER UPON PROPERTY AND RELEASE OF LIABILITY

I/We, ________________________________ the undersigned, warrant to the Department of Economic Sustainability in Palm Beach County, Florida, that I/we am/are the legal owner(s) and occupant(s) of the property located at:

Address ____________________________________________

_____________________________________________ The above - mentioned property owner(s) hereby: Authorize Palm Beach County, Florida, (County), its agents and employees to enter upon said property, and permit reasonable inspections of the land and improvements at reasonable times, when deemed necessary by the County, in connection with the water line and/or sewer line hook-ups, and the abandonment of the existing septic tank and drain field. Warrant that any required permission has been obtained from all lien holders or mortgagees that authorize the stated water line and/or sewer line hook-ups and the abandonment of the existing septic tank and drain field. Release, indemnify and hold harmless the County, its agents and employees, of and from any and all liability, claims, losses, damages and causes of actions which may arise out of the performance of the above described construction work, as well as any and all liability arising out of claims of lien holders and mortgagees with reference to the above mentioned property. I/We understand and acknowledge that all payments made by the County will be made directly to the plumbing contractor and/or the agency providing water and/or sewer service, and not directly to owner. Further, owner understands and acknowledges that no payments will be made by the County for any fees previously paid by owner or for any charges or indebtedness incurred by owner.

WITNESS SIGNATURE: OWNER’S SIGNATURE(S)

Signature Signature

Print Name Print Name

Signature

Print Name STATE OF FLORIDA COUNTY OF PALM BEACH The foregoing instrument was acknowledged before me this day of____________, 20__ by _________________________who has/have produced ___________________________ as identification and who did not take an oath.

Notary Signature___________________________ Notary Public - State of Florida Commission # Expires on ________________________

14


ASSET ADDENDUM TO APPLICATION

To determine the eligibility of applicants for the MHI Program, the following asset information is required for all occupants including minors.

Assets include: Debit Cards Cash Held in Savings and/or Checking Accounts Trust Funds Equity in Real Estate Other Capital Investments Stocks Bond Treasury Bills Certificate of Deposits Money Market Funds IRA Accounts Retirement and Pension Funds Lump Sum Receipts (e.g. lottery winnings, insurance settlement, etc.) Personal Property Held for Investments (e.g. gem or coin collections,

paintings, antique cars, etc.).

Personal property such as furniture, automobiles and clothing are not included.

A. I (we) hereby state the combined value of my (our) assets Do exceed $5,000. Do not exceed $5,000. Total Value of Assets: $ Total Annual Income Expected to be derived from Assets: $ . B. I/We do not have any assets at this time. ____________________________ __________ Applicant Signature Date ____________________________ Print Name ____________________________ __________ Applicant Signature Date ____________________________ Print Name

15


VERIFICATION OF ASSETS DISPOSED I/We certify that during the two year (24 months) period preceding the effective date of my certification or recertification of eligibility for program participation, I/We have have not disposed of more than $1,000.00 in asset(s) for less than fair market value. If asset(s) were disposed of for less than fair market value, describe: Asset Date of Disposition 1. 2. 3. The amount received for the asset(s) disposed: 1. $ 2. $ 3. $ __________ Print Name Date __________ Signature Date __________ Print Name Date __________ Signature Date WARNING: Florida Stature 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities relating to financial conditions is a misdemeanor of the first degree and is punishable by fines and imprisonment provided under S 775.082 or 775.83.

16 Revised 2-17-16

PALM BEACH COUNTY DEPARTMENT OF ECONOMIC SUSTAINABILITY

INSURANCE/MOLD REMEDIATION HOLD HARMLESS AFFIDAVIT Whereas, I/We understand and agree that I/We must provide Palm Beach County (County) with a copy of my/our current Homeowner’s Hazard Insurance Policy. If the exterior of my/our home is covered by Home Owners Association (HOA) I/We will provide a copy of the insurance binder and a copy of my/our contents insurance policy. _________________ _________________ Homeowner’s Initials Homeowner’s Initials

Whereas, I/We understand and agree that in order to receive approval for the rehabilitation of my/our roof, I/We must have a valid Homeowner’s Hazard Insurance with sufficient coverage for the assisted property. _________________ _________________ Homeowner’s Initials Homeowner’s Initials

Whereas, I/We understand and agree that my/our Homeowner’s Hazard Insurance policy must be in effect during and after the close-out of the County’s rehabilitation. If the insurance policy is set to expire 60 days after the date of intake, I/We also understand that it is my/our responsibility to provide an updated valid Hazard Insurance Policy prior to its expiration. Also it is a requirement to maintain valid insurance throughout the affordability period. _________________ _________________ Homeowner’s Initials Homeowner’s Initials Whereas, I/We understand and agree that if a determination of MOLD or suspicion of MOLD exists, the cost of MOLD remediation must be covered by my/our homeowner’s Insurance policy or at my/our own expense. The County will held harmless for all assessments and remedies. _________________ _________________ Homeowner’s Initials Homeowner’s Initials NOW, THEREFORE, in consideration of the financial assistance provided to me/us by the County, I/We will hold harmless and release the County from any and all expenses incurred by me/us and the agencies acting on my/our behalf. _________________ _________________ Homeowner’s Initials Homeowner’s Initials

Additionally, I/We understand and acknowledge that the County will not reimburse nor pay any funds to cover my/our Homeowner’s Insurance Premium now or in the future that may result from buying Homeowner Insurance for the purpose of program funding. _____________ _____________ Homeowner’s Initials Homeowner’s Initials WITNESS MY HAND AND SEAL: By: ____________________________ By: ____________________________

Homeowner’s Signature Homeowner’s Signature

By: ____________________________ By: ____________________________ Witness Signature Witness Signature

State of Florida Palm Beach County The foregoing instrument was acknowledged before me this day of , 2016 by __________________________________________who is (are) personally known to me or who has (have) produced __________________________________ as identification. Notary Seal ______________________________________

Signature of Notary Public ______________________________________ Name of Notary Typed, Printed or Stamped Commission No. ________________________

12-28-15 17

FOR A LIST OF HUD APPROVED HOUSING COUNSELING AGENCIES

PLEASE VISIT THE HUD WEBSITE BELOW:

http://www.hud.gov/offices/hsg/sfh/hcc/hcs.cfm?&webListAction=search&searchstate=FL#searchArea



18 REVISED 2-17-16

MORTGAGE AND HOUSING INVESTMENTS HOMEBUYER EDUCATION PROGRAM CERTIFICATION

Date: __________________________ I,___________________________, of ________________________do hereby affirm that the under-signed applicant has successfully completed the First -time Homebuyers’ Education course which I conducted for the purpose of applying for assistance through the Palm Beach County Mortgage and Housing Investments Program. I further certify that the course was conducted in a classroom setting, for a minimum of six (6) hours. I used material as approved by the Neighborhood Reinvestment or___________________________________________________, a substantially equivalent HUD recognized curriculum (Indicate name of curriculum). I affirm that the course was presented and understood in the language of ___________. ________________________________________________________________ Instructor’s Signature Witness

I, __________________________________________, am a First Time Homebuyer and do hereby affirm that I have successfully completed the education course as stated above. The training, held on _________________________, was conducted over a total of six (6) hours as required by the Palm Beach County Mortgage and Housing Investments Program. ___________________________________ __________________________ Applicant Signature Witness ___________________________________ __________________________ Applicant Signature Witness The foregoing instrument was acknowledged, subscribed and/or sworn to before me by ______________________________________________ (the Counselor) and _______________________________________________ (the Applicant/s) who has/have produced _______________________________________ as identification and who did not take an oath. GIVEN UNDER MY HAND and SEAL of OFFICE, this _______day of________20__. ______________________________ Notary Public-State of Florida

Commission #__________________ (SEAL) Expires On: ____________________

a. You can also call 888-995-HOPE (4673), 24 hours a day, 7 days a week, 365 days a year, to immediately speak to an expert advisor in over 160 languages. Calls are answered within seconds. This valuable, around-the-clock service is available completely free of charge.

19 REVISED 2-17-16

One-on-One Homebuyer Checklist Date: ________________________ I, , of do hereby affirm that the under-signed applicant(s) have successfully completed two hours of one-on-one counseling for the purpose of applying for assistance through the Palm Beach County Mortgage and Housing Investments Program. I affirm that the counseling was presented and understood in the language of ______________. Please place a checkmark in the appropriate box for each item that was covered. 1. Credit Management

a. Credit Cards yes___ no___

b. Credit Debt yes___ no ___

2. Closing Procedures yes __ no ___ 3. Individual Budget yes __ no ___ 4. Post Closing yes __ no ___ 5. Protecting Your Investment yes__ no ___ 6. The Home Inspection yes __ no ___ 7. Repair yes __ no ___ 8. Predatory Lending yes __ no ___ 9. How to Select a Realtor/Home yes __ no ___ 10. "As Is" Sales Contract yes __ no ___

Applicant signature: _____________________________________________ Applicant signature: ______________________________________________ Loan Officer / Counselor’s signature: __________________________________ The foregoing instrument was acknowledged, subscribed and/or sworn to before me by ______________________________________________ (the Counselor) and _______________________________________________ (the Applicant/s) who has/have produced _______________________________________ as identification and who did not take an oath. GIVEN UNDER MY HAND and SEAL of OFFICE, this____ day of ___________ 20___. ______________________________ Notary Public-State of Florida (SEAL) Commission #__________________

20


Non-Profit / Developer’s Fee Schedule Non-Profit/Developer’s Name: _____________________________________________________

Non-profit/Developer’s Address: _____________________________________________________

Non-Profit /Developer’s Telephone Number: _______________________________________________

$500 Fee Education Requirement: Is your organization A HUD Certified Homebuyer Education Training Provider? ________ Did you provide the required 8 hours homebuyer education Training and certification?

$300 Fee Underwriting Conditions: Did your organization assist homebuyer with providing Underwriting conditions to Palm Beach County including, but not limited to writing Letters of explanation submitted for derogatory debt on the homebuyer’s credit report?

$250 Fee Property Services: As the Non-Profit, did you ensure that either your organization (or a realtor) was actively involved in the eligible property selection process?

AND If the home is located within a HOA or Condo Association, was the applicant provided a clear understanding of what responsibilities they have within an association?

AND During the homebuyer education training, was a thorough overview of property taxes, homeowners insurance, discussed Homestead exemption, filing process and mandatory escrows (i.e. was the applicant informed that property taxes and insurance can increase on an annual basis)?

$200 Fee Liaison: Did your organization commit to communicating with all parties involved in this real estate transaction until the file is closed and funded? Non-Profit must submit a Contact sheet for all parties involved in the transaction.

(Please note that if the Sellers, Realtors, Buyers Etc., Repeatedly Contact MHI, the file is subject to reduction in Liaison fee at MHI discretion.)

$250 Fee File packaging and submittal (Including the answers needed to complete the Intake Form): The Non-Profit is required to submit a complete and accurate file upon initial Submission through Intake review process.

(Rejected files are subject to reduction in file submittal fee at MHI discretion.)

I/We affirm that all of the services identified above were performed or will be performed by the Non-Profit prior to funding. I/We fully understand that on behalf of my family, the non-profit agency will be receiving a fee from Palm Beach County for each service performed/provided. I/We understand that the non-profit fee of $ will be deducted from the total subsidy awarded for the acquisition and if needed rehabilitation of my home. Date of Homebuyer’s Training Completion: ________________________________ ____________________________________________ __________________________________ _________ Applicant’s Name Applicant’s Signature Date ____________________________________________ __________________________________ _________ Co-Applicant’s Name Co-Applicant’s Signature Date ____________________________________________ __________________________________ _________ Provider’s Name Provider’s Signature Date

*Provide original Fee Schedule to the County*

21

PALM BEACH COUNTY Department of Economic Sustainability

Mortgage and Housing Investments Foreclosure Prevention Program

Non-Profit Recommendation & Fee Authorization

Non-Profit Organization:

Non-Profit Address:

Applicant’s Name:

Assigned MHI staff:

Date of Homeowner’s Initial Interview:

I. Services Rendered:

$500.00 Mortgage Delinquency & Default Resolution Counseling

Foreclosure preventative strategies, program compliance, and property compliance to include but, not limited to: lien searches, Palm Beach County maintains second lien position, housing counseling, budget verification, credit analysis, determination of homeowners ability to maintain monthly mortgage payments and other related costs after assistance awarded, act as a conduit between lender/attorney, verify mortgage default status and indebtedness, explore available remedies to reinstate mortgage, and negotiate on behalf of the applicant to reach final resolution (i.e. loan modification, reinstatement, etc.)

Weekly written status updates are required; reports are due every Friday to the assigned Mortgage and Housing Investments staff.

II. Recommendation of eligibility/ineligibility determination and justification:

I/We recommend

APPROVAL of funding in the amount of $___________________

(attach supporting documentation – i.e. letter of completion and lender’s reinstatement/agreement letter, etc…). Requested amount, including reinstatement & non-profit fee, cannot exceed $15,000.

DENIAL (Explain)*:

*Attach separate page if necessary

Process Completion Date:

Non-Profit Counselor:

Print Name Signature

Telephone Number Email Address

Applicant(s): Print Name Signature

Print Name Signature


Mortgage and Housing Investments Veterans Homeownership and Preservation Program (VHPP)

Non-Profit Organization: __________________________________________________________

Address of Non Profit: __________________________________________________________

Phone Number of Non Profit: __________________________________________________________

Applicant(s) Name: __________________________________________________________

Date of Home Buyers Training Completion: ______________________________________________

_____ $2,000 Fee Purchase Assistance

• Determine Program’s Eligibility (Veteran’s benefit DD-214 Documentation)

• Case file management (processing, addressing inquiries, intake, service referrals, follow up, file packaging, etc…)

• Education Requirement (provide household budget, original One On One checklist, original homebuyer certification, and copy of homebuyer certificate of completion)

• Property Services (actively involved in the eligible property selection process)

• Liaison (active communication between all parties) • On-going project management • Project Write Up (provide brief summary with photos detailing

benefits to applicants)

____ $2,500 Fee Rehabilitation Assistance • Determine Program’s Eligibility (Veteran’s benefit DD-214

Documentation) • Case file management (processing, addressing inquiries, intake,

service referrals, follow up, file packaging, etc…) • Liaison (active communication between all parties) • On-going project management • Project Write Up (provide brief summary with photos detailing

benefits to applicants)

I/We affirm that all of the services identified above were performed or will be performed by the Non-Profit prior to funding. I/We fully understand that on behalf of my/our family, the non-profit agency will be receiving a fee from Palm Beach County for each service performed / provided. I/We understand that the non-profit fee of $____________($2,500 maximum) and will be deducted from the total subsidy awarded for the acquisition and if needed rehabilitation of my/our home.

______________________________ ____________________________ ________________ Applicant Name Applicant Signature Date ______________________________ ____________________________ ________________ Co-Applicant Name Co-Applicant Signature Date ______________________________ ____________________________ ________________ Provider Name Applicant Signature Date

*Provide original fee schedule to the County*

22 REVISED 2-1-16

Department of Economic Sustainability

Mortgage and Housing Investments Subordination Policy

Purpose: To specify the terms and conditions acceptable to Mortgage and Housing Investments (MHI) for approval of subordination requests. Palm Beach County MHI will only subordinate its position if the current interest rate of the first mortgage is lowered by a minimum of two percentage points or the term of the first mortgage is reduced by a minimum of ten (10) years. Subordination request for other reasons will be considered on a case-by-case basis by the Director of Department of Economic Sustainability.

Palm Beach County MHI will not subordinate its position when the property owner is receiving cash for the sole purpose of paying credit card and other short term debt. Palm Beach County MHI will secure its interest in the home with a Mortgage and Promissory Note. Both are amortized up to thirty (30) years. During this time, the property owner must reside on the premises. Should any of the following events occur before the term of the loan expires, the financing received from the Mortgage and Housing Investments becomes due and immediately payable:

1. The property owner defaults on the first mortgage; 2. The house is sold; 3. The house is rented; 4. The house is leased or subleased; 5. The property ceases to be occupied by the owner; or 6. The transfer of title

I have read and understand the Department of Economic Sustainability Mortgage and Housing Investments Subordination Policy. _________________________ _____________________ Print Name Print Name _________________________ _____________________ Signature Signature Date__________________

F~4506-T (Rev, September 2015) Department of the Treasury Internal ReverlUe Se!vice

Request for Transcript of Tax Return ~ Do not sign this form unless all applicable lines have been completed.

... Request may be rejected if the form is incomplete or illegible.

II>- For more in1ormation about Form 4506~T, visit www.;rs.gov/form4506t.

OMS No. 1545-1872

TIp. Use Form 4500-T to order a transcript or other return !nformation free of charge. See the producllis! balow. You can quickly request transcripts by using Ollf automated self-help service tools. Please visit us allRS.gov end cUck on ~Gat a Tax Transcripl ... ~ undar "Tools" or call 1-600-908-9946. If you need a copy of your return, use Form 4506, Request ftH' Copy of Tax Return. There Is a fee to get a copy of your return.

1e Name shown on tax relum. If a joint relum, enter the name shown first.

1 b First social security number on tax return, individual taxpayer identification number, or employer identification number (see instructions)

2a If a Joint return, enter spouse's name shown on tax return. 2b Second social security number or indMdual taxpayer identification number if joint tax retum

3 Current name, address Uncluding apt., room, or sulle no.), city, state, and ZIP code (see instructions)

4 Previous address shown on the last return filed if different from line 3 (see instructions)

5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party's name, address, and telephone number.

Cautino: [f the tax transcript is being mailed to a third party, ensure that you have filled in nnes 6 through g before signIng. SIgn and date the form once you have filled In these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax transcrIpt to the third party listed on line 5, the IRS has no control over what the third party does with the information. II you would like to limit the thIrd party's authority to disclose your transcript information, you can specify this limitation in your written agreement with the third party.

6 Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form

number per request. ... C:--:CC;--CC-C-:CC-:c::-::---::,-. a RetlJm Transcript, which Includes most of the Une Items of a tax return as filed with the IRS. A tax return transcript does nol refleat

changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series, Form 1065, Form 1120, Form 1120-A, Form 1120·H, Form 1120-1, and Form 11205. Return transcripts are available for the current year and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days D

b Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the relum was filed. Return Information Is limited to Items such as tax l1abllily and estimated tax payments. Account transcripts are available for most returns. Most requests w1l1 be processed within 10 business days D

c Record of Account, which provides the most detailed information as It is a combination of the Relum Transcript and the Account Transcript. AVailable for current year and 3 prior tax years. Most requests will be procassed within 10 business days 0

7 Verification of Nonflling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available after June 15th. There are no availability restrictions on prioryear requests. Most requests will be processed wlthin 10 business days. D

8 Form W-2, Form 1099 series, Form 1098 &eries, or Form 549a series transcript. The IRS can provide a transcript thai inCludes data from these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For example, W-2 information for 2011, filed in 2012, will likely not be available from the IRS until 2013. If you need W-2 information for retirement purposes, you should contact the Social Security Administration at 1·800-772-1213. Most requests will be processed within 10 business days D

Caution: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed with your return, you must use Form 4506 and request a copy of your return, which includes all attachments.

9 Year or period requested. Enter the ending date of the year Of period, using the mm/ddlyyyy formal. If you are requesting more than four years or periods, you must attach another Form 4506·T. For requests relallng to quarterly tax returns, such as Form 941, you must enter each quarter or tax period separately. I I I I I I I I I I I I

Caution: Do not sign this form unless all applioable lines have been completed.

Signature of taxpayer{s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax information requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to exeoute Form 4506-T on behalf of the taxpayer. Note: For transcripts being sent to a third party, this form must be received within 120 days of the signature date.

D SIgnatory attests that hefshe has read the attestation clause and upon 80 reading deClares that he/she has the authority to sign the Form 4506-T, See instructions.

Sign Here

~ SIgnature {see Instructions)

~ THle {if line 1a above Is a ~orpotation, partnership, estate, or trust)

~ Spouse's signature

For Privacy Act and Paperwork Reduction Act NotiC9, see page 2,

"""

Date

Cat. No. 37667N

23

Phone number of taxpayer on line 1aor2a

Form 4506-T (Rev. 9·2015)

Fmm8821 Tax Information Authorization OMB NO.l54,S·"!!s

For IRS Use Only

(Rev. Man::h 2015)

Department of the Treasury Internal Revenue Service

~ Information about Fonn 8821 and its instructions is at www.irs.govlform8821.

.. Do not sign this form unless all applicable tines have been completed. .. Do not use Form 8821 to request copies of your tax returns

or to authorize someone to represent you.

1 Taxpayer information. Taxpayer must sign and date this form on line 7. Taxpayer name and address Taxpayer identification number{s)

_ . Tor.ph"" •

~.

Daytime telephone number I Plan number (if applicable)

2 Appointee. If you wish to name more than one appointee, attach a list to this form. Check here if a list of additional appointees is attached ~ D

Name and address CAF No. ... ------------_ ..... ------_._--------_ .... --------.. ---------_.--._. __ .. PTIN

T elePh-one-No~·-.·.~~~~~~~·.~~-::.~:_·_·""".~~~~~~~~~~~~~~~~~._~._~.",-_______ ~~~~~~~~~~~~~~~ Fax No. Check if -new~-Ad-dress--tr-Teie--hone-N-;;~'--D"-Fa;'No:'T:]"

3 Tax Information. Appointee is authorized to inspect and/or receive confidential tax information for the type of tax, forms, periods and specific matters you list below See the line 3 instructions ,

(a) (b) (e) (<I) Type of Tax Information (Income, Tax Form Number Year(s) or Perlod(s) Specific Tax Matters

Employment. Payroll, Excise, Estate, Gift, Civil Penalty, Sec. 4980H Payments, etc.} (1040, 941, 720, etc.)

. . . .. 4 SpecifiC use not recorded on Centrahzed Authonzation File (CAF). If the tax Information authOrization IS for a specifiC

use not recorded on CAF, check this box. See the instructions. If you check this box, skip lines 5 and 6 . . . . . . ~ 0

5 Disclosure of tax Information (you must check a box on line Sa or 5b unless the box on line 4 is checked):

a If you want copies of tax information, notices, and other written communications sent to the appointee on an ongoIng basis, check this box . . . . . . . . . . . . . . .. ................ ~ 0 Note. Appointees will no longer receive forms, publications, and other related materials with the notices.

b If you do not want any copies of notices or communications sent to your appointee, check this box .~ 0

6 Retention/revocetion of prior tax information authorizations. If the line 4 box is checked, skip this line. If the line 4 box is not checked, the IRS will automatically revoke all prior Tax Information Authorizations on file unless you check the line 6 box and attach a copy of the Tax Information Authorization(s) that you want to retain. . . . . . . . . . . . ... D

To revoke a prior tax information authorization(s) without submitting a new authorization, see the line 6 instructions.

7 Signature of taxpayer. if signed by a corporate officer, partner, guardian, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that [ have the authOrity to execute this form with respect to the tax matters and tax periods shown on line 3 above.

"IF NOT COMPLETE, SIGNED, AND DATED, THIS TAX INFORMATION AUTHORIZATION WILL BE RETURNED •

.. DO NOT SIGN THIS FORM IF IT IS BLANK OR INCOMPLETE.

Signature Dale

PlintName Title (if applicable)

For Privacy Act and Paperwork Reduction Act Notice, see Instnrctlons. Cal. No. 11596P Form8821 (FIev.3·2015)

24

Social Security Administration

Consent for Release of Information Form Approved OMB No. 0960-0566

You must complete all required fields. We wilt not honor your request unless aU required fields are completed. (*signifies a required field). TO: Social Security Administration

*My Fu" Name *My Date of Birth *My Social Security Number (MM/DDfYYYV)

I authorize the Social Security Administration to release information or records about me to: "NAME OF PERSON OR ORGANIZATION: "ADDRESS OF PERSON OR ORGANIZATION: PALM BEACH COUNTY 100 AUSTRALIAN AVENUE SUITE 500

DEPARTMENT OF ECONOMIC SUSTAINABILITY WEST PALM BEACH, FL 33406

MORTGAGE & HOUSING INVESTMENT SECTION

*1 want this information released because: We may charge a fee to release information for non-program purposes.

*Please release the following information selected from the list below: You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.

1. 0 Social Security Number 2. 0 Current monthly Social Security benefit amount 3. 0 Current monthly Supplemental Security Income payment amount 4. 0 My benefit or payment amounts from date to date ____ _

5. 0 My Medicare entitlement from date to date ____ _ 6. 0 Medical records from my claims folder(s) from date to date ____ _

If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office.

7. 0 Complete medical records from my claims folder{s) 8. 0 Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,

determination or questionnaire)

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41 (d}{2004)) that I have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all applicable fees for requesting information for a non-program-related purpose.

*Signature: _________________________ *Date: ___________ _

*Address:

Relationship (If not the subject of the record): *Daytime Phone: __ .,-.,--,--,-__

Witnesses must sign this form ONLY if the above signature is by mark: (X). If signed by mark: (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above. 1.Signature of witness 2.Signature of witness

Address(Number and street,CitY,State, and Zip Code) Address(Number and street,CitY,State, and Zip Code)

Form SSA-3288 (07-2013) EF (07-2013) 25

Updated 4-4-16

Annual Income Limits for West Palm Beach and Boca Raton Metropolitan Statistical Area (MSA)

FY 2016 Median Family Income

(HOME up to 80%; State, SHIP, Workforce Housing up to 140%)

$65,400

Number of Persons

in Household

Extremely Low

Income (30%)

Very Low Income (50%)

Low Income (80%)

Moderate Income (120%)

Workforce Income (140%)

1 $14,150.00 $23,550.00 $37,650.00 $56,250.00 $65,940.00 2 $16,150.00 $26,900.00 $43,300.00 $64,560.00 $75,320.00 3 $20,160.00 $30,250.00 $48,400.00 $72,600.00 $84,700.00 4 $24,300.00 $33,600.00 $53,750.00 $80,640.00 $94,080.00 5 $28,440.00 $36,300.00 $58,050.00 $87,120.00 $101,640.00 6 $32,580.00 $39,000.00 $62,350.00 $93,600.00 $109,200.00 7 $36,730.00 $41,700.00 $66,650.00 $100,080.00 $116,760.00 8 $40,890.00 $44,400.00 $70,950.00 $106,560.00 $124,320.00

Palm Beach County Mortgage & Housing Investments *HUD.gov Florida Housing Finance Corporation Posted 3/31/16;

*Effective March 28, 2016

27

MEMORANDUM

TO: Employer(s) & Financial Institution(s) FROM: Department of Economic Sustainability, Mortgage and Housing Investments RE: Verification Request(s) APPLICANT:

PRINT YOUR NAME HERE ================================================ Please complete the attached verification request for the above named individual and return as soon as possible. For expediency, fax the completed form to the attention of [email protected] at (561) 656-7553 and mail the original. DO NOT MAKE CORRECTIONS. Call for a new form. The above has applied to Palm Beach County for housing assistance under a government funded program administered by this office. Completing this verification promptly will allow the application to be processed in a timely manner. Employers, if annual income computation varies: • Report total year to date income and recent history based

on last two years’ earnings. • Use the comment area to clarify, if any of the information

requested requires an explanation • Confirm the date of a change and include it in your remarks,

if the applicant’s duties have changed. Financial Institutions: Include all information and/or account(s) applicable to the individual named above. If you have further questions, please feel free to contact DESVerify at [email protected]. Thank you for your time and cooperation.

Department of Economic Sustainability

Mortgage & Housing Investments

100 Australian Avenue - Suite

#500

West Palm Beach, FL 33406

(561) 233-3600

FAX: (561) 656-7553

http://www.pbcgov.com/des/ �

Palm Beach County Board of County Commissioners

Mary Lou Berger, Mayor

Hal R. Valeche, Vice Mayor

Paulette Burdick

Shelley Vana

Steven L. Abrams

Melissa McKinlay

Priscilla A. Taylor

County Administrator

Verdenia C. Baker

Equal Housing Opportunity

“An Equal Opportunity Affirmative Action Employer”



http://www.pbcgov.com/des/

WARNING: Florida Statute 817 provides that willful false statements or misrepresentation concerning income, asset or liability information relating to financial condition is a misdemeanor of the first degree, punishable by fines and imprisonment provided under Statutes 775.082 or 775.83. 28

DEPARTMENT OF ECONOMIC SUSTAINABILITY MORTGAGE & HOUSING INVESTMENTS

THIRD-PARTY VERIFICATION OF EMPLOYMENT

Note to Employer: State and/or Federal Regulations require us to verify employment history and income information for the person that has provided authorization below, in order to determine their eligibility for program assistance. Your cooperation in providing the requested information below is most appreciated. AUTHORIZATION: I hereby authorize the release of requested information. A copy of the executed "Authorization for the Release of Information" is attached which indicates my agreement with the release of information requested for the sole purpose of determining eligibility for program assistance.

Applicants Name Applicants Signature

Applicants Social Security Number Date PLEASE RETURN INFORMATION TO: Name: [email protected] Phone: 561-233-3600 Fax: (561) 656-7553 Department: Department of Economic Sustainability, Mortgage & Housing Investments Address: 100 Australian Avenue, Suite 500, West Palm Beach, FL 33406

Name of Employer: _______________________________________ Position: Employer’s Address: _______________________________________Date of hire: __________________________ Probability of continued employment (please circle one): YES or NO Number of hours worked per week: _____

Current Pay Rate: $ Pay Frequency (WEEKLY / Bi-Weekly / MONTHLY): Fulltime / Part-time hrs per ___

Total anticipated Annual Base Pay Earnings over the next 12 months: $

Overtime Pay Rate: $ Expected overtime hours during next 12 months, based on Avg. ____hrs per_____

Total anticipated Overtime Earnings the next 12 months: $ Consistency (Regular/Occasional)

Probability and expected date of any pay increase: Anticipated NEW rate of pay: $

Amount of Other Compensation anticipated during the next 12 months (bonus, commission, tips): $

Frequency of Other Compensation, if applicable (please circle one): WEEKLY / BI-WEEKLY / MONTHLY / ANNUALLY

Vacation Pay (please circle one): YES or NO If yes, number of days: _____________________

Retirement Account (please circle one): YES or NO Amount Accessible to Employee: $______________

Penalty for withdrawal (please circle one): YES or NO Penalty Amount/Percentage: ___________________

Total anticipated Gross Annual Income (including all other compensation) over next 12 months: $

Total Gross Income Earned in 20 : $ ___________Total Gross Income Earned in 20 : $

EMPLOYER COMMENTS:

Signature of authorized representative: _______________________________________________________________

Printed Name: Title: ______________________________________

Date: __________________________________ Phone: _________________________Fax: _____________________ NOTE: For ALL applicable Household Members 18 years or over, obtain a signed copy of this form for each verification to be completed. Send form directly to the appropriate employment source; do not send form through applicant. Upon receiving verification, date-stamp, and compare information to that received on application. Make any necessary notations, date and initial. If significant differences exist between amount reported and verified, obtain a written explanation from applicant and attach to file.


29

DEPARTMENT OF ECONOMIC SUSTAINABILITY MORTGAGE & HOUSING INVESTMENTS

REQUEST FOR VERIFICATION OF DEPOSIT (Applicant, please complete this section.) NAME OF BANK: ADDRESS:

Telephone Number: FROM / RETURN TO: NAME:

[email protected]

ADDRESS:

Department of Economic Sustainability Mortgage & Housing Investments 100 Australian Avenue, Suite 500 West Palm Beach, FL 33406

PHONE:

(561) 233-3600 FAX 561-656-7553

APPLICANT INFORMATION: (Applicant, please complete this section.) NAME(S): SOC. SEC. NO: ADDRESS:

NOTE TO VERIFYING AGENCY: The applicant(s) identified herein has applied for housing assistance under a government assisted program administered by this office. The information requested in this verification is for the confidential use of this agency and its funders. Please furnish the information requested below and return this form to the address indicated above.

AUTHORIZATION BY APPLICANT(S): (Applicant, please print and sign your name below.) I/We hereby authorize release of the requested information: _____________________________ ___________ Name Signature Date _____________________________ ___________ Name Signature Date

NOTE: The section below must be completed by your bank and sent directly to us. DEPOSIT DATA: TYPE OF ACCOUNT

ACCOUNT NUMBER

OPENING DATE

CURRENT BALANCE

AVERAGE BALANCE (Previous 6 months)

AVERAGE INTEREST (Previous 6 months)

Checking

$

$

$

Savings

$

$

$

Certificate of Deposit

$

$

$

Money Market

$

$

$

IRA

$

$

$

Other

$

$

$

Other

$

$

$

INFORMATION PROVIDED BY THE BANK OR FINANCIAL INSTITUTION REPRESENTATIVE : _____________ ___________________________________ Print Name & Title Signature Date

___________________________________ Institution Stamp (required)


PROFIT & LOSS STATEMENT

For Period To

Applicant (s) Name: ______________________________________________________

Applicant (s) Company Name: ______________________________________________

Applicant (s) Company Address:

REVENUE

SALE - OTHER _ -

OTHER -

OPERATING EXPENSES

CONTRACT LABOR -

EQUIPMENT RENTAL -

MERCHANTS SERVICES -

RENT -

SUPPLIES -

TELEPHONE -

UTILITIES -

OTHER _ -

OTHER -

TOTAL EXPENSE $

GROSS INCOME / (LOSS) $

Prepared by:

Name:

*Company Address:

Phone:

Signature:

Date:

WARNING: Florida Statue 817 provides that willful false statements or misrepresentations concerning

income, asset or liability information relating to financial condition is a misdemeanor of the first degree,

punishable by fines and imprisonment provided under Statues 775.082 or 775.83.

*PLEASE ATTACH YOUR BUSINESS CARD

30 Revised 2-17-16

IMPORTANT PLEASE STOP AND READ CAREFULLYdiscover.pbcgov.org/HES/BHI/Revised Application...

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