Housing Rehabilitation Program Assistance Application

TOWN OF CARY

HOUSING REHABILITATION PROGRAM

APPLICATION FOR ASSISTANCE

Please complete all pages of this application in its entirety and sign the last page. This information is needed to determine your eligibility for the Town of Cary’s Housing Rehabilitation Program. You must own your own home to qualify. All information in this form is confidential. Applications will be processed on a first-come, first served basis. If you need assistance in completing this application, please contact the Town of Cary Housing Rehabilitation Program at (919) 380-2782..

Date:

Head of Household:

Date of Birth:

Spouses Name:

Date of Birth:

Address: (Number) (Street)

(City) (State) (Zip)

Phone Number (Home):

Phone Number (Work):

Do you own any other real estate property? Yes No If “Yes” please list address:

FAMILY COMPOSITION (List each person residing in your home)
Family Member Number	NAME (Last, First)	Relationship to Head of Household	Voluntary Information
Family Member Number	NAME (Last, First)	Relationship to Head of Household	Age	Sex	Ethnic Origin
1	Head of Household	Self
2
3
4
5

INCOME: (List the income of each person residing in your home.)
Family Member Number	Name of Employer or Income Source	Address of employer/income source	Employer Telephone Number	Annual Income Last Year	Current Gross Income Per Mo./Per Wk
1
2
3
4

CHECKING/SAVINGS ACCOUNTS and OTHER ASSETS (Describe)

Asset

Name of Bank or Description/Address of Asset Owned

Estimated Amount or Value

Checking Acct

Yes No

Savings Acct

Yes No

Stocks/Bonds

Yes No

INFORMATION ABOUT YOUR HOME
Age of Home (years):	How long have you owned and lived in the home as your primary residence? Years:
Do you presently have a mortgage on your home? Yes No If “Yes” what is the name of your mortgage company?
Do you have homeowner’s insurance on your home? Yes No If “Yes” what is the name of your insurance company?
Is your home a mobile/manufactured home? Yes No If “Yes” do you own the land on which the home is located? Yes No
Do you operate a business out of your home? Yes No If “Yes” please provide the name and the nature of the business.

PROVIDE A GENERAL DESCRIPTION OF WORK NEEDED

A. Air Conditioning/Heating:

B. Plumbing:

C. Roofing:

D. Electrical:

E. Other:

Please certify each of the following statements by initialing on the line next to the statement.

(If you cannot certify to each of the following you may not qualify for assistance.)

A. I have owned and occupied the home listed above for the past year or longer ______________

(Initial)

B. I understand the Town of Cary may obtain a title and credit report for qualification ___________

(Initial)

I/We certify that all the information I/we have given in connection with this application, either in writing or orally is true and correct. I/We understand that make false, fictitious or fraudulent statements or representations voids my application for assistance and may be punishable by fines or imprisonment. I/We further understand that it is the policy and obligation of the Town of Cary to prosecute violations.

Signature of Applicant ____________________________________Date:____________

Signature of Co-Applicant ____________________________________ Date:____________

June, 2006