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BLUE VALLEY COMMUNITY ACTION PARTNERSHIP

620 5th Street, P.O. Box 273, Fairbury, NE 68352-0273

Phone: 402-729-2278 Fax: 402-729-2801

Website: www.bvca.net

OWNER OCCUPIED HOUSING REHABILITATION PROGRAM APPLICATION

SECTION I: Applicant Data

First Name*

Last Name*

DOB*

SS#:*

Home Phone:

Cell:*

Email Address

Co-Applicant?

First Name:

Last Name:

DOB:

SS#

Co-Applicant Phone Number

Email Address

Street Address

City

State

Zip Code

County:

How long at this address:?

Others living with you at this address:

A Name	B Age	C Relationship

Add New Entry

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SECTION II: Employment and Income Data

Applicant

Employer:

Employer Address

Employer City:

Employer State

Employer Zipcode:

Employer Phone Number

Applicant Gross Income

Co-Applicant

Employer:

Address

City:

State

Zipcode:

Employer Phone Number

Spouse Gross Income

Other Applicant Income

Include all income from all sources. *Sources may include child support, social security, pensions, alimony, etc.

Applicant Other Income:

Spouse Other Income:

Other Income:

Total Income:

ASSETS:

Checking Account:

Savings Account:

Retire Funds:

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Section III: Expenses

What are the basic expenses per MONTH for your home?

Electric

Gas

Water/Sewer

Fuel Oil

Coal/Wood

Kerosene

Real Estate Tax

Homeowners Insurance

Other:

Total Expenses Per Month:

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Section IV: Additional Home Information

Do you own your home?*

Are you buying your home on contract?*

Is the property to be rehabbed your primary residence?*

Is it your intention to make this your primary residence for a least the next ten years?*

Do you live in a mobile home?*

Are the property taxes paid and current?*

Do you have home owner’s insurance?*

Is your home located in a 100-year flood plain?*

Is any other Agency providing assistance regarding accessibility issues?*

What is the approximate age of your home?*

How many bedrooms?*

How many bathrooms?*

What is the heating source (s) in your home?*

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Section V: Acknowledgement and Signature(s)

My/Our signature(s) below certifies that the information contained in this application is accurate and complete to the best of my/our knowledge. I hereby grant permission to Blue Valley Community Action Partnership, Inc. (BVCA) to verify any or all information contained herein with respect to this application for assistance. I understand the information in this application is strictly confidential, and is provided solely for the purposes of determining my/our eligibility for assistance under the Owner-Occupied Housing Rehabilitation program. No information contained herein will be released to any other local, state, or federal agency for any purpose without my express written consent, except as it may pertain to my receipt of the funding resources made available through this application. I/We do certify that all information written or verbal that is remitted to Blue Valley Community Action Partnership, Inc. now or in the future, for the purpose for obtaining funds from the Owner-Occupied Housing Rehabilitation program the I/We are applying for are true to the best of my/our knowledge. I/We understand that any knowingly and/or willfully falsified documentation or statement(s) may be grounds for denial for participation in the Owner-Occupied Housing Rehabilitation program applied for, and that any and all Rehabilitation construction in progress will cease immediately. I/We understand and agree that any program funds obtained under knowingly and/or willfully falsified documentation or statement(s) will be reimbursed immediately and if full to Blue Valley Community Action partnership, Inc.

Applicant #1 Signature:

Signature - Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.*

Date:*

Applicant #2 Signature:

Signature - Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.

Date: