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2. Please select the type of CDBG Neighborhood Rehab funding you are applying for.*

   1. Single Family Rehab (1-4 units)
   2. Multi-Family Rehab (4+ units)
4. Applicant Information
6. First Name*
7. Last Name*
9. SSN: *
10. Date of Birth*
    Date of Birth
12. Cell Telephone*
13. Home Telephone*
14. Work Telephone
16. Homeowner Address*
18. Female Head of Household*

    1. Yes
    2. No
19. Number of Dependents (include self and spouse/partner)*
21. Do you own any additional Properties?*

    1. Yes
    2. No
22. Ethnicity (please select the best option for you)*
    -- Select One --White - Non-HispanicWhite - HispanicAmerican Indian/Alaska NativeBlack/African American - Non-HispanicAsian AmericanAmerican Indian/Alaska Native & WhiteBlack/African American & WhiteAsian/Pacific IslanderAmerican Indian/Alaska Native & Black/African AmericanBlack/African American - HispanicAsian WhiteNative Hawaiian/Other Pacific IslanderOther Multi-RacialOther
24. Second Property Address*
26. Third Property Address
28. Rehab Property Information
30. Rehabilitation Property Address*
31. Number of Dwelling Units/Rooms Rented*
33. Which neighborhood is the property located?*
    -- Select One --Battle HillBryant GardensCarhartColonial CornersDowntown White PlainsEast White PlainsEastviewFerris AvenueFisher HillFulton StreetGedney FarmsGedney ManorGedney MeadowsGedney ParkGreen AcresHaviland ManorHighlandsHolbrookeIdle ForestNorth BroadwayNorth StreetNorth White PlainsDeKalbOld Mamaroneck RoadProspect ParkReynal ParkRidgewayRocky DellRosedaleSaxon WoodsSecor GardensSoundviewWestminster RidgeWinbrookWoodcrest Heights
34. Are you the property owner?*

    1. Yes
    2. No
35. Does the owner live on the property?*

    1. Yes
    2. No
36. Are there additional owners on the deed or mortgage?*

    1. Yes
    2. No
38. Additional Owner - First Name*
39. Additional Owner - Last Name*
40. Additional Owner - Date of Birth*
    Additional Owner - Date of Birth
41. Additional Owner - SSN:*
43. Is this inquiry related to an outstanding building code violation?*

    1. Yes
    2. No
44. Description of work to be performed:*
46. Are there any outstanding liens (other than mortgage(s)) or judgements affecting this property?*

    1. Yes
    2. No
47. Please explain:*
49. Are any property tax or mortgage payments in arrears?*

    1. Yes
    2. No
50. Please Explain:*
52. Primary Applicant: Income Information
54. Employment Income*
55. Social Security Income*
57. Child Support Income*
58. Alimony Income*
60. Property 2 Rental Income*
61. Property 3 Rental Income*
63. Additional Owner Employment Income*
64. Additional Owner Social Security Income*
65. Additional Owner Pension or Disability Income (IRA, Annuity)*
67. Additional Owner Child Support Income*
68. Additional Owner Alimony Income*
70. Other Income*
71. Income Total*
73. Applicant's Employment Address*
75. Additional Owner's Employment Address*
77. Do you currently rent room(s) in your home or unit?*

    1. Yes
    2. No
79. Roomer or Tenant Name (1):*
80. Monthly Rent (1): $*
82. Roomer or Tenant Name (2):
83. Monthly Rent (2): $
85. Roomer or Tenant Name (3):
86. Monthly Rent (3): $
88. Roomer or Tenant Name (4):
89. Monthly Rent (4): $
93. Income Data
    Please complete the following income data questions for the rehab property ONLY - all submitted documentation must support information provided below. Complete for Single Family Home Rehab projects only.
95. Mortgage (principal and interest payments)*
96. Real estate taxes - City, School, County, sewer/water (unless included in mortgage payments)*
98. Home Insurance Cost*
99. Other*
101. Total*
105. Asset Information
     Please complete the following asset information for other properties and business assets. Complete for Single Family Home Rehab projects only.
107. Checking Account Balance(s)*
108. Savings Account(s)*
110. Value of bonds, stocks owned*
111. Estimated value of other property owned*
113. Total*
117. Certification
     I/We, certify that I/we have examined all the information contained above and certify that it is true and correct. I/we, agree to maintain the current status of affordable housing unit for a period of three years. I/We as property owner(s) agree that the City’s obligation to provide payment is contingent upon the property owner(s);
119. A. Using payment solely in connection with the work; B. Not amending the contracts without the prior written approval of the City; C. Paying all cost in connection with the work and paying all cost in connection with any additional work (“Additional Work”) which may be performed; D. Permitting the City and its Agents and Designees to enter the Property to make periodic inspections of the work; and E. Complying with all the procedures established by the City and for the said Neighborhood Rehabilitation Program
121. The Property Owner hereby agrees to indemnify and hold the City and the City’s officers, employees and agents: harmless against any and all claims, liabilities and expenses in connection with the contract(s), the work and any additional work.
123. WARNING: ANY PERSON WHO KNOWINGLY AND WILLINGLY MAKES FALSE OR FRAUDULENT STATEMENTS MAY BE DETERMINED INELIGIBLE FOR ALL COMMUNITY BLOCK GRANT PROGRAM ASSISTANCE AND HELD LEGALLY RESPONSIBLE.
125. Homeowner Signature*
126. Date*
     Date
128. Homeowner Signature (2)*
129. Date*
     Date
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134. 1. Receive an email copy of this form.
135. Email address

     This field is not part of the form submission.

136. Submit Submit and Print

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